Community Service Agency Title Xix Certification Intent To Contract Form Page 2

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It is the intent of
to enter into a contract with
T/RBHA Name Here
Provider/Applicant Name Here
for the provision of behavioral health rehabilitation and/or support services.
Signature of T/RBHA Representative
Printed Name of T/RBHA Representative
Telephone Number
Date
Initial Effective Date: 7/01/2016

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