Please complete the following: Point of contact: Name of your agency: Email address: Total number of subunits and subcontracts: Telephone: Proposed effective date: Mailing address: Please complete the following for each subunit or subcontract included in your MAC invoice Narrative Description Modified Modified Modified Name subunit or County County The narrative description of the client or clinic based MER (this must County subcontract Wide MER Wide MER specify the source of the data, calculation methodology, definitions Wide MER (If neither, use name and Client and Clinic of the numerator and denominator, and the frequency with which of LHJ) ONLY Based MER based MER the MER will be calculated). Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No Yes Yes Yes No No No
Please complete the following: Point of contact: Name of your agency: Email address: Total number of subunits and subcontracts: Telephone: Proposed effective date: Mailing address: Please complete the following for each subunit or subcontract included in your MAC invoice Name subunit or subcontract (If neither, use name of LHJ) Modified County Wide MER ONLY Modified County Wide MER and Client Based MER Modified County Wide MER and Clinic based MER Narrative Description The narrative description of the client or clinic based MER (this must specify the source of the data, calculation methodology, definitions of the numerator and denominator, and the frequency with which the MER will be calculated). Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
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