………………………………………………………. SIGNED by Signature [INSERT AUTHORISED ………………………………………………………. Title SIGNATORY’S NAME] for and on behalf of ………………………………………………………. [INSERT PROVIDER NAME] Date SERVICE COMMENCEMENT AND CONTRACT TERM Effective Date [The date of this Contract] [or as specified here] Expected Service Commencement Date Longstop Date Service Commencement Date Contract Term [ ] years/months commencing [ ] [(or as extended in accordance with Schedule 1C)] Option to extend Contract Term YES / NO Notice Period (for termination under [ ] months GC17.2) SERVICES Service Categories Indicate all that apply Continuing Healthcare Services (CHC) Community Services (CS) Diagnostic, Screening and/or Pathology Services (D) End of Life Care Services (ELC) Mental Health and Learning Disability Services (MH) Patient Transport Services (PT)
SIGNED by ………………………………………………………. Signature [INSERT AUTHORISED SIGNATORY’S NAME] for and on behalf of [INSERT PROVIDER NAME] ………………………………………………………. Title ………………………………………………………. Date SERVICE COMMENCEMENT AND CONTRACT TERM Effective Date [The date of this Contract] [or as specified here] Expected Service Commencement Date Longstop Date Service Commencement Date Contract Term [ ] years/months commencing [ ] [(or as extended in accordance with Schedule 1C)] Option to extend Contract Term YES / NO Notice Period (for termination under GC17.2) [ ] months SERVICES Service Categories Indicate all that apply Continuing Healthcare Services (CHC) Community Services (CS) Diagnostic, Screening and/or Pathology Services (D) End of Life Care Services (ELC) Mental Health and Learning Disability Services (MH) Patient Transport Services (PT)
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