EXHIBIT D- WOA ACCEPTANCE FORM.pdf

This is a Work Authorization Acceptance Form template used by Cal ICH (California Integrated Care Health) for contractor deliverable approval and acceptance. The form establishes a standardized process for reviewing and authorizing work completed under a Work Authorization Agreement between Cal ICH and contracting parties. The document is structured in three parts: Part 1 captures general information including the contractor name, agreement details, and work authorization number; Part 2 lists deliverables by number and description for tracking purposes; and Part 3 provides approval signature blocks for both the contractor and Cal ICH representatives, with designated space for recording approval dates and authorization status.

The form allows Cal ICH to formally approve deliverables as submitted or deny them if they do not meet established expectations, with provision for documentation of denial reasons. Approval authority rests with the Cal ICH HDIS IT Manager, who must sign and date the form along with the contractor representative. This acceptance form serves as the contractual documentation mechanism to confirm satisfactory completion of work tasks and authorize payment or progression to subsequent work phases under the work authorization agreement.