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STATE OF NORTH CAROLI COUNTY OF WAKE tin` DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES PROVIDER PARTICIPATION AGREEMENT MEDICAID TITLE XIX 3404353 053 Provider Number(s) Lee County Health Department Name of Provider 106 Hillcrest Drive Street Address 3404420 053 (919)775-3603 Telephone Number Sanford NC 27330 City State Zip Pursuant to the Interagency Agreement between the Department of Human Resources, Division of Medical Assistance (DHR,DMA) and the Department of Environment, Health, and Natural Resources (DEHNR), by this agreement the above-named provider will participate cooperatively in the provision of approved Medicaid services to eligible recipients of the North Carolina Medical Assistance Program. Approved services for this agreement are described in the attached service addenda. The provider certifies that the clinic is operated to provide medical care in the form of physician supervised clinical services which are diagnostic, therapeutic, rehabilitative and/or palliative in nature. The provider certifies that: (1) Patient care is performed under the direct supervision of a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by State law or under the written orders, which are reviewed and updated annually, of such practitioners. (2) Practitioners are on the salaried or contractual staff of such clinic or are voluntarily donating their service to said clinic. (3) Patient services provided are under complete control of the local participating provider. (4) Physicians or other licensed practitioners are not billing the Title XIX Program separately for their services rendered on behalf of the provider. The Provider of Services Agrees: 015 1. To comply with the terms of the Interagency Agreement, the provisions of Title XIX of the Social Security .Act, and the regulations issued