Enter Basic Contract Information
Administrative Information
Basic Contract Details
| Vendor Name |
Managed Health Network (MHN)
|
| Vendor Number (3____ for AP and 00___ for AR) |
328110
|
| Vendor Contact Name |
Kristin Yokoyama
|
| Vendor Contact Email |
[email protected]
|
| Contract / Amendment Title |
MHN Extension
|
| Contract / Amendment Amount |
$16,000.00
|
| Is this a new agreement or an amendment to an existing agreement? |
Amendment
|
| If this is if a Contract Amendment, what is the Contract Number? |
9278
|
| Supplemental Insurance (for Risk team only) |
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Upload Contract Documents
Upload Documents
| Upload Contract or Amendment Authorization Form |
Contract_Amendment_Authorization_Form_-_MHN_2022_One-Year_Ext.docx.pdf
|
| Upload Agreement or Amendment |
CityofWestHollywood22C_s__Revised_ma_08192022_(002).pdf
|
| Upload Insurance Documents (COI, Endorsements, WOS, etc.) |
RE_ MHN - Employee Assistance Program Agreement.pdf, RE COI Status Managed Health Network (MHN).msg
|
| Describe changes to Insurance Requirements, if any (if no insurance is required, type "None required") |
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| Upload approval for insurance changes, if any (e.g., email from Risk) |
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| Describe changes to Contract Template, if any (If none, type "None required") |
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| Add any notes you may have for Finance and Risk Review teams. |
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Supplemental Risk Information
General Liability Details
Automobile Policy Details
| Endorsements |
NO INS REQUIRED
|
Workers Comp Policy Details
Professional Liability Policy Details
