Exhibit 10.175


 


 


AMENDMENT

to the

PROVIDER SERVICES AGREEMENT

between

FOUNDATION HEALTH SYSTEMS AFFILIATES

and

STARCARE MEDICAL GROUP DBA GATEWAY MEDICAL GROUP


 


The Provider Services
Agreement (“Agreement”), effective March 1, 1999, between StarCare Medical
Group dba Gateway Medical Group (“PPG”) and Foundation Health Systems
Affiliate(s) (“FHS”) is hereby amended effective July 1, 2000.


 


FHS and PPG hereby agree to
amend the Agreement as follows:


 


1)   Article
VI TERM AND TERMINATION, Section 6.2 Without Cause Termination is deleted in
its entirety and replaced as follows:


 


6.2          Without Cause Termination.  FHS may terminate this
Agreement at the scheduled renewal date upon one hundred twenty (120) days
prior written notice to the other party. 
In the event FHS provides PPG with such notice, FHS may, at its option,
begin to transition Members immediately under this Agreement to another
Participating Provider after such notice.


 


2)  Addendum B Section B 1.1, STANDARD HMO.  Professional Capitation Rates. 
Capitation Rates, is deleted in its entirety and replaced as follows:


 


B.            STANDARD HMO.


 


1.             Professional Capitation Rates.


 


1.1          Capitation Rates.  PPG Capitation for Standard HMO
Members shall be determined on a monthly basis by multiplying the following
normalized PMPM rates by the age, sex and benefit plan factors set forth in
Addendum B for each assigned Member. 
Normalized rates represent the PMPM prior to the adjustment for PPG’s
assigned Members’ age, sex and benefit plan. 
Actual PPG gross Capitation shall fluctuate from month to month to the
extent that PPG’s age, sex and benefit plan mix fluctuates.


 




	
  Standard
  HMO Capitation

  
	
  July
  1, 2000

  	
   

  	
  January
  1 2001

  
	
  ***

  	
   

  	
  ***

  






 


3)  Addendum B, Section B.3.1 STANDARD HMO, Shared Risk Budget is
deleted in its entirety effective January 1, 2001 and replaced as follows:


 


3.1          Shared Risk Budget.  HMO
shall fund the Shared Risk Budget for Members, with normalized rates.  These normalized rates shall be adjusted for
PPG’s assigned Members by the age, sex and benefit plan factors as set forth in
Addendum B.  Actual Shared Risk Budget
shall fluctuate from month to month to the extent that PPG’s age, sex and
benefit plan mix fluctuates.


 




	
  Standard
  HMO Shared Risk Budget

  
	
  January
  1, 2001

  
	
  ***

  






 


Gateway Medical Group


Contract effective March 1, 1999


Amendment effective July 1, 2000


 












*** Confidential Information
omitted and filed separately with the Securities and Exchange Commission.


 


1

















 


4)  Addendum B, Section B.3.2 STANDARD HMO, Shared Risk
Administration, deleted in its entirety and replaced as follows:


 


3.2          Shared Risk Administration.  As a
contingency for any PPG liability under this Shared Risk Program, HMO shall
deduct *** of PPG’s Capitation for Standard HMO Members and place such amount
in the Withhold Fund as described in the Agreement.


 


In the event the shared risk claims exceed the shared risk budget at the
interim settlement date, HMO may, at its sole discretion, withhold from PPG’s
gross monthly capitation up to *** of PPG’s monthly capitation and may continue
such withhold until the final shared risk settlement.  The withheld amount shall be placed in the Withhold Fund as
described in the Agreement.  If there is
a deficit at the time of final settlement, HMO may at it’s sole discretion,
continue to withhold up to *** of PPG’s capitation for Standard HMO Members and
place such amount in the Withhold Fund as described in this agreement.


 


Each Reconciliation Period, HMO shall calculate Shared Risk Claims in
accordance with the Operations Manual and compare such claim cost to the
corresponding Shared Risk Budget.  HMO
shall perform both an interim and final settlement.  In the event that such claims are less than the Shared Risk
Budget for the Interim Period, PPG’s share of the settlement shall be ***
subject to Section 4.3 of this Agreement.


 


Shared Risk Claims with dates of service within the Reconciliation
Period and paid by March 31 of the following year shall be used in the
calculation.  Shared Risk Services
incurred within the Reconciliation Period but paid after March 31 of the
following year will be included in the next Reconciliation Period
calculation.  In the event any amounts
remain in the Withhold Fund following the reconciliation of any shared risk
program, those excess funds shall be paid to PPG by April 30 of the following
year.


 


5)  Addendum B, Section C.1, SMALL GROUP, Professional Capitation
Rates.  Capitation Rates, is deleted in
its entirety and replaced as follows:


 


C.            SMALL GROUP HMO.


 


1.             Professional Capitation Rates.


 


1.1          Capitation Rates.  PPG
Capitation for Small Group HMO Members shall be determined on a monthly basis
by multiplying the following normalized PMPM rates by the age, sex and benefit
plan factors set forth in Addendum B for each assigned Member.  Normalized PMPM rates represent the PMPM
prior to the adjustment for PPG’s assigned Members’ age, sex and benefit
plan.  Actual PPG gross Capitation shall
fluctuate from month to month to the extent that PPG’s age, sex and benefit
plan mix fluctuates.


 




	
  Small
  Group HMO Capitation

  
	
  July
  1, 2000

  
	
  ***

  






 


6)  Addendum B, Section C.3.2, SMALL GROUP, Shared Risk
Administration is deleted in its entirety and replaced as follows:


 


3.2       Shared Risk Administration.  As a
contingency for any PPG liability under this Shared Risk Program, HMO shall
deduct one percent (1%) of PPG’s Capitation for Standard HMO Members and place
such amount in the Withhold Fund as described in the Agreement.


 


2

















 


In [ILLEGIBLE] event the shared risk claims exceed the shared
[ILLEGIBLE] budget at the interim settlement date, HMO may, at its sole
discretion, withhold from PPG’s gross monthly capitation up to five percent
(5%) of PPG’s monthly capitation and may continue such withhold until the final
shared risk settlement.  The withheld
amount shall be placed in the Withhold Fund as described in the Agreement.  If there is a deficit at the time of final
settlement, HMO may at it’s sole discretion, continue to withhold up to *** of
PPG’s capitation for Standard HMO Members and place such amount in the Withhold
Fund as described in this agreement.


 


Each Reconciliation Period, HMO shall calculate Shared Risk Claims in
accordance with the Operations Manual and compare such claim cost to the
corresponding Shared Risk Budget.  HMO
shall perform both an interim and final settlement.  In the event that such claims are less than the Shared Risk
Budget for the Interim Period, PPG’s share of the settlement shall be ***
subject to Section 4.3 of this Agreement.


 


Shared Risk Claims with dates of service within the Reconciliation
Period and paid by March 31 of the following year shall be used in the
calculation.  Shared Risk Services
incurred within the Reconciliation Period but paid after March 31 of the
following year will be included in the next Reconciliation Period
calculation.  In the event any amounts
remain in the Withhold Fund following the reconciliation of any shared risk
program, those excess funds shall be paid to PPG by April 30 of the following
year.


 


7) Addendum B, Section D.1
INDIVIDUAL HMO, Professional Capitation Rates. 
Capitation Rates, is deleted in its entirety and replaced as follows:


 


D.    INDIVIDUAL HMO.


 


1.             Professional Capitation
Rates.


 


1.1          Capitation Rates.  PPG
Capitation for Individual HMO Members shall be determined on a monthly basis by
multiplying the following normalized PMPM rates by the age, sex and benefit
plan factors set forth in Addendum B for each assigned Member.  Normalized PMPM rates represent the PMPM
prior to the adjustment for PPG’s assigned Members’ age, sex and benefit
plan.  Actual PPG gross Capitation shall
fluctuate from month to month to the extent that PPG’s age, sex and benefit
plan mix fluctuates.


 




	
  Individual
  HMO Capitation

  
	
  July
  1, 2000

  
	
  ***

  






 


8)  Addendum D, Section B.3.2 INDIVIDUAL HMO, Shared Risk
Administration, is deleted in its entirety and replaced as follows:


 


3.2       Shared Risk Administration.  As a
contingency for any PPG liability under this Shared Risk Program, HMO shall
deduct *** of PPG’s Capitation for Standard HMO Members and place such amount
in the Withhold Fund as described in the Agreement.


 


In the event the shared risk claims exceed the shared risk budget at the
interim settlement date, HMO may, at its sole discretion, withhold from PPG’s
gross monthly capitation up to *** of PPG’s monthly capitation and may continue
such withhold until the final shared risk settlement.  The withheld amount shall be placed in the Withhold Fund as
described in the Agreement.  If there is
a deficit at the time of final settlement, HMO may at it’s sole discretion,
continue to withhold up to


 


3

















 


*** of [ILLEGIBLE] capitation
for Standard HMO Members and [ILLEGIBLE] such amount in the Withhold Fund as
described in this agreement.


 


Each Reconciliation Period, HMO shall calculate Shared Risk Claims in
accordance with the Operations Manual and compare such claim cost to the
corresponding Shared Risk Budget.  HMO
shall perform both an interim and final settlement.  In the event that such claims are less than the Shared Risk
Budget for the Interim Period, PPG’s share of the settlement shall be ***
subject to Section 4.3 of this Agreement.


 


Shared Risk Claims with dates of service within the Reconciliation
Period and paid by March 31 of the following year shall be used in the
calculation.  Shared Risk Services
incurred within the Reconciliation Period but paid after March 31 of the
following year will be included in the next Reconciliation Period
calculation.  In the event any amounts
remain in the Withhold Fund following the reconciliation of any shared risk
program, those excess funds shall be paid to PPG by April 30 of the following
year.


 


9)  Addendum B, Section G. 4. Commercial POS, Professional Capitation
Rate.  Professional Capitation Rates is
deleted in its entirety and replaced as follows:


 


4.             Professional Capitation Rate.  PPG
shall be compensated for rendering professional In-Network Services to
Commercial POS Members at the PMPM amounts set forth for Commercial HMO Members,
less a *** Withhold (Professional Capitation). 
This Withhold shall partially fund the Professional Out-of-Network
Budget.


 


10)  Addendum B, Section G. 6.1 Commercial POS,
Institutional Shared Risk Program, POS Shared Risk Budgets, is deleted in its
entirety effective January 1, 2001 and replaced as follows:


 


6.             Institutional Shared Risk Program.


 


6.1          POS Shared Risk Budgets.  The
budgets shall be determined for each Commercial POS population: Standard POS,
Small Group POS and, at a later date, Individual POS Members.  Each Budget shall cover In-Network,
Out-of-Network and Out-of-Area Shared Risk Services.  Each of the normalized Shared Risk Budgets
shall be equal to the normalized HMO Shared Risk Budget, or institutional
capitation PMPM, if applicable, and multiplied by one hundred ten percent
(110%).  Actual Shared Risk Budget shall
fluctuate from month to month to the extent that PPG’s age, sex and benefit
plan mix fluctuates.


 


	
  Effective Date

  	
   

  	
  Standard
  HMO Shared

  Risk

  + 10% =

  	
   

  	
  Small
  Group HMO

  Shared Risk

  + 10% =

  	
   

  	
  Individual
  HMO

  Shared Risk

  + 10% =

  	
   

  
	
  January 1,
  2001

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


11)  Addendum B, Section I. Pharmacy Shared Risk Program is deleted in
its entirety effective January 1, 2001 and replaced as follows:


 


I.              Pharmacy Shared Risk Program.  PPG
shall not participate in the Pharmacy Shared Risk Program.  PPG shall use its best efforts to have
Member Physicians and participating providers prescribe from the HMO drug
formulary.  PPG shall cooperate with HMO
recommendations for pharmacy treatment guidelines and shall provide upon HMO’s
request, documentation regarding its internal processes and procedures for
pharmacy utilization management. 
Furthermore, HMO shall notify PPG of identified outlier Member
Physicians.  PPG shall cooperate in creating
and implementing action plans for improvement in pharmacy utilization for such
Member Physicians.  HMO and appropriate
PPG representatives shall meet


 


4

















 


quarterly
to review PPG’s pharmacy utilization, and to discuss opportunities and action
plans for pharmacy utilization improvement. 
PPG shall submit to Health Net a 2001 Pharmacy Performance Improvement
action plan, documentation regarding its internal processes and procedures for
pharmacy utilization management, and status of programs currently in various
stages of implementation no later than April 1, 2001.  Upon review and approval by Health Net, progress of implemented
programs shall be monitored by Health Net on a bi-monthly basis.  In addition, the Health Net clinical
pharmacy department will develop PPG specific programs the group to review and
incorporate into their action plan.


 


12)  Addendum C is amended by the addition of the following Section J.
HCFA REQUIRED LANGUAGE:


 


J. HCFA REQUIRED LANGUAGE


 


I. DEFINITIONS


 


1.1.         Downstream
Providers means a health care provider who or which is contracted with Provider
to render services to Members.


1.2.         Health
Care Financing Administration (HCFA) means the agency within the Department of
Health and Human Services that administers the Medicare Program.


1.3.         Member
means an individual who has enrolled in or elected coverage in Health Net
Seniority Plus, an M+C Organization.


 


II.
ACCESS:  RECORDS AND FACILITIES


 


Provider agrees:


 


2.1.         To give
the Department of Health and Human Services (HHS), and the General Accounting
Office (GAO) or their designees the right to audit, evaluate, inspect books,
contracts, medical records, patient care documentation, other records of
subcontractors, or related entities for the later of six (6) years, or for
periods exceeding six (6) years, for reasons specified in the federal
regulation.


2.2.         To
safeguard the privacy of any information that identifies a particular Member
and to maintain such records in an accurate and timely manner.


 


III. ACCESS:
BENEFITS & COVERAGE


 


Provider agrees:


 


3.1.         To not
discriminate based on health status.


3.2.         To pay
for emergency and urgently needed services consistent with federal regulations,
if such services are Provider’s liability.


3.3          To pay for renal dialysis services for Members
temporarily outside the service area, if such services are Provider’s
liability.


3.4.         To
direct access to mammography screening and influenza vaccinations.


3.5.         To not
collect any co-payment or other cost sharing for influenza vaccine and
pneumoccal vaccines.


3.6.         To
direct access to in-network women’s health specialist for women for routine and
preventative services.


3.7.         To have
approved procedures to identify, assess and establish a treatment plan for
Members with complex or serious medical conditions.


3.8.         To
provide access to benefits in a manner described by HCFA.


 


5

















 


IV. MEMBER PROTECTIONS


 


Provider agrees:


 


4.1.         To work
with Health Net in conducting a health assessment of all new Members within
ninety (90) days of the effective date of enrollment.


4.2.         To
provide all covered benefits to Members in a manner consistent with
professionally recognized standards of health care.


4.3.         To
comply with all confidentiality and Member record accuracy requirements.


4.4.         To hold
harmless and protect Members from incurring financial liabilities that are the
legal obligation of Health Net or Provider. 
In no event, including but not limited to, nonpayment or breach of an
agreement by Health Net, Provider, or any intermediary, shall Provider bill,
charge, collect a deposit from or receive other compensation or remuneration
from a Member.  Provider shall not take
any recourse against a Member, or a person acting on behalf of a Member, for
services provided.  This provision also
does not prohibit (i) collection of applicable coinsurance, deductibles, or
co-payments, as specified in the Evidence of Coverage, or (ii) collection of
fees for non-covered services, provided the Member was informed in advance of
the cost and elected to have non-covered services rendered.


4.5.         To
protect Members who are hospitalized from loss of benefits through the date of
discharge or through the period of time HCFA premiums are paid.


 


V. DELEGATION


 


Provider agrees:


 


5.1.         To
maintain delegated functions consistent with Health Net’s requirements and
compliant with M+C’s regulations and Health Net’s policy and procedures as set
forth in the Health Net Seniority Plus Participating Provider Group Operations
Manual.


5.2.         To
comply with any applicable delegation requirements between Health Net and
Provider.


 


VI. PAYMENT AND
FEDERAL FUNDS


 


Provider agrees:


 


6.1.         To
include specific payment and incentive arrangements in agreements with all
Downstream Providers.


6.2.         To pay
claims promptly according to HCFA standards and comply with all payment
provisions of state and federal law. 
HCFA requires non-contracted provider claims to be paid within thirty
(30) days of receipt and contracted provider claims to be paid within sixty
(60) days of receipt.


6.3.         That
Members health services are being paid for with Federal funds, and as such,
payments for such services are subject to laws applicable to individuals or
entities receiving Federal funds.


 


VII. REPORTING AND DISCLOSURE


 


Provider agrees:


 


7.1.         To
submit to Health Net all data, including medical records, necessary to
characterize the content and purpose of each encounter with Member.


7.2.         To
submit and certify the completeness and truthfulness of all encounter data.


 


VIII. QUALITY ASSURANCE / QUALITY IMPROVEMENT


 


Provider Agrees:


 


8.1.         To
cooperate with an independent quality review and improvement organization’s
activities pertaining to provision of services for Members.


8.2.         To
comply with Health Net’s medical policy, quality assurance program, and medical
management program.


 


6

















 


IX. COMPLIANCE


 


Provider
agrees:


 


9.1.         That
Provider must notify any contracting healthcare provider being terminated, in
writing, of the reason(s) for denial, suspension or termination determinations.


9.2.         To
provide Health Net with at least sixty (60) days written notice before
terminating an agreement without cause.


9.3.         To meet
the requirements of all other laws and regulation, including Title VI of the
Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans
with Disabilities Act, and all other laws applicable to recipients of Federal
funds.


9.4.         To
comply with all applicable Health Net procedures and Health Net Seniority Plus
Participating Provider Group Operations Manual including, but not limited to,
the accountability provisions.


9.5.         To
comply with and require that all Downstream Providers comply with applicable
state and Federal laws and regulations, including Medicare laws and regulations
and HCFA instructions.


9.6.         To not
employ or contract with individuals excluded from participation in Medicare
under Section 1128 or 1128A of the Social Security Act.


9.7          To adhere to Medicare’s appeals, expedited
appeals and expedited review procedures for Health Net Members, including
gathering and forwarding information on appeals to Health Net, as necessary.


 


X. PRIVATE FEE FOR SERVICE


 


Provider
agrees:


 


10.1.       That
contracts with private Fee-for-Service providers must specify uniform Fee-for-Service
payment rates.


10.2.       That
Provider cannot charge more than cost sharing and balanced billing amounts
permitted under the applicable Health Net plan.  Health Net must specify cost sharing amounts, and balance billing
may not exceed fifteen percent (15%) of uniform payment rate.


 


XI. ADOPTION OF MEDICARE RISK PROGRAM CONTRACT
REQUIREMENTS


 


Provider
agrees:


 


11.1.       That all
contracts must be signed and dated.


11.2.       To serve
Members during the term of this Addendum.


11.3.       To comply
with the regulatory requirements and Health Net’s guidelines promulgated by
HCFA, which are more fully documented in Health Net’s policies, procedures, and
manuals.


 


13) 
Addendum B.2 DIVISION OF RESPONSIBILITY, MATRIX OF HMO, PPG AND SHARED
RISK/HOSPITAL CAPITATED SERVICES, COMMERCIAL HMO AND POINT OF SERVICE BENEFIT
PROGRAMS is amended effective January 1, 2000 as follows:


 


	
  MATRIX EFFECTIVE 1/1/2000

  
	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL
SERVICES

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
   

  	
   

  
	
  •
  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Covered Immunosuppressive

  	
   

  	
  ***

  	
   

  	
   

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSPLANT EVALUATIONS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  ***

  	
   

  



 












***         All references to the division of financial responsibility
have been deleted.


 


 


7

















 


14)  Addendum C, Section D.2. ADMINISTRATION OF SHARED RISK BUDGET FOR
MEDICARE HMO AND POS, Pharmacy Reconciliation For Medicare HMO Members, is
deleted in its entirety effective January 1, 2001 and replaced as follows:


 


2.             Pharmacy Shared Risk Program.  PPG
shall not participate in the Pharmacy Shared Risk Program.  PPG shall use its best efforts to have
Member Physicians and participating providers prescribe from the HMO drug
formulary.  PPG shall cooperate with HMO
recommendations for pharmacy treatment guidelines and shall provide upon HMO’s
request, documentation regarding its internal processes and procedures for
pharmacy utilization management. 
Furthermore, HMO shall notify PPG of identified outlier Member
Physicians.  PPG shall cooperate in
creating and implementing action plans for improvement in pharmacy utilization
for such Member Physicians.  HMO and appropriate
PPG representatives shall meet quarterly to review PPG’s pharmacy utilization,
and to discuss opportunities and action plans for pharmacy utilization
improvement.  PPG shall submit to Health
Net a 2001 Pharmacy Performance Improvement action plan, documentation
regarding its internal processes and procedures for pharmacy utilization
management, and status of programs currently in various stages of
implementation no later than April 1, 2001. 
Upon review and approval by Health Net, progress of implemented programs
shall be monitored by Health Net on a bi-monthly basis.  In addition, the Health Net clinical
pharmacy department will develop PPG specific programs the group to review and
incorporate into their action plan.


 


15)  Addendum D PREFERRED PROVIDER ORGANIZATION (PPO), EXCLUSIVE
PROVIDER ORGANIZATION (EPO), POINT OF SERVICE (POS), BENEFIT PROGRAMS shall be
amended by the addition of the following section D MEDICARE SELECT BENEFIT
PROGRAMS, Medicare Select Programs.


 


D.            MEDICARE SELECT BENEFIT PROGRAMS


 


1.             Medicare Select Programs.  Under
the Medicare Select Programs PPG shall accept Medicare assignment from Members
for Contracted Services covered under the Medicare Program, and shall bill and
accept payment from Medicare as payment in full for such services, except for
applicable Copayments and deductibles. 
PPG shall bill HMO and not Members for such Copayments and deductibles
or for Contracted Services rendered that are not covered under Medicare, but
which are covered under the applicable Medicare Select Program.  PPG shall submit claims to HMO in accordance
with the terms of the Agreement.


 


2.             Compensation for Medicare Select Members.  PPG
shall be paid the fee-for-service compensation rates as set forth in Addendum E
of the Agreement for Contracted Services rendered under the Medicare Select
Program.


 


Except as provided in this
Addendum, all other provisions of the Agreement between Health Net and Provider
not inconsistent herewith shall remain in full force and effect.  This Addendum shall remain in force as a
separate but integral addition to such Agreement to ensure compliance with
required HCFA provisions, and shall terminate upon the termination of such
Agreement.


 


8

















 


IN WITNESS WHEREOF, the parties hereto have executed this Agreement by their officers duly
authorized to be effective on the date and year first written above.


 


	
  Gateway Medical Group

  	
  Foundation
  Health Systems Affiliates

  
	
   

  	
   

  
	
   

  	
   

  
	
  /s/ RAJ
  TAKHAR

  	
   

  	
  /s/ CHRISTOPHER CIANO

  	
   

  
	
  Signature

  	
  Signature

  
	
   

  	
   

  
	
  RAJ TAKHAR

  	
   

  	
  Christopher
  Ciano

  	
   

  
	
  Print Name

  	
   

  	
   

  
	
   

  	
   

  
	
  Chief Executive Officer

  	
   

  	
   

  
	
  Title

  	
  Senior Vice President and
  General Manager- South

  
	
   

  	
   

  
	
  11/9/00

  	
   

  	
  12-07-00

  	
   

  
	
  Date

  	
  Date

  
	
   

  	
   

  
	
  33-0843-838

  	
   

  	
   

  
	
  Federal Tax Identification
  Number

  	
   

  



 


9