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CONTRACT STATUS FORM
O 856 O
DATE: September 01, 2023 RECEIVED Eli))
DIVISION(S): Administration SEP 01 2023
(Lead Division listed first) 0
CONTRACTOR: CalViva Health (Fresno, Kings & Ng"�dETRAgFSS q H
SERVICES: Tri-Counties Health Authority - Joint Provision of Medi-Cal Managed
Care
CONTRACT TERM: 3/3/09 to 3/2/24 E
ADDITIONAL INFO: Evergreen Agreement-Please Review
ORGANIZATION #(s): N/A
CONTRACT AMOUNT: $0.00
Contract#: A-09-080 State/Vendor #: N/A
Lead Dept: DPH Other Dept(s):
Complete the information below and return to DPH Contracts by:December 1, 2023
Extend contract through: 3 / Z 20 LL
With no changes in terms or conditions.
❑ With the following change(s):
❑ Evergreen: Continue contract through: 20
Cancel contract effective: , 20
Additional Information e.g., anticipated effective ate/term, contract extension, etc.):
Approved by:
Program Supervisor/Staff Analyst: Date:
Division Manager: Date:
Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090