Loren Data's SAM Daily™

FBO DAILY - FEDBIZOPPS ISSUE OF MAY 16, 2013 FBO #4191
SOLICITATION NOTICE

Q -- Two(2) Internal Mediicine Physicians

Notice Date

5/14/2013
 

Notice Type

Combined Synopsis/Solicitation
 

NAICS

561320 — Temporary Help Services
 

Contracting Office

Department of Health and Human Services, Indian Health Service, Aberdeen Area Office, Federal Building, 115 4th Avenue SE, Aberdeen, South Dakota, 57401
 

ZIP Code

57401
 

Solicitation Number

RFQ13-049
 

Archive Date

5/31/2013
 

Point of Contact

Linda M Suess, Phone: 605-685-6771
 

E-Mail Address

lsuess@abr.ihs.gov
(lsuess@abr.ihs.gov)
 

Small Business Set-Aside

N/A
 

Description

REQUEST FOR QUOTATIONS (THIS IS NOT AN ORDER) RFQ-13-049 1 05/17/2013 / IHS1202691 1. REQUEST NO. AND/OR DMS REG. 1,, I d. CITY I e. STATE I f. ZIP CODE I d. STATE I e. ZIP CODE PAGE OF PAGES 1-2 2. DATE ISSUED RATING THIS RFQ IS W IS NOT A SMALL BUSINESS SET-ASIDE 5A. ISSUED BY 1 6. DELIVER BY /Date) 1 Linda.suess@ihs.gov 1 605 1 685-6771 1 3. REQUISITIONIPURCHASE REQUEST NO. 7. DELIVERY OTHER FOB DESTINATION (See Schedule) 9. DESTINATION a. NAME OF CONSIGNEE 5b. FOR INFORMATION CALL (NO COLLECTCALLS) 4. CERT.FOR NAT. DEF. UNDER BDSA REG.2 NAME Linda M. Suess, Contract Specialist b. STREET ADDRESS P.O. Box 1201 c. CITY Pine Ridge, SD TO: SD TELEPHONE NUMBER AREA CODE I NUMBER a. NAME 57770 5a ON OR BEFORE CLOSE OF BUSINESS 05/13@ 12:OO~m MAT b. COMPANY 10. PLEASE FURNISH QIJOTATIONS TO IMPORTANT: This is a request for information, and quotations furnished are not offerors. If you are unable to quote, I THE ISSUING OFFICE IN BLOCK 1 olease so indicate on this form and return it to the address in Block 5a This reauest does not commit the Government 1 to pay any costs incurred in the preparation of the submission of this quotation or to contract for supplies or services. Supplies are of domestic origin unless otherwise indicated by quoter. Any representations and/or certifications attached to this Request for Quotations must be completed by the quoter. 1 1. SCHEDULE (Include applicable Federal, State and local taxes) Firm Fixed-Price, Non-Personal service contract for Two (2) Internal Medicine Physicians for OPC/IPC at the Pine Ridge Service Unit, Pine Ridge, SD. Period of performance will be fiom 05120120 13 through 09130/20 13. The contractor is to perform as outlined in the attached Statement of Work. The quoted "unit price" must be an allinclusive cost. I c' STREET ADDRESS ITEMNO. I SUPPLIESISERVICES (a) Two (2) Internal Medicine Physicians M-F 8am to 4:30 PM(1ess lunch) QUANTITY I UNIT I UNITPRICE I AMOUNT PAYMENT (b) URGENT & COMPELLING b. STREET ADDRESS 1 (c) I I (d) c. COUNTY a. NAME (Type ofprint) I I I I I I AUTHORIZED FOR LOCAL REPRODUCTION FormFlowDelrina Inc. STANDARD FORM 18 (REV 6-95) Previous edition not usable Prescribed by GSA-FAR (48 CFR) 53-215-I(a) 16. SIGNER b. TELEPHONE AREA CODE (e) (f) d. CITY e. STATE f. ZIP CODE c. TITLE (type orprint) NUMBER CONTINUATION FOR RFQ-013- PAGE 2 OF 2 PAGES ITEM NO. (a) DUNS & BRADSTREET NUMBER: (The Duns & Bradstreet number is required. Provided you do not have it, you may call 866-705-5711 and obtain one.) You will need a DUNS & BRADSTREET NUMBER to be awarded the purchase order. WHAT I S SAM? The System for Award Management (SAM) is a Federal Government owned and operated free web site that consolidates the capabilities in CCRfFedReg, ORCA, and EPLS. FORMER CCR REGISTRANTS If you had an active record in CCR, you have an active record in SAM. You do not need to do anything in SAM at this time, unless a change in your business circumstances requires updates to your Entity record(s) in order for you to be paid or to receive an award or you need to renew your Entity(s) prior to its expiration. SAM will send notifications to the registered user via email 60,30, and 15 days prior to expiration of the Entity. To update or renew your Entity records(s) in SAM you will need to create a SAM User Account and link it to your migrated Entity records. You do not need a user account to search for registered entities in SAM by typing the DUNS number or business name into the search box. FEDERAL TAX ID NUMBER: EMAIL ADDRESS: NET TERMS: QUANTITY (c) UNIT (d) UNIT PRICE (e) AMOUNT (0 SECURITY CLEARANCE Performance of this contract will require routine access by employees of the Contractor or its subcontractors to facilities or systems controlled by the Indian Health Service (I.H.S.). Before starting work requiring routine access to I.H.S. facilities or systems each person must complete a FBI National Criminal History Check (Fingerprint Check) adjudicated by an I.H.S. employee using the Office of Personnel Management Personnel Investigations Processing System. Contractors shall allow five business dnys for I.H.S. processing of fingerprints taken electronically at an I.H.S. site and thirty business days for non-electronic processing of fingerprints using FBI Form FD-258. A list of I.H.S. sites with electronic fingerprint capability is available from the Contracting Officer. In addition, no Contractor or subcontractor employee shall be permitted to perform work under this contract if listed on the HHS Office of Inspector General List of Exclucled IndividualslEntities (LEE),h ~~://exclusions.oie;.hhs.govA.s soon ns practicnble prior to the sL1t-t of work, the perforlnance of the work the Contractor shall provide to the Contracting Officer the names of all individunls to be used in performance of work for screening against the LEIE. During the performance of the Contractor shall provide the Contracting Officer the names of any additional or substitute employees for screening they begin work. The Contractor is responsible for conducting security preclearance investigations sufficient depth to ensure that each Contractor or subcontractor employee referred to I.H.S. is not on the LEE and can obtain a favorable fingerprint clearance. Each security preclearance shall be conducted sufficiently in advance of the start of perfomlance to avoid delays caused by denial of access. If this is a Time and Materials, -hhr-Hou~'mC ost Reimbursement eontraet, the eontractor shatl notehaqe-forerbereimbimsed-fm-labohro urs-or-otherc osts incmed-foremployees who are unable to perform due to denial or access or the excess time required to resolve and clew unfavorable security clearance findings. If this is a Fixed Price contract, denial of access due to security clearonce findings shall not be a basis for excusable delay or an increase to the contract amount. STATEMENT OF WORK Internal Medicine Physician Services (NON-PERSONAL SERVICE) DESCRIPTION OF SERVICES. The Contractor shall provide Internal Medicine Physician services required for the Pine Ridge Comprehensive Health Care Facility. The mission of the Pine Ridge Comprehensive Health care Facility in Pine Ridge, South Dakota is to provide the best possible health care services to the Native American population on the Pine Ridge Indian Reservation. The 35-bed facility is also known as the Pine Ridge Indian Health Service Hospital, The Pine Ridge Service Unit, or the IHS Hospital. The Aberdeen Area Indian Health Service (AAIHS) requires contractor support to assist in the recruitment and placement of emergency room physicians into temporary duty assignments in health centers and hospitals in the AAIHS. The purpose of the contract is for the recruitment, credentialing, and placement of internal medicine physicians into various locations in the Aberdeen Area. This contract is a non-personal health care services contract, as defined at Far Part 37.101 under which the Contractor is an independent contractor and which shall allow the Government to evaluate the quality of professional and administrative services provided, but retains no control over the medical, professional aspects of the services rendered, (e.g., professional judgments, diagnosis for specific medical treatment). The Contractor shall indemnify the Government for any liability producing act or omission by the contractor, its employees and agents occurring during contract performance. The Contractor shall maintain medical liability insurance, in the coverage amount acceptable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medical specialty concerned. The Contractor shall fiunish physicians for internal medicine assignments in Aberdeen Area hospitals. I.H.S. facility in Pine Ridge, South Dakota, will require internal medicine physicians on an ongoing basis. Contract physician care shall cover the range of medicine typically provided in a rural civilian practice of similar size. The Contractor shall provide physicians to perform the necessary medical procedures for patients in both outpatient and inpatient situations, but this position will not involve overnight call, unless emergency condition develops. (See Appendix A for the types of services historically provided.) Upon the receipt of an I.H.S. service unit task order, the Contractor shall locate, credential, and have available sufficient staffing to provide physician coverage for 8 hour shifts, occasionally extra hours may be necessary (up to 55 hourslweek). The work schedule will consist of a Monday - Friday 8:00 am - 4:30 pm.Task Orders shall be issued 2 1 days in advance of the need but some tasks orders may provide the Contractor with a limited time in which to respond. The standards of medical practice and duties of the Contractor through its physicians shall be determined pursuant to Governing Body bylaws, medical staff bylaws, rules and regulations of the appropriated I.H.S. hospital, applicable provisions of law including but not limited to rules and regulations of any and all governmental authorities relating to licensure and regulation of physicians and hospitals, and standards and recommendations of CMS (Centers for Medicare and Medicaid Services) compliance. The contract resulting from this solicitation shall: 1. be a non-personal health care services contract under the Contractor is an independent contractor: 2. allow the Government to evaluate the quality of professional and administrative services provided, but retains no control over the medical, professional aspects of the services rendered, (e.g., professional judgments, diagnosis for specific medical treatment); 3. requires the Contractor to indemnify the government for any liability-producing act or omission by the Contractor, its employees and agents occurring during contract performance; require the Contractor to maintain medical liability insurance, in the coverage amount acceptable the contracting officer, which is not less than the amount normally prevailing within the local community for the specific specialty; and 4. require the Contractor to ensure its subcontracts for provisions of health care service, contain the requirements of the clause at FAR 52.237-7, including the maintenance of medical liability insurance. 1.1. CONTRACTOR RESPONSIBILITY. 1.1.1. Provides internal medicine services to approximately 600 patient visits per month to a patient population ranging in age fiom young adult to geriatric. 1.1.2. The physician's actual clinical duties will be in accordance with hisher credentialed privileges. 1.1.3. The physician shall practice within the Medical Staff By-Laws of the Pine Ridge Comprehensive Health Care Facility. 1.1.4. Primary duty will be to provide outpatient care in our IPC clinic. But may provide direct hands-on patient care in both inpatient and outpatient settings durning the normal duty day. Performs triage, assesses, and re-assesses patients throughout the patient visits. Ensures documentation of medical assessments and observations are documented accurately in the patient's health care record. When necessary completes all transfer forms, writes admittingldischarge orders, daily progress notes and complete H&P and discharge summary according to the Pine Ridge IHS Medical Staff By-laws. Documents consultations in the patient's health care record when called in to assist an emergency room physician. 1.1.6. Implements, evaluates and is consulted on outpatient and inpatient policies, procedures and instructions. 1.1.7. Establishes inter-personal and intra-departmental relationships to enhance optimal patient care. 1.1.8. Demonstrates competent and effective oral and written communication. 1.1.9. Provides appropriate patiendfamily member teaching and education; evaluates effectiveness and level of patiendfamily member understanding of teaching provider. 1.1.10. Utilizes the RPMSEHR computer softwarelprogram for entering and signing of medical orders such as laboratory studies, and directly signing and dating radiological studies, etc. 1.1.11. Obtain necessary information on patients seen in the clinic, such as medical records, x-ray films and reports, and pathology slides and reports and documents pertinent normal and abnormal test results in the patient's medical record. 1.1.12. Maintain familiarity and comply with hospital antiseptic polices and procedures. Maintain familiarity and comply with all Federal, State, Indian Health Service, CMS regulations, and departmental regulation and requirements. 1.1.13. Ensure a safe work environment and employee safe work habits. 1.1.14. REFERRALS AND CONSULTS. The provider shall follow IHS Contract Health regulations and policies when arranging for a referral or consult. The family practice physician shall be required to consult with other specialty practitioners for consultative opinions and continuation of care. The provider shall inform patients of the required referral or consult by indicating the specialty involved. 1.1.15. PRESCRIPTIONS. The provider shall use and follow the IHS formulary for prescriptions for all patients The formulary list is approved and maintained by the Pine Ridge IHS Pharmacy and Therapeutics Committee. Any drug not listed on the formulary must be approved by the Pharmacy and Therapeutics Committee. 1.2. PROCEDURE GUIDANCE. Contractor providers shall perform procedures compatible with the medical facility's operating capacity and equipment. New medical procedures/se~icess hall not be introduced without prior recommendation to, and approval of the Clinical Director or authorized representative. 1.3. PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. The Contract health care providers shall provide patients with the utmost care and attention. All patients shall be assured of their privacy and personal dignity. The Contractor shall ensure strict compliance to the release of Protected Health Information in accordance with the Code of Federal Regulation, Title 45, Public Welfare, Subtitle A, Department of Health and Human Services, Part 164, Security and Privacy (45 CFR 164) and AFI 41-210, "Patient Administration Functions" paragraph 2.2.3, "Health Insurance Portability and Accountability Act (HIPPA)" and paragraph 2.3, "General Guidelines on Releasing Medical Information". 1.4. COMMUNICATION. The Contractor shall ensure contract providers maintain open and professional communication with members of the Medical Staff. Complaints validated by the Quality Assurance Personnel (QAP) and Clinical Director shall be reported in writing to the Contracting Officer (CO) and the Contractor for action. 1.4.1. ENGLISH LANGUAGE REQUIREMENT. The contractor provider(s) shall read, understand, speak, and write English fluently. 1.5. DOCUMENTATION. Contractor personnel shall prepare all documentation to meet or exceed established CMS standards and Pine Ridge IHS Medical Staff Bylaws. 1.6. AVAILABILITY: 1.6.1. HOURS OF OPERATION: Contractor coverage will be for 8 hour shifts, occasionally additional hours may be required (up to 55 hour work week). The work schedule will consist of a Monday - Friday 8:00 am - 4:30 pm. Routine work hours will be scheduled by the Clinical Director to correspond to the needs of the facility. The physician shall arrive for each scheduled shift in a well-rested condition and shall have had at least six hours rest from all other duties. 1.6.2. FEDERAL HOLIDAYS. When the holiday is on a Saturday, the preceding Friday will be the federal holiday. When the holiday is on a Sunday, the following Monday will be the federal holiday. Asterisk (*) indicates the dates change each year. List of Federal Holidays (a) 1 January New Year's Day (b) 3rd Monday in January * Martin Luther King's Day (c) 31M~o nday in February* President's Day (d) Last Monday in May * Memorial Day (e) 4 July Independence Day (0 1" Monday in September * Labor Day (g) 2nd Monday in October * Columbus Day (h) 11 November Veteran's Day (i) 4th Thursday in November * Thanksgiving (j) 25 December Christmas 1.6.3. ON CALL DUTY. On call duty is not required, although in emergencies, additional hours may be required. 1.6.4. CONTINUITY OF SERVICESIREPLACEMENT STAFF. The Contractor point of contact shall ensure qualified personnel are available to provide coverage at all times even during scheduled absences of primary contract providers. 1.6.5. The IM Physician services are considered vital to the Government and must be continued with minimal interruption. In order to minimize interrupted services, the incumbent contractor shall exercise its best efforts and cooperation to effect an orderly and efficient transition to a successor. 1.6.6. PERFORMANCE OF SERVICES DURING CRISIS DECLARED BY THE NATIONAL COMMAND AUTHORITY. On occasion, services may be required to support an activation or exercise of contingency plans outside the normal duty hours. Emergency situations (i.e., accident and rescue operations, civil disturbances, natural disasters) may necessitate the contractor provide increased or reduced support as determined by the contracting officer. The Government will negotiate an equitable adjustment with the contractor for the cost of these emergency requirements. 1.7. ORIENTATION. The Contractor shall ensure that all new contract providers participate in the Pine Ridge IHS Facility orientation with an overlap of services to include one additional day. Providers must arrive on a Monday - Friday excluding holiday and participate in the orientation prior to providing services at the Hospital. 1.7.1 RECORDS. The contractor shall document all patient encounters legibly in the patient medical record. All documentation shall be timed and dated. Verbal ordered are to be used as infrequently as possible. In the event of a major disaster or code all verbal orders are to be signed off immediately following the code or disaster. All Medical records must be signed by the providers and charge ticket completed at the end of the visit. All Medical records are to be completed by the end of the provider's scheduled shift. All documentation shall meet the current CMS guidelines. 1.7.1.2 Final payment will be withheld until all medical records are completed by the contract physician. 1.8. PERSONNEL REQUIREMENTS 1.8.1. CONTINUING MEDICAL EDUCATION (CME)/ CERTIFIED EDUCATION UNITS (CEU) REQUIREMENTS. Maintain CME and review pertinent journals, books and publications. Health care providers registered or certified by nationavmedical associations shall continue to meet the minimum standards for CME to remain current. CME hours shall be reported to the credentials office for tracking by the Clinical Director. 1.8.2. LICENSUREIREGISTRATION. Non-personal services contract personnel providing care at the Pine Ridge facility must maintain a current active and unrestricted license in at least one of the 50 United States or US territories. 1.8.3. CERTIFICATION. The provider must have national andlor state (required) approved and current board certification or board eligible in the American Board of Internal Medicine. 1.8.3.1. Copies of required certification for each Provider shall be furnished to the Contracting Officer prior to performance on this contract. 1.8.4. FORMAL EDUCATION. The provider must have a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited college or university in the specialty area required to complete the FTE. 1.8.5. EXPERIENCE. The provider must have a minimum of 3 years of experience within IM practice to include fellow and residency time within the past 36 months prior to provider beginning performance at Pine Ridge IHS. 1.8.6. Maintain certification in Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS). 18.7 LABILITY INSURANCE. The contractor shall maintain current medical liability insurance, in the coverage amount acceptable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medial specialty concerned. 1.9. QUALITY CONTROL: The contractor shall develop and maintain a quality program to ensure emergency room services are performed in accordance with commonly accepted commercial practices, manufacturers' recommendations, this contract, and all federal, state, and local laws and regulations. As a minimum, the contractor shall develop quality control procedures addressing the areas identified in the Service Delivery Summary. The contractor shall develop and implement procedures to identify, prevent, correct, and ensure non recurrence of defective services. The contractor shall provide a copy of the quality control plan to the contracting officer no later than the orientation date, and updated copies as changes occur. Records of all inspections conducted by the contractor and corrective action taken shall be made available to the government upon request. 2. SERVICE DELIVERY SUMMARY. INTERNAL MEDICINE - PHYSICIAN. 2.1. The Government shall periodically evaluate the Contractor's performance by appointing a project officers to monitor performance to ensure services are received. The Government project officer along with the PI Coordinator, Clinical Director or her designee shall evaluate the Performance Objective (General) 1. Medical practice must be within the standards of their credentialed specialty 2. Documents medical assessments, History and Physicals, observations, discharge summaries and daily progress notes. 4. Utilizes RPMSIEHR to enter and sign off lab results 6. Complies with safety policies. 7. Consults with other specialty practitioners 8. Maintains patient privacylconfidentiality. 9. Adheres to work duties and scheduled for shifts. 10. Maintains continuing medical education, licensing, registration, and certifications 11. Complaints on quality of care andlor conduct. Performance Measure 100% compliance required. 100% compliance required 90% of labs must be signed off at end of each shift Zero violations 100% compliance required Zero breaches of privacy No more than 2 unplanned absences per quarter 100% compliance required Not more than 2 per quarter. Contractor's performance through inspections of call logslreports and receive and investigate all complaints from base personnel. The Government may inspect each task as completed or increase the number of quality assurance inspections if deemed appropriate because of repeated failures or because of repeated customer complaints. Likewise, the Government may decrease the number of quality assurance inspections if performance dictates. The Government Contracting Officer shall make final determination of the validity of customer complaint(s). 2.2. If any of the services do not conform to contract requirements, the Government may require the Contractor to perform the services again in conformity with contract requirements, at no increase in contract amount. When the defects in services cannot be corrected by reperformance, the Government may - (a) Require the Contractor to take necessary action to ensure that future performance conforms to contract requirements; and (b) Reduce the contract price to reflect the reduced value of the services performed. 3. GOVERNMENT-FURNISHED PROPERTY AND SERVICES. 3.1. EQI-IIPMENT. Contract providers shall have joint use of all available equipment for performing services required by this contract: 3.2. PERSONAL PROTECTIVE EQUIPMENT (PPE). The Government will furnish the contract provider(s) with appropriate PPE. The Government will be responsible for any repair, cleaning and inventory required for the PPE. This does not include any type of uniform or laboratory coat. 3.3. IDENTIFICATION CREDENTIALS. The Pine Ridge IHS will provide each contract provider with the required identification card. 3.4. FORMS. The Pine Ridge IHS will provide required Government forms used in the performance of services. 3.5 SLIPPLIES. The Pine Ridge IHS will provide medical and non-medical supplies commonly used in the facility for the care and management of patients and the performance of the requirements of this contract. 3.6 HOUSING. For the purpose of this contract, the Government will furnish housing for the contractor which can be rented though the IHS Housing Manager. 3.7 UTILITIES. For the purpose of this contract, the government will furnish all required utilities (such as water, telephone, electricity, etc.) at no cost to the contractor. Government phones and computers are not to be used for personal phone calls or e-mails. 3.8 MEALS - are available at the hospital for the contractor at a cost of around $3.00/meal. Meal tickets are available for purchase through the finance office. 3.9. SERVICES. 3.9.1. Administrative support. Pine Ridge will provide normal office administrative support services, to include telephone and utilities. 3.9.2. Patient scheduling. Clinic personnel will assist in patient scheduling. Complete administrative control of the patient shall remain with the facility. 3.9.3. Pine Ridge will provide all other ancillary personnel services required, including personnel to move patients or equipment. 3.9.4. Housekeeping services will be provided by the facility. 3.10. CONTRACTOR FURNISHED ITEMS AND SERVICES 3.10.1. GENERAL. Except for those items or services specifically stated in Section Ill to be Government furnished, the Contractor shall furnish everything required to perform this contract in accordance with all of its terms. 3.10.2. CONTRACTOR OWNED EQUIPMENT. The physician will provide hislher own stethoscope. 3.10.3. INITIAL INSPECTION. Contractor owned equipment will be inspected and approved by the biomedical equipment maintenance section prior to use in the facility. This includes personal items such as coffee makers and radios. 4. GENERAL INFORMATION 4.1. PERSONNEL. 4.1.I. POINT OF CONTACT. The Contractor shall provide a point of contact who shall be responsible for the performance of the work. The point of contact shall have full authority to act for the Contractor on all matters relating to the daily operation of this contract. The Contractor shall designate this individual, in writing, to the Contracting Officer (CO) before the contract start date. An alternate may be designated, but the Contractor shall identify those times when the alternate shall be the primary point of contact. 4.1.2. CRIMINAL BACKGROUND CHECK REQUIREMENTICHILD CARE NATIONAL AGENCY CHECK WITH INQUIRIES (CNACI). The Government will conduct at government expense, a CNACI and state criminal history checks on individuals providing direct, unsupervised child care services under this contract. As a minimum, the Contractor shall contact the Pine Ridge Contracting Officer for obtaining all necessary forms and directions for filing background check information in writing and electronically on personnel hired at the beginning of the contract. This action shall take place no later than five (5) working days from contract award date. Contractor shall submit completed personnel background check applications within twenty (20) working days after award date to the Contracting Officer for processing. Contractor personnel will be required to be fingerprinted. Requests for personnel hired subsequent to the contract start date shall be submitted to the Government not later than five (5) workdays from the employee's first duty day. Contractor shall provide a list of substitute contract personnel fulfilling contingency situations (i.e. absences of certified contract personnel). Names of substitutes and credentials shall be provided 30 calendar days in advance to accomplish background checks. Contractor personnel receiving unfavorable CNACls shall not be employed. IHS may employ an individual pending completion of successful background checks. 4.1.2.1. Background checks will be based on fingerprints of individuals obtained by a Government law enforcement officer and inquiries conducted through the Federal Bureau of Investigation (FBI) and state criminal history repositories. 4.1.2.2. Individuals shall have the right to obtain a copy of any background check pertaining to themselves and to challenge the accuracy and completeness of the information contained in the report. 4.1.2.3. lndividuals who have previously received a background check shall provide proof of the check to the Clinical Director or obtain a new one. 4.1.2.4. CONFI-ICT OF INTEREST. The Contractor shall not employ any person who is an employee of the United States Government if the employment of that person would create a conflict of interest. The Contractor shall not employ any person who is an employee of HHS (Health and Human Services), unless such person seeks and receives approval in accordance with the Department of HHS. 4.1.2.5. APPEARANCE. Employees are expected to comply with reasonable dress, grooming and hygiene standards based on comfort, productivity, health and type of position occupied. Employee attire will be in good repair, and should not be considered offensive, disruptive or unsafe. 4.1.2.6. Contract providers shall display their Identification badge on their outer clothing. 4.1.2.7. PROTECTIVE CLOTHING. When required and supplied by the Government, the provider shall wear special protective clothing and shoe covers. When duties will be performed in specified areas, a disposable protective hood shall be worn to ensure infection control standards are met. The Government will provide this hood. These items shall remain the property of the Government and shall not be removed from the facility. After use, protective clothing shall be turned in or destroyed as directed by the Infection Control Policy. 4.2. PRIVILEGING REQUIREMENTS. The contract providers' credentials shall be reviewed and approved by the Credentialing Specialist and the Credentialing Committee. The Contractor is responsible for ensuring that proposed providers possess the requisite credentials to enable granting of privileges by the Pine Ridge Medical Staff sufficient to allow for performance of all tasks identified. 4.2.1. Initial applications for clinical privileges, to include credentials action history, malpractice history, and certified true copies of the documents listed below, shall be submitted to the Pine Ridge Credentialirlg Committee, through the Credentialing Specialist, no later than 5 calendar days after receipt of notice of contract award. a. Copy of valid, current unrestricted state license and applicable Board Certification. (Submission required with proposal) b. Documentation of continuing education and training. c. Current Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS). (Submission required with proposal) d. A signed consent for release of information. e. Current copy of Drug Enforcement Agency (DEA) certificate.. f. A list of all states in which contract provider currently holds or has held a license to practice related services. g. A current copy of the proposed contract provider's professional resume, accompanied by that individual's sworn affidavit of the truthfulness of same, indicating experience, training, and technical expertise in the type of care to be rendered.. h. Certification of current physical examination. The certification shall contain a statement signed by the examining physician stating that the employee is free of any contagious diseases. The physical examination shall be current as of 12 months prior to application for privileges. 4.2.2. Applications for privileges will be screened through the National Practitioners Data Bank. 4.2.3. Professional staff appointments and clinical privilege actions will be based on review of documents listed in paragraph 4.2.1 above. Re-appointment shall occur not less than every two years, in accordance with Pine Ridge Medical Staff Bylaws. 4.2.4. DENlAL/TERMlNATlON OF PRIVILEGES. Actions to limit, suspend, or revoke clinical privileges will be in accordance with the procedures outlined in the Medical Staff Bylaws. The Clinical Director, will notify the Contracting Officer, and provide copies of pertinent documentation, as soon as possible when the necessity to exercise such authority becomes apparent. The Contracting Officer will notify the Contractor of the initiation of the revocation process if such action becomes apparent. 4.2.5 REVIEW OF CREDENTIALS PACKAGES. The Government reserves the right to limit the number of credentialing packages it will evaluate. 4.3. HEALTH REQUIREMENTS. 4.3.1. Contract providers providing services under this contract shall receive a pre-employment physical examination prior to commencement of work and annually thereafter. The contract provider shall provide proof of current immunizations status and a current PPD within the past year. 4.3.2. Not later than five (5) working days prior to commencement of work, certification shall be provided to the QAP that the provider has completed the medical evaluation required above. This certification shall state the date on which the examination was completed, the name of the doctor who performed the examination, and a statement concerning the physical health of the individual. The certification shall also contain the following statement: "(Name of contract provider) is suffering from no contagious diseases to include, but not limited to, Tuberculosis, Hepatitis, and Venereal Disease." 4.3.3. OSHA requires that all contract personnel who will have occupational exposure to blood or body fluids, or other potentially infectious materials, shall receive Hepatitis B vaccine, sign a voluntary declination, or have documented proof of immunity to Hepatitis B infection. Personnel who sign declinations may change their minds at anytime and receive the Hepatitis B vaccine without penalty. 4.3.4. The contractor is responsible for reporting to the Clinical Director, all information necessary to assure hospital records can be maintained correctly, and therefore comply with the CMS, OSHA, and CDC health record requirements. 4.4. EMERGENCY HEALTH CARE. Pine Ridge will provide emergency health care for the contract providers for injuries incurred while on duty in the facility. These services will be billed to the Contractor at the current full reimbursement rate. 4.5 MEDICAL QUALITY IMPROVEMENTIRISK MANAGEMENT (QIIRM). 4.5.1. The contract provider(s) shall participate in QIIRM activities to the extent required by Section 2C, AFI 44-1 19 and the individual Pine Ridge IHS QIIRM plan or regulation. 4.5.2. The Government will evaluate the providers' professional, as differentiated from administrative, performance under this contract using Quality Improvement standards specified in paragraphs 2.12 and 2.13. Nothing in this paragraph precludes the Government from also conducting inspections under the lnspectionlAcceptance requirement of FAR clause 52.212-4. 4.6. PERFORMANCE EVALUATION 4.6.1 The Pine Ridge Hospital will evaluate the contractor's performance under this contract. Evaluations will be provided to the contractor, in writing. These evaluations may be used by as a record of contractor performance history for the purpose of evaluation in other competitive or noncompetitive acquisitions. 4.7. FREEDOM OF INFORMA'I'ION ACT (FOIA) PROGRAM. All FOIA requests shall be delivered immediately to the Medical Records Supervisor. 4.8. The contractor shall return identification badge and house keys to the security office, upon completionlterrnination of the contract, as appropriate. 4.8.1. Physical Security. The contractor shall safeguard all government property, including controlled forms provided for contractor use. At the close of each work period, government equipment, facilities, and other valuable materials shall be secured. 4.8.2. Security Training. The contractor will ensure all contractor employees receive initial and recurring security education training from the sponsoring agency's security manager. 4.8.3. Weapons, Firearms, and Ammunition. Contractor employees are prohibited from possessing weapons, firearms, or ammunition, on themselves or within their contractor-owned vehicle or privately-owned vehicle while on the Pine Ridge Compound. 4.8.4. Reporting Requirements. Contractor personnel shall report to an appropriate authority any information or circumstances of which they are aware may pose a threat to the security of IHS personnel, contractor personnel, or patients. 4. The contractor shall immediately report to the Security Office or Housing Director It is strongly recommended that the provider have the Flu and HlN 1 vaccinations 4.9.1. 'The contractor shall prohibit the use of keys, issued by the government, by any persons other than the contractor's employees and the opening of locked areas by contractor employees to permit entrance of persons other than contractor employees engaged in performance of contract work requirement in those areas. 4.9.2. Lock Combinations. (If Applicable) The contractor shall control access to all government provided lock combinations to preclude unauthorized entry. The contractor is not authorized to record lock combinations without written approval by the Government Program Manager. Records with written combinations to authorized secure storage containers, secure storage rooms, or certified vaults, shall be marked and safeguarded at the highest classification level as the classified material maintained inside the approved containers. 5. The contractor shall be accountable for their time. 5.1. Work records will be issued upon arrival to the IHS facility. Contractor will need to record the time at which they begin their shift and the time they complete their shift. At the end each pay period the time card will be given to the Clinical Director and a new one issued. H- l BUSINESS ASSOCIATE AGREEMENT CLAUSE Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulation, the Standards of Privacy of Individual Identifiable Health Information at 45 C.F.R. Part 160 and 164, Subpart A and E ("Privacy Rule"), the Indian Health Service is required to enter into an agreement with the Business Associate, pursuant to which the Business Associate shall comply with and appropriately safeguard Protected Health Information ("PHI") that it will use and disclose when performing functions, activities or services ("Services") for the Indian Health Service. The Business Associate by signing the contract shall comply with the following terms in addition to other applicable contract terms and conditions relating to the safekeeping, use and disclosure of PHI. Definitions Terms used in this Agreement, but not otherwise defmed, shall have the same meaning as those terms contained within the Privacy Rule. Agreement: "Agreement" shall mean this clause and any other provisions of this contract that are incorporated by reference; Business Associate: "Business Associate" shall mean the Contractor, also known as 1 1; Covered Entity: "Covered Entity" shall mean the Indian Health Service; Designated Record Set: "Designated Record Set" shall mean (1) a group of records maintained by or for a covered entity that is: (i) The medical records and billing records about individuals maintained by or for a covered health care provider, (ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan, or (iii) Used, in whole or in part, by or for the covered entity to make decisions about individuals. (2) For purposes of this paragraph, the.term record means any item, collection, or grouping of information that includes protected health information and is maintained, collected, used, or disseminated by or for a covered entity. (45 C.F.R. tj 164.501) Individual: "Individual" shall have the same meaning as the term "individual" in 45 C.F.R. tj 164.501 and shall include a person who qualifies as a personal representative in accordance with 45 C.F.R. tj 164.502(g); Privacy Rule: "Privacy Rule" shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 C.F.R. Parts 160 and 164, Subparts A and E; Protected Health Information: "Protected Health Information" shall have the same meaning as the term "protected health information" in 45 C.F.R. tj 164.501, limited to the information created or received by the Contractor fiom or on behalf of the IHS; Required BY Law: "Required By Law" shall have the same meaning as the term "required by law" in 45 C.F.R. tj 164.501; Secretaw: "Secretary" shall mean the Secretary of the United States Department of Health and Human Services or his designee. Section 1 - Privacy Rule Compliance The Business Associate agrees to comply with the Business Associate Agreement requirements under the Privacy Rule and the provisions of this Agreement throughout the term of this Agreement. The Business Associate agrees that it will require all of its agents, employees, subsidiaries, affiliates and subcontractors, to whom the Business Associate provides PHI, or who create or receive PHI on behalf of the Business Associate for the IHS, to comply with the Privacy Rule and to enter into a written agreement with the Business Associate that provides the same restrictions, terms and conditions as set forth in this Agreement. Any subcontracts shall be let as provided for in this contract but, notwithstanding any exemption fiom any requirement for written consent contained in the subcontracting clause, the Business Associate shall nonetheless obtain the Contracting Officer's written consent before placing any subcontract pursuant to which the contractor discloses PHI to the subcontractor. Section 2 - Permitted Uses and Disclosures The Business Associate shall not use or disclose PHI except as provided for in this Agreement, the Privacy Rule or other applicable law, to perform functions, activities or services for or on behalf of the IHS as specified herein. The Business Associate agrees that it may use or disclose PHI on behalf of the IHS only; (1) upon obtaining the authorization of the patient to whom the PHI pertains (45 C.F.R. §§ 164.502(a)(l)(iv) and 164.508(b)); (2) for the purpose of treatment, payment or health care operations (45 C.F.R. $6 164.502(a)(l)(ii) and 164.506); or (3) without an authorization or consent, if in accordance with 45 C.F.R. 164.506, 164.510, 164.512, 164.5 14(e), 164.514(f) or 164.5 14(g). Except as otherwise limited in this Agreement, the Business Associate may use PHI for the management and administration of the Business Associate or to carry out responsibilities of the Contractor required by law. Section 3 - Safeguards The Business Associate shall develop and use appropriate procedural, physical and electronic safeguards to protect against the use or disclosure of PHI or the Privacy Rule. The Business Associate will limit any use, disclosure or request for use or disclosure of PHI to the minimum amount necessary to accomplish the intended purpose of the use, disclosure or request in accordance with the requirements of the Privacy Rule. Section 4 - Safeguards for Electronic PHI The Business Associate shall implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of any electronic PHI that it creates, receives, maintains, or transmits on behalf of the IHS as required by 45 C.F.R. parts 164, subpart C, Security Standards for the Protection of Electronic Health Information. Section 5 - Re~ortingo f Disclosure The Business Associate shall promptly report to the IHS any knowledge of uses or disclosures of PHI that are not in accordance with this Agreement or applicable law. In addition, the Business Associate shall mitigate, to the extent practicable, any harmful effect that is known to the Business Associate of a use or disclosure of PHI by the Business Associate in violation of the requirements of the Privacy Rule. Section 6 - Records; IHS Access The Business Associate shall maintain records of PHI received fiom or created or received on behalf of the IHS and shall document subsequent uses and disclosures of such information by the Business Associate. The Business Associate shall promptly make available to the IHS, such information as the IHS may require to fulfill its obligations to provide access to, provides a copy of, and account for disclosures with respect to PHI pursuant to the Privacy Rule (e.g., 45 C.F.R. tj 164.528 (individual request for an accounting of PHI disclosures)) and other applicable law. Section 7 - Records; Individual Access The Business Associate shall maintain a designated record set, as defined by the Privacy Rule (45 C.F.R. 5 164.501), for each patient for which it has PHI. In accordance with a patient's right to access his PHI under the Privacy Rule, the Business Associate shall make available all PHI in the patient's designated record set to the patient to whom that information pertains, or to the patient's authorized representative, upon request by the patient or his authorized representative to meet the requirements under 45 C.F.R. 5 164.524. The Business Associate shall document all disclosures under this section and shall promptly make such information available to the IHS pursuant to section 6 above. Section 8 - Disclosure Upon request, the Business Associate shall make available to the IHS or to the Secretary, PHI and the Business Associate's internal practices, books and records, including its policies and procedures, including any agreements required by Section 1 with subcontractors, vendors and other agents relating to the use and disclosure of PHI received from the IHS, or created or received by the Business Associate on behalf of the IHS, for purposes of determining the IHS' compliance with the Privacy Rule. The Business Associate shall not disclose PHI to any requesting party other than as provided for in this section and sections 2 and 7 above. The Business Associate shall forward all other requests to the IHS for handling. Section 9 - Amendments of Information The Business Associate shall make PHI available to the IHS for the IHS to fulfill its obligations pursuant to the Privacy Rule to amend PHI and shall, as directed by the IHS, incorporate any amendments into PHI held by the Business Associate and ensure incorporation of any such amendments into PHI held by its agents or subcontractors. The Business Associate shall not make any amendments to PHI and shall forward all amendment requests to the IHS Contracting Officer for approval. Section 10 - Obligations of the IHS The IHS Contracting Officer shall provide the Business Associate with its notice of privacy practices, produced under 45 C.F.R. 5 164.520 and any changes to the notice. The IHS Contracting Officer shall also provide the Business Associate with any changes in, or revocation of, individuals' authorizations to use or disclose PHI, if such changes affect the Business Associate's permitted or required uses or disclosures of PHI. The IHS Contracting Officer shall notify the Business Associate of any restrictions to the use or disclosure of PHI that the IHS has agreed to pursuant to an individual's request under 45 C.F.R. fj 164.522. The IHS shall not request that the Business Associate use or disclose PHI in any manner that would violate the Privacy Rule if done by the IHS. Section 1 1 - Material Breach; Termination If the Business Associate breaches a material obligation of this Agreement or fails to comply with the Privacy Rule, the IHS will give the Contractor an opportunity to cure the breach, but if the Contractor fails to cure the breach, the IHS will terminate the Agreement, as provided in Federal Acquisition Regulations 52.249-8 Default (Fixed-Price Supply and Service). If, at the determination of the IHS Contracting Officer, neither cure nor terminations are feasible, IHS shall report the material breach to the Secretary. Termination of this Agreement shall not affect any provision of this Agreement, which, by its wording or nature, is intended to remain in effect and to continue to operate in the event of termination. Termination of the underlying contract between the parties will result in the termination of this Agreement. Section 12 - Return or Destruction of Information When this Agreementlcontract terminates, the Business Associate, at the IHS's option, shall return to the IHS, or destroy, all PHI in its possession, and keep no copies of PHI except as requested by the IHS or required by law. The IHS Contracting Officer shall notify the Business Associate whether the Business Associate must return or destroy any PHI in its possession. If the Business Associate or its agent or subcontractor destroys any PHI, then the Business Associate will provide the IHS with documentation evidencing such destruction. Any PHI maintained by the Business Associate shall continue to be extended the same protections set forth in this Agreement for as long as it is maintained. Section 13 - Tenn The term of this Agreement shall begin on the effective date of this modification and or contract award and end with the completion of the contract, except as provided in Section 12. Section 14 - Amendment of Agreement After the date of execution of this Agreement and after learning that material changes have been made to the Privacy Rule, the parties agree to amend this Agreement to ensure that it complies with the Privacy Rule and that IHS can continue to comply with the Privacy Rule. Section 15 - Miscellaneous Provisions (1) All notices under this Agreement shall be as provided in this contract; (2) This Agreement shall be binding upon, inure to the benefit of and be enforceable by and against the Parties and their successors and assigns. Any novation, assignment, or other transfer of rights, interests, or duties under this Agreement by the Contractor shall be as provided in this contract; (3) Any ambiguity in this Agreement shall be resolved to bring the Agreement into compliance with the most current version of the Privacy Rule; (4) If a court of competent jurisdiction deems any provision of this Agreement unenforceable, such provision shall be severed fiom this Agreement and every other provision of the Agreement shall remain in full force and effect. CONTRACTORS P$RFORMANCE CONDITIONS & ~PONSlBLITneS: 1. Contiactor is rtxpmible for reporting all taxes liom wages med under thi4 contract to the appropriate State and Federal Agencies, provided the awardee is an individual. 2. CSbnbactclr iS responsible for hidher owh reliable transportation in the performuice of the contract. 3.. Cohtractol. is nespo&ible fot Fringe Beoefits and other bendits such as health, rctireknt, etc. for hidha employees, if other than self. 4. Con-tor is responsible for maintaining satisfactory standards of cainpetenix, conduct, appearance and integrity. The quality of work performance of the dntractor shall be subject to review. 5. Conbeetor is nsponsible-for itoti-g the desigriated supwrisorldir&m if hishe ail1 be late, ill or unable to *ark for 0th reasons. 6.' C011.ttxi~teoatr ns no leave and is compensated only for hours acmally worked tit the agreed compensatory rate.. 7; Cantractor is reqonsible far signing-in and signing-out of immediate @ark area, utilizirig in-house, smein of acdountability... PO Number "r. -... Per your request, the Senior Contracting Ofllcer, ~berde& Area Indian Health Service has agreed to a temporary waiver of the character investigatkm for (Name of Contractor). Thls'ternporary walver has been agreed to wfth the understanding that you wil! continue the process of accomplishing the character investigation in amdance with Public Law 101-630, Indian Child Protection and Family Vlolence Prevention Act and Public Law 101-647, Crime Cantrol Act. Upon completion of the character Investigatlon, you shall noflfy the Contracting Offlmr. Your slgnamre indicates you are taking the responsibtltty %o awre the Senlw Contracting Officer that the above named lndilvldual will not have unmonitored antact Nth Xndlan children. Thls agreemetlt Is in effect untfl the Senior ContracHng officer Is notifled that the above named contractor has sucxesshlly completed the background imrestigation. Iu nclestand that In accordance wlth~edlonk l1 of the Crlme Conh-ol Act of 1990 (P;L 101- 647.and P.L. 101630), that hllur'e to comply with these stahres wlll result In my immediate removal; CONTRACTOR DATE ' I hereby assure that such continuous monitoring will occur when said individual is in contact with Indian Children under the age of 18 years, 1 am aware, and will assure, that those providing DIRECT SIGHT MONITORING shall as a mlnlmum, have had a successfully completed NACI. 1 certify that the permanent federal employees asslgned to provide DIRECT SITE MONrrORTNG has met the requirements of Section 231 of the Crime Control Act of 1990 (P.L. 101-630). SIGNATURE OF INDIVIDUAL RESPONSIBLE FOR DIRECT SIGHT MONlTORING SERVICE UNIT DIRECTOR DATE DATE Addendum to ~ecl.amti01f1o r ~edbrlelm P&ymk(Of P 306) Irrdtan-fIdmrvicece Chad Care & Indian Child Care Worker l?ositions * As 4 Item 15a. Agency Specific Qudons Nalhe: Social Security Number:.. (Picase Prlut) Job Title in ~nnouncement: ~nnouncemeth ~ ukber: Sath 4108 of the M- Indian L&Mon, Public Inw 101-630, a related tbr po- in tho lhplmat ofHcsllhandHuniioSavicesthat inw~r~laroontaa[wittSor0011trolova~ohi~.n#~taustcnanr~~ hidf ab r the#positioas &avm not bcar fdgui lty of or plcadcd mlo ccl~tdcmar gull@t o certain ainacs. To muto oqmpiimce w+h tlte above hrws,.the following qu.& are' added to 'the Dhtion for Federal EJmptopmnt. 1) Have you eva been ~atcdfor or charged with a crime involving a child? YES NO #P&S, provide the be, erpIuM#orl of violaiian. di@m&ion dtb dort or charge, place of oc~umlaa,n d the Mme and address ofdkepoCIos dkptwnfo r court InwM].. 2), fiv&.ybue va. heen fmdg uilty of,. or antered a plea of nolo codendere (no contest) or pit o, my felonioris or. misdemeanor off- rmderPederal State, or 'tribal law involving aim& of violence; sexual assault, molestadon, exploitation, codact or pmstitution; or crinoas agW persons; or offeapej committed a+t children? =-No- [KPB,p rovide ihe d a l ~ap lmration ofthe violation. disposition of & west or charge,p iam ofoccurrence, and che name and addms ofthe police dwenr or.court inwiw........ I &that (I) my response to these questions is made under penalty of perjury, which is punishable by fma of up to $2,000 ar 5 years imprisonmeht, or both; and (2) I have nxeived notice that a crimiaal check will be cqnducted. I undeistad my right to obtain a copy of any criminal history report aradc available tu thc Indian Health Service and my right to drallwge the accuracy and completeness of any information contained in tbe report ~ppIic!aut'e ~lgnrkre (slgu In ink] Date PuMic Burden sta~eiicIn amor&Gak RcduchiA ct (5mE20.8 {b)(3> a Federal agency may not duct or sponsor, and a person is not teqaired to respond to, a collection o hfbmation unless it displays a wrcntly valid OMB control number. Respondeats must be firmed on the reporting inshun&, id instwtiom, or ma cover letter) the masons for whicb the infhmath will6.c uIle.ctEd; the waytbe~tion\Rillbcusbdtoautbertheproptrptrformanceof~~asof~agtacy wldwrmpomesb tbeeolkctionoEtha~onarevor~c@, edCoobtainabenefiit(cittog auUmrit$ or: mawlatory (citing authority); aiui the natute and extend of mdidcntialitty to be ptwided, if any (ciang authority)). Public vrting burden for tiis coUdon of infodon is esthkd to avcqc 15 &u&a par response, kt- hefo r reviewing iastmd~nsse~a ding data soma, gathbg adm aintaining (he necessary &ta, and completing and revicw-q the co~dounna tion Send cammnb rqquding thc burden astirnate or any other aspect of tbis collection of iufonnation to the BIS PWIn formation Calledioa Clearanca Staq 12300 Twinbmok Paricway, Suite 4450, RocMlIe, MD 20852. Please do not semi wnrplded tiha co(&cclon instrumen& to &is ddm. &RM APPROVED: 0.M.D. NO. 0917-0028 Expires 11/3012005 (PLEAS@ COMPLETE ANb RETURN) LICENSURE REQUIRErnNT PERSONAL AND NONPERSONAL SERVICB CONTRA@rORS SIKALL 88 SUB1Em TO d SAMs QUALITY ASSURANCE, CREDENTIALS, LICENSURB, AND OTHER QUALIFICATION. STWARD AS mOSE REQWD OF IHS PERSONNEL. IN ADDITION, HBAI,TH CARE PROVIDERS, OWR THAN PRO'FESSIONALS, MUST BE LICBNS'aD IN A =Am, * iDISTlUCT OP COLUMBLA, PUERTO RTCO, OR A TERRJTORY OF THfl UNTTEiD STAm TO. PWORM ?W1 CONTRACT SERVICES WITHIN IHS FACXLm. TKE CONTRAmG OFFICER WILL INSERT TI= I?OLIX)WING CERT~CATIONS TATEMENT INA LL '. PURCHASE ORDEW AND CONTRACTS POR PROPESSIONAI; MEDlCAL SEDk~CBS: MY LICENSE TO PRACTICE a' HAS EEAS NOT BEEN TER.MINATRD,SUISPENDBD,O R REVOaD IN ANY STATE, THB DISTRICT OF COLUMBIA, PUER'liO RICO, OR A TEliaZTORY OF 7%E U.S. I CtJIUWbITLY HOLD AN ACTIVB MEDICAL LICENSE IN POLWW~GSI 'ATs(S):..$TAm,LMCEStlRE NO,, ISSm DATE f HAVE AN INACTIVE MEDICAL LICENSE IN TfIE FOLLOWING STATE@): '.STATE LICENSW NO, ISSUE DATE 1 HEREBY CERTIFY THAT THE PWKPOSFS OP APPLICATION OF TWE FALSE STATEMENTS PROWIONS OF THE PROGRAM FRAUD CNlL REMEIDLES ACT OF 1986 (45 CFR 79), THAT TO TIie BEST OF MY KNOWLEDGE, EACH OF THE MOVE STATEMENTS IS TRUE, ACCURATE, AND DOES NOT OMIT ANY MATERIAL FACT THAT WOULD RENDER THE STATEMENT FALSE, FTCTITIOUS, FRAUDULENT AS A RESULT THE. OrnSION. - - -- L___.-- SIGNATURE OF PRACTiTIONER DATE ~eclarationfo r ~ederaEl rnploymelit The Inlarmalku, dleded on lhls limn;is used lo determirbe BCcePlBbjMy for Federal and Federal amtracl empbyment and ya*enmUmontstehraIntheGovemnMslifeInawahctl~;am YaumeybaaWp~etetNsfonnatwry%medulngthe hhhg pmosss. Fdlaw lnsbuctlons hat Ihe agendy provides. If you are dected, before you am appdnted you wll be asked to update your responses on.lt~lfcsn m and on other maledab wbmmed rkvlng hea pp1lcat)on process and then to recenify (hat yoor anwas are he. An.yutr answers must b Wfula nd &mpbte. A false statement on any part of thls declarstJor\o r altMfa m or sheds. fpay be grounds for nat hiyou, or for Wring you aFter yw. Wgln work. Also, yorrmay be punistied by a fine or. Impdamn* (U.S. Codq title 18, sedion 1001)... Bthq type your response3 on lhis form or p?nt dearly In dark Ink If you need additional space, aUach lellerke' sw(.8.5. X Y.13. iWey av nm,S odal tj~wityP( unber, and item numb& on bch sheel We recommend Wt you keep a phdocopy of W~formkryow~eoor&. PtWicy Act Statement t............,..... -. ~ho'.~lflcde P ersonnel Management is.&M la requtjd this br(c#matkn under siwtlans 1302,3301,3304,3320, ad8 T18 of Wle 6, U. 9; Cab. Gedloclli 04 of bi 5 abows W-Wllce cif Recsbnnel Management to ddegate personnel m'magement Rnctlons (a a(her Federal agendes. H ~ary,'~.usuaWumyJ~uw Umw ith anather fmor forms, lhts form'ftyy be used In oamludhg an lmresllgation to detervine your sulWlity w your abilKy b hold a secw&y &raw, and It may be dsddsed lo 'authorized afflctats making ddur,'subseqiant delennhtlons. Your Sg&l,Searrhy Number (SSN) Is needed b kaep'aw mmds amrate. because other peopla may have-& same nilme and bbih dalir. ~~~~Law 104-134 (AprR 26,1096) ~~ Fede'fd afw~%s to use Utk numbec: b he@ WenUfy individuals in agency reds. GMng ua your SSN or my other inlodon is voluntary. Hmver,'U.ya! do JI& glve us your SSN or &y other. Wannation requested, we cannot pracess your applicdion Incomplete ddressg.a i..i:d dP Cod& Wy also slow processkrg. i?OUIlME USES: Any dido6ure of thls reootd or tn'htkrr In,thrs mrd'lsi n accordandewlth ~wushes fo und h System NdlCEI OPWOOVF-I, Cherd Personnet Recorzls. lWi system dkYvs dtsdasum of Information to: hlnlng fadi61es; agahlqtlacs deddhg dakns Ibr mtiremerrl. inaurw, unemployment, d health benef~Iso; 'mdals in YtigaUar or admink+raUve pmceedii where Uw Government $ B pm(B W @nfoicemenal gerdc oncerning a vlufatlqn of @J or regulation; Federal agencies for $atlsW reporls and studies; oDfidals of labor organlmtions remgnized by law In connectbn with represenletlon d ampbyeos;...Federal agencies or dher sources wquestiry) lnfarmation fbr Fderal agendes in wnnection wiih hirlng or retaining. security dearance, sh~rityw suibbility Invesligahs, classifying (obs,o ontractlng, or Issulng Ikemes, grants, or dher Wfits; public and phte organlzatbnq lndudlng news medii. which grant orpuWldzo empbyke redognitlotlons and awards; the Merit Sydorns Froted!on Board, the OHice d Speclel Counsel. the E$al Empli>yment Oppoilunlty Commlssbn. the Federal Labor Relath AuthUy, (he Na(lonal Archives and Records Admiriisklbn, and Congreidanlrl oRicas h connection with their offrdal fundlons; prospective nafbFederal ernpbyers mncerniqj tenure of empbmenl cMT service status, length of sewlce, ad Ihe date and nature o(edlon for separation as shown on the SF 50 (or aulhorizod excoption) da spedfccally MenWi indlvldual; cequesllng arQaniiaUons ar h\dklduah cvmemlng the hcuno address and olher relwant information cm those wtm might have cantradsd an hss w been exposed to a health hazard; authorized Fedem1 and non-Federal agendas far uso in computer matching; spouses or dependent chiidran asking wlwW the~m pbyee has changed from a selfad-family to a self-only hsaW bepelits enmfiment; indtyiduels wrklng on a contract. servke, &nl,-cooperalive ree em ow, or.J ob for the ~ederagl ov&rnenl; non-agoncy members of an agen~pso tfarmance or olhor panel; and &-apphted tepressnlatlves d empbyoes mncernlng information issued lo Ule employees about CItnoss-&-duty w agency-ti disaMnrj reUre'ment pmcedurss. Publk Burden Statement *... ' Pubk braden reportiog for 1Ws dlsdion of. hlonnal/on k estlmeted to vary fran 5 to 30 ml- with an averego d 15 mbwbs pet response, indudng lhw for ing.tcudom. searching exkiting data wukes, g-ilherkag the dab neebed, end armpleeng and reviewiclg the colkdion of loformation. Send comments regarding the burden esllmata or any olher mped d Ihe w&edkn d Monnatbn. inclwlkrg susgestbns for reducing bls bwdpn, to Ihe U.S. Olfice ol Personnel M8nagsmsr11. Reports and hmia Manager (32080182), Washtw(on. DC 20415-7900. The WE! number, 3206-0182. is vsH. OPM may rml cdlecl this InFomtetbn, and you are clot required lo respond, unless Ws number ts displayed. Declaration for Federal Employment GENERAL INFORIWA~OU.... -~,F~~~AMEIE~~~~~~W 1 2so.cw-sECUBtTY-NUMSER +.# - 3. PLACE w BIRTH (/ndtnie c~fyahdd ale or coun&y) Selective Service Registration... - -...,....... 4. If you am e & barn eh[)e cember 31,1969, &are at le&t 18 years d age, civil& employment law (5 U.S.C. 3328) requires kt + 4. DATE OF BIRI'H (MMJ~) a 5. OTHER NAMES WEB USED (For wn@em, aiden name. nidmame, aIc) you must mglder wlth the Selecllve Sen/ice System, imless yw meet caQh exemptlone. 7a Are you a male born efter Deader 31.19W YES NO IfCIVO"sX(p76andkNWSw~to7b. 7b. Heve yw registered with tlue SeledVve Service Sysh? YES a NO./f7VOw ga lo 7a 7c. If WO: &&be your reas6n(s)h Item M 6........... Milifary Servlce 8. Have you ever served In tk United shies niWq?..a YES MB~O~MOW rn NO Rpu armwftd %S,' kjrt f e branch. dates. and lype of &charge f' ectlve duly... 6. PHONE NUMBERS (Wear ee oodes) Background Infomiation...... '.,,..,.. -,... Par all qws~onsp,r ovide all addltlonal requested information under Item q6 or on attached sheots. The circumstances d each went yau liatwlll be conddered. HOlHWwr. In timl cases you can still be considered for Federal jobs. For queatlons 9,10, and 11, your answers should lndude convictions resulUng from a ptoa of ndo conlendere (no contest). but omlt (1) trafk fines of $300 or leas, (2) anyvlolauon of bw corned before your 16lh Mrthday, (3) any vtolation of law committed before your 18th birthday if RnaRy dedded In Juvenile court or under a Ywlh Offenderlaw, (4) any coWon set wlde under the Federa( Youth Cwredlons Ad or similar state law, and (6),my convldbn for whlch the recod wik expunged under Federal or state law. 9. Dullng the lest 10 years. hove YOU been convldad, been Imprisoned, been on probation. or been on parole? (Indudes ieknles, fharms or expl&s violations, mfsdemeanors. and all other offenses.) H %Sea use ilem I6 to p~~vldthee dale, expranallbn of Ule Watton, place of occunwce, and the name and address of he pdice derzartment a. mrt Wohmd. 10. Have you been convIded by a militaly courtmartla1 In tho past 10 years? (Ifno mUItruyserwb, enswer 'NO.? M No ~S;usaH em 16 to provide the date, exp4naUon of ~Ylev iolation, place of oocurrence. and the name snd 8dUress of thw mllitary auUmrUy or couit ktvdved. 11. ~re~nbvr~wcharge~foran~~idetlond&1f'~~~,*'use~m18toprwide(hedeto,expi~naYtElSo nd~M~I, ~~pl8b~d0~~~~,and~e~ame~l~d8bd~~~polPce'~~q~0~rlInvohred. 12. Ourlng the lest 5 years, have you been fired fm any Jab la any reason, did yali quit efter being (dd that w El a woukl be fired, dW you leave eny job by mutual agmemnt bemuse of spe& problems, or were you debarred from YES Fedml employment by the Ofb at Pemnel M-ment or ony odher Federal agem IfVES.'lnre Hem 18 to provWe the date, m twphallon of Ute problem, reason bor leavinfl, and ffm etnpbyw'8 name qd address. 13. Are you deA~Uenotn eny Federal debt3 (Indudes detlnquencles arishg from Federal taxes, bans, merpaynmtof YES NO benefi\s, and OWN debts lo the U-S. Government, plus ddauUs d Federally guaranteed or insured bns such as dldatadhansmwapabns.) IfnSauaPM,i6bpaXhlh~~U1,nd~Iofm~ ordef&andstepsLhatywmiaklngtodthemarwpiryffre,&&, L US. ORb of Ptmw~dMt mgemen( W :~61~)1-36&'m5 -Fa**- 6U~W2,Un.~.jua6sll,6. aVbedkilrl2001. RrrbuaadlCm~d~ Declaration for Federal Employment -14A 8nyl4f-~uela~~h~8~~ment~~M-you~-thtsW (Include: father, mother, huabaml, wife. son, d#rghter, b-. slster, uncle, aunt ilmt coudn, nephew, tlleoe, YES NO f~-in-leW,tm~n4~n-W,. dsughlerhr4aw.. bmtherWaw, slsfer-h-laws, bpfather, dqmohr, stepson, &epdaughter, slepbdher, sIe~ha~li b,rol het, and half ulster.) If VES;uuae &em t6.6 loprorkle Ule..&ltve9~,~,snddhe&~t~,ap~dlJle~mted~arces~nhldr~~(~rel~~..a a 95. Oo you recab, M have you applied fix, retirement pay, pemh or other retired pay based on mllltacy, YES NO Federel chilim. or Dbtrld of CdumMa Govmt service? cl Contlnuatl~nS pace /Agency Optional Questions Y '. -.. 16. ~mvided elqb requested In items 7 tkowh 16 tyd 18c In tbe space W or on attached sheets. Be sure to klen(ilyattad\ed sheets. with ywr ~ameW. al Sea#ity Nunber, end Uem number, and to indude ZIP Codes h a0 addresses. If any questlomale $thted below, please enswr ak instructed (&we qmsrYans am spw%lo purpodtkm &r~(~egenoyfsa utlroriired b ask MI. ~edfidablon6$/ idditforial Questions :...,........ AWLCANT: lf you are appwng for a posHIon a@ have not yet boen.ae!ecW, cereWJy miew your enswers on Ws fom end any athhed sheets. When thla fonn and all a(tached mate&& are &t.e, r.ead 8em 17, and complete t7a..AWOlMEE: ffwa m hlng appohted,.care~revlewy~on~ th~9mcib ith~anda ny.Yk@ed shee(s, hch$Irtg any dherapplloa-. tmldu4 lhal your agency has a(tached to lhls fohn. It any lnformati$~m qubs borp66 be acw& es ofthe date you em dgnbg. milke changes wthlsfotm or lhe attachmts andlor ptMe updated h!fom\ation.Mi adcpunql sheets;hWallm and chtfns ail chargBs arid additlans. When this form end all atlaehed ptterlels dm scCura@,'*d ltew 1l;vdI ?,m ad 18,a nd answer 18% lab, and I&as appropriate. 17. ~~*ti~Ld.to~u'~td~k~psand~kf,allof(hs~~bmmandat~b~~forF&~lndudhg any altached appticallon meterlels. is true, correct, aunplete, and made in good faltjrt understand that a false or 'umont answer to any questlon or item on any part d thls declaration or Rs aW'hments may be grounds for not hlridmo. or for flrh me after I begln work, and muy bo punlshilble by fina or Lnprlsohment I undenllbnd that a!y !yWn l give my be lwstl@ed krpuposa of detemining elfglbnlty for Feded empkqtnent as alkwed by or Presidential order. 1 consent to he romlease oi Wwm.aUa Wt my ablty and fiUms tor Federal empldyment by smploy6rs. schools. law enforcemerit k@mdes, and other kwllvlduals ahd organlaalions lo Investlgalm, pelsomet speciallds, and other auWdmi employees or representatives cR the F&1 Gouemt I understand that for flwncisl or hdlng insntutlocls, medlcal hsUt~ho.s pitals, health care professknals, and #ma other sowcos d informalion, a sepamle spedfi reteaso may be wedad. and 4 may be contacted for such a release at a later date. 17a. Applicant% Slgnahrre:, Dato -- (Sign &t ink) MnOlbbdwdnhd ffcawdm MMlDOlYYYY 17b. Appointee's Signature:,.. I.(+in inIloF.. Data...,.. 18. Apwhtee (On@ respuaci ~yf ou have twerr-emib~y ~th~o Federal ~&&nt before): your e1ea~mtd3 life insurance duriig pr~vlousF- l employnvenl may affed your eWWf or fife lduremxt dulng ywn ew rtppdnlrnent;T hose qmtlons ere asked to b@~pcilswuwlmmkeadde-h. 18a. When dM you leave yourlastF~lfob?, U1 IMIW DATE: 18b. When )&I Worked for the Federal ~werwyekth e last Yme. dld yau waive'~asich e1 n8ucak or YES NO DoNotKw any type of sptlana~li te 1nsurance7. rim II -Lid 18c..If yw amjwred.YESnt o llem I&.d id you latercancel the walver(s)? If your answer lo Hem 180 bs YES NO DoNotKnow -0: uw itwn 16 to M~thWe typ e(8) d imrance for WIIw~tdv ers W~Uno t canceled. n~n1..... u kd.I+ U.S. Oflice of Persomel Management NW 1&6001- opbn~~n)#i ~uac.tmz.jsm.am,amisl~e fwuao~orRuonb*~rdlabromnd m 52.204-3 Taxpayer ldentification As prescribed in 4.905, insert the following provision: (a) Definitions. "Common parent," as used in this provision, means that corporate entity that owns or controls an affiliated group of corporations that files its Federal income tax returns on a consolidated basis, and of which the offeror is a member. "Taxpayer ldentification Number (TIN)," as used in this provision, means the number required by the Internal Revenue Service (IRS) to be used by the offeror in reporting income tax and other returns. The TIN may be either a Social Security Number or an Employer ldentification Number (b) All offerors must submit the information required in paragraphs (d) through (f) of this provision to comply with debt collection requirements of 31 U.S.C. 7701(c) and 3325(d), reporting requirements of 26 U.S.C. 6041, 6041A, and 6050M, and implementing regulations issued by the IRS. If the resulting contract is subject to the payment reporting requirements described in Federal Acquisition Regulation (FAR) 4.904, the failure or refusal by the offeror to furnish the information may result in a 31 percent reduction of payments otherwise due under the contract. (c) The TIN may be used by the Government to collect and report on any delinquent amounts arising out of the offeror's relationship with the Government (31 U.S.C. 7701 (cI(32). If the resulting contract is subject to the payment reporting requirements described in FAR 4.904, the TIN provided hereunder may be matched with IRS records to verify the accuracy of the offeror's TIN. (d) Taxpayer Identification Number (TIN). o TIN: o TIN has been applied for. o TIN is not required because: o Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the United States and does not have an office or place of business or a fiscal paying agent in the United States; o Offeror is an agency or instrumentality of a foreign government; o Offeror is an agency or instrumentality of the Federal Government. (e) Type of organization. o Sole proprietorship; o Partnership; o Corporate entity (not tax-exempt); o Corporate entity (tax-exempt); o Government entity (Federal, State, or local); o Foreign government; o International organization per 26 CFR 1.6049-4; o Other (f) Common parent. o Offeror is not owned or controlled by a common parent as defined in paragraph (a) of this provision. o Name and TIN of common parent: Name TIN (End of provision) 52.204-6 Data Universal Numbering System (DUNS) Number As prescribed in 4.607(a), insert the following provision: DATAU NIVERSANLU MBERINSGY STEM(D UNS) NUMBER(A PR2 008) (a) The offeror shall enter, in the block with its name and address on the cover page of its offer, the annotation "DUNS" or "DUNS+4" followed by the DUNS number or "DUNS+4" that identifies the offeror's name and address exactly as stated in the offer. The DUNS number is a nine-digit number assigned by Dun and Bradstreet, Inc. The DUNS+4 is the DUNS number plus a 4-character suffix that may be assigned at the discretion of the offeror to establish additional CCR records for identifying alternative Electronic Funds Transfer (EFT) accounts (see Subpart 32.1 1) for the same concern. (b) If the offeror does not have a DUNS number, it should contact Dun and Bradstreet directly to obtain one. (1) An offeror may obtain a DUNS number- (i) Via the Internet at http://fedqov.dnb.com/webform or if the offeror does not have internet access, it may call Dun and Bradstreet at 1-866-705-571 1 if located within the United States; or (ii) If located outside the United States, by contacting the local Dun and Bradstreet office. The offeror should indicate that it is an offeror for a U.S. Government contract when contacting the local Dun and Bradstreet office. (2) The offeror should be prepared to provide the following information: (i) Company legal business name. (ii) Tradestyle, doing business, or other name by which your entity is commonly recognized. (iii) Company physical street address, city, state and ZIP Code. (iv) Company mailing address, city, state and ZIP Code (if separate from physical). (v) Company telephone number. (vi) Date the company was started. (vii) Number of employees at your location. (viii) Chief executive officerlkey manager. (ix) Line of business (industry). (x) Company Headquarters name and address (reporting relationship within your entity). (End of provision) 52.204-8 Annual Representations and Certifications As prescribed in 4.1202, insert the following provision: ANNUALR EPRESENTATIOANNSD CERTIFICATION(SJA N2 006) (a)(l) The North American Industry Classification System (NAICS) code for this acquisition is [insert NAICS code]. (2) The small business size standard is [insert size standard. (3) The small business size standard for a concern which submits an offer in its own name, other than on a construction or service contract, but which proposes to furnish a product which it did not itself manufacture, is 500 employees. (b)(l) If the clause at 52.204-7, Central Contractor Registration, is included in this solicitation, paragraph (c) of this provision applies. (2) If the clause at 52.204-7 is not included in this solicitation, and the offeror is currently registered in CCR, and has completed the ORCA electronically, the offeror may choose to use paragraph (c) of this provision instead of completing the corresponding individual representations and certifications in the solicitation. The offeror shall indicate which option applies by checking one of the following boxes: [ ] (i) Paragraph (c) applies. [ ] (ii) Paragraph (c) does not apply and the offeror has completed the individual representations and certifications in the solicitation. (c) The offeror has completed the annual representations and certifications electronically via the Online Representations and Certifications Application (ORCA) website at http://orca.b~n.govA. fter reviewing the ORCA database information, the offeror verifies by submission of the offer that the representations and certifications currently posted electronically have been entered or updated within the last 12 months, are current, accurate, complete, and applicable to this solicitation (including the business size standard applicable to the NAICS code referenced for this solicitation), as of the date of this offer and are incorporated in this offer by reference (see FAR 4.1201); except for the changes identified below [offeror to insert changes, identifying change by clause number, title, date]. These amended representation(s) and/or certification(s) are also incorporated in this offer and are current, accurate, and complete as of the date of this offer. FAR CLAUSE # TITLE DATE CHANGE Any changes provided by the offeror are applicable to this solicitation only, and do not result in an update to the representations and certifications posted on ORCA. (End of provision) 52.219-1 Small Business Program Representations As prescribed in 19.308(a)(I), insert the following provision: (a)(l) The North American Industry Classification System (NAICS) code for this acquisition is [insert NAICS code]. (2) The small business size standard is [insert size standard]. (3) The small business size standard for a concern which submits an offer in its own name, other than on a construction or service contract, but which proposes to furnish a product which it did not itself manufacture, is 500 employees. (b) Representations. (1) The offeror represents as part of its offer that it o is, o is not a small business concern. (2) [Complete only if the offeror represented itself as a small business concern in paragraph (b)(l) of this provision.] The offeror represents, for general statistical purposes, that it o is, o is not, a small disadvantaged business concern as defined in 13 CFR 124.1002. (3) [Complete only if the offeror represented itself as a small business concern in paragraph (b)(l) of this provision.] The offeror represents as part of its offer that it o is, o is not a women-owned small business concern. (4) [Complete only if the offeror represented itself as a small business concern in paragraph (b)(l) of this provision.] The offeror represents as part of its offer that it o is, o is not a veteran-owned small business concern. (5) [Complete only if the offeror represented itself as a veteran-owned small business concern in paragraph (b)(4) of this provision.] The offeror represents as part of its offer that it o is, o is not a service-disabled veteran-owned small business concern. (6) [Complete only if the offeror represented itself as a small business concern in paragraph (b)(l) of this provision.] The offeror represents, as part of its offer, that- (i) It o is, o is not a HUBZone small business concern listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration, and no material change in ownership and control, principal office, or HUBZone employee percentage has occurred since it was certified by the Small Business Administration in accordance with 13 CFR Part 126; and (ii) It o is, o is not a joint venture that complies with the requirements of 13 CFR Part 126, and the representation in paragraph (b)(6)(i) of this provision is accurate for the HUBZone small business concern or concerns that are participating in the joint venture. [The offeror shall enter the name or names of the HUBZone small business concern or concerns that are participating in the joint venture:.] Each HUBZone small business concern participating in the joint venture shall submit a separate signed copy of the HUBZone representation. (c) Definitions. As used in this provision- "Service-disabled veteran-owned small business concern"- (1) Means a small business concern- (i) Not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans; and (ii) The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran. (2) "Service-disabled veteran" means a veteran, as defined in 38 U.S.C. 101 (21, with a disability that is service-connected, as defined in 38 U.S.C. 101 (1 6). "Small business concern" means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding on Government contracts, and qualified as a small business under the criteria in 13 CFR Part 121 and the size standard in paragraph (a) of this provision. "Veteran-owned small business concern" means a small business concern- (1) Not less than 51 percent of which is owned by one or more veterans (as defined at 38 U.S.C. lOl(2)) or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans; and (2) The management and daily business operations of which are controlled by one or more veterans. "Women-owned small business concern" means a small business concern- (1) That is at least 51 percent owned by one or more women; or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and (2) Whose management and daily business operations are controlled by one or more women. (d) Notice. (1) If this solicitation is for supplies and has been set aside, in whole or in part, for small business concerns, then the clause in this solicitation providing notice of the set-aside contains restrictions on the source of the end items to be furnished. (2) Under 15 U.S.C. 645(d), any person who misrepresents a firm's status as a small, HUBZone small, small disadvantaged, or women-owned small business concern in order to obtain a contract to be awarded under the preference programs established pursuant to section 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal law that specifically references section 8(d) for a definition of program eligibility, shall- (i) Be punished by imposition of fine, imprisonment, or both; (ii) Be subject to administrative remedies, including suspension and debarment; and (iii) Be ineligible for participation in programs conducted under the authority of the Act. (End of provision) Alternate I (Apr 2002). As prescribed in 1 9.308(a)(2), add the following paragraph (b)(7) to the basic provision: (7) [Complete if offeror represented itself as disadvantaged in paragraph (b)(2) of this provision.] 'The offeror shall check the category in which its ownership falls: Black American. Hispanic American. Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians). Asian-Pacific American (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru). Subcontinent Asian (Asian-Indian) American (persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands, or Nepal). Individual/concern, other than one of the preceding. 52.219-2 Equal Low Bids As prescribed in 19.308(c), insert the following provision: EQUALL ow BIDS( OCT1 995) (a) This provision applies to small business concerns only. (b) The bidder's status as a labor surplus area (LSA) concern may affect entitlement to award in case of tie bids. If the bidder wishes to be considered for this priority, the bidder must identify, in the following space, the LSA in which the costs to be incurred on account of manufacturing or production (by the bidder or the first-tier subcontractors) amount to more than 50 percent of the contract price. (c) Failure to identify the labor surplus areas as specified in paragraph (b) of this provision will preclude the bidder from receiving priority consideration. If the bidder is awarded a contract as a result of receiving priority consideration under this provision and would not have othetwise received award, the bidder shall perform the contract or cause the contract to be performed in accordance with the obligations of an LSA concern. (End of provision) CLAUSES INCORPORATED BY REFERENCE (Non-Personal Healthcare Service Purchase Order) FAR CITATION: 52.252-1 : Solicitation Provision Incorporated by Reference. (FEB 1998) This solicitation incorporates one or more solicitation provisions by reference, with the same force and defect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. The offeror is cautioned that the listed provisions may include blocks that must be completed by the offeror and submitted with its quotation or offer. In lieu of submitting the full text of those provisions, the offeror may identify the provision by paragraph identifier and provide the appropriate information with its quotation or offer. Also, the full text of a solicitation provision may be accessed electronically at thislthese address(es): http://arnet.aov/far/index.html. I. Federal Acquisition Regulations (FAR) (48 CFR Chapter 1) Clauses No. FAR Citation Clause Title Clause Date 1. 52.204-7 Central Contractor Registration April 2008 2. 52-213-4 Terms and Conditions - Simplified October 2008 Acquisitions (Other Than Commercial Items) 3. 52.217-8 Option to Extend Services November 1999 4. 52.21 7-9 Option to Extend the Term of March 2000 The Contract 5. 52.222-3 Convict Labor June 2003 7. 52.222-2 1 Prohibition of Segregated Facilities February 1999 8. 52.222-26 Equal Opportunity March 2007 9. 52.222-3 5 Equal Opportunity for Special Disabled September 2006 Veterans, Veterans of the Vietnam Era, and Other Eligible Veterans 10. 52.222-36 Affirmative Action for Workers with June 1998 Disabilities 1 1. 52.222-37 Employment Reports on Special September 2006 Disabled Veterans, Veterans of The Vietnam Era, and other Eligible Veterans Service Contract Act of 1965 November 2007 Statement of Equivalent Rates for May 1989 Federal Hires 11. Federal Acquisition Regulations (FAR) (48 CFR Chapter 1) Clauses No. FAR Citation Clause Title Clause Date 14. 52.222-43 Fair Labor Standards Act and November 2006 Service Contract Act - Price Adjustment (Multiple Year and Option Contracts) 15. 52.222-44 Fair Labor Standards Act and February 2002 Service Contract Act - Price Adjustments Pollution Prevention and Right -to-Know Information Drug-Free Workplace Privacy Act Notification Privacy Act Restriction on Certain Foreign Purchases Payments Discounts for Prompt Payment Extras Availability of Funds Availability of Funds for the Next Fiscal Year Prompt Payments Payment by Electronic Funds Transfer - Central Contractor Registration Disputes Protest after Award Applicable Law for Breach of Of Contract Claim August 2003 May 2001 April 1984 April 1984 June 2008 April 1984 February 2002 April 1984 April 1984 April 1984 October 2008 October 2003 July 2002 August 1996 October 2004 111. Federal Acquisition Regulations (FAR) (48 CFR Chapter 1) Clauses No. FAR Citation Clause Title Clause Date 31. 52.237-1 Site Visit April 1984 32. 52.237-2 Protection of Government Buildings April 1984 Equipment & Vegetation 33. 52.237-3 Continuity of Services January 1991 34. 52.237-7 Indemnification and Medical Liability January 1997 Insurance 35. 52.242-15 Stop-Work Order August 1989 36. 52.243-1 Changes-Fixed Price August 1987 37. 52.249-1 Termination for the Convenience of April 1984 the Government (Fixed Price) (Short Form) 38. 52.249-8 Default (Fixed-Price Supply and April 1984 Service) 39. 52.253-1 Computer Generated Forms January 1991 CLAUSES INCORPORATED IN FULL TEXT (Non-Personal Healthcare Service Purchase Order) I. Federal Acquisition Regulations (FAR) (48 CFR Chapter 1) Clauses No. FAR Citation Clause Title Clause Date 1. 52.204-3 Taxpayer Identification October 1998 2. 52.204-6 Data Universal Numbering System (DUNS) Number April 2008 3. 52.204-8 Annual Representations & Certifications January 2006 4. 52.219-1 Small Business Program Representations May 2004 5. 52.2 19-2 Equal Low Bids October 1995 52.204-3 Taxpayer Identification As prescribed in 4.905, insert the following provision: TAXPAYER IDENTIFICATION (OCT 1998) (a) Definitions. "Common parent," as used in this position, means that corporate entity that owns or controls an affiliated group of corporations that files its Federal income tax returns on a consolidated basis, and of which the offeror is a member. "Taxpayer Identification Number (TnV)," as used in this provision, means the number required by the Internal Revenue Service (IRS) to be used by the offeror in reporting income tax and other returns. The TIN may be either a Social Security Number or an Employer Identification Number. (b) All offerors must submit the information required in paragraphs (d) through (0 of this provision to comply with debt collection requirements of 3 1 U.S.C. 7701(c) and 3325(d), reporting requirements of 26 U.S.C. 6041,4051A, and 6050M, and implementing regulations issued by the IRS. If the resulting contract is subject to the payment reporting requirements described in Federal Acquisition Regulation (FAR) 4.904, the failure or refusal by the offeror to furnish the information may result in a 3 1 percent reduction of payments otherwise due under the contract. (c) The TIN may be used by the Government to collect and report on any delinquent amounts arising out of the offeror's relationship with the Government (3 1 U.S.C. 77010(3)). If the resulting contract is subject to the payment reporting requirements described in FAR 4.904, the TIN provided hereunder may be matched with IRS records to verify the accuracy of the offeror's TIN. (d) Taxpayer Identification Number (TIN) TIN: TIN has been applied for. TIN is not required because: Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected withthe conduct of a trade or business in the United States and does not have an office or place of business or a fiscal paying agent in the United States; Offeror is an agency or instrumentality of a foreign Government; Offeror is an agency or instrumentality of the Federal Government. (e) Type of organization. Sole proprietorship; Partnership; Corporate entity (not tax-exempt); Corporate entity (tax-exempt); Government entity (Federal, State, or local); Foreign government; International organization per 26 CFR 1.6049-4; [7 Other 9 (f) Common parent. Offeror is not owned or controlled by a common parent as defined in paragraph (a) of this provision. Name and TIN of common parent: Name TlN (End of provision) 52.204-6 Data Universal Numbering System (DUNS) Number As prescribed in 4.607(a), insert the following provision: DATAU NIVERSANLU MBERINSGY STEM(D UNS) NUMBER(A PR2 008) (a) The offeror shall enter, in the block with its name and address on the cover page of its offer, the annotation "DUNS" or "DUNS+4" followed by the DUNS number or "DUNS+4" that identifies the offeror's name and address exactly as stated in the offer. The DUNS number is a nine-digit number assigned by Dun and Bradstreet, Inc. The DUNS+4 is the DUNS number plus a 4-character suffix that may be assigned at the discretion of the offeror to establish additional CCR records for identifying alternative Electronic Funds Transfer (EFT) accounts (see Subpart 32.1 1) for the same concern. (b) If the offeror does not have a DUNS number, it should contact Dun and Bradstreet directly to obtain one. (1) An offeror may obtain a DUNS number- (i) Via the Internet at http://fedgov.dnb.com/webform or if the offeror does not have internet access, it may call Dun and Bradstreet at 1-866-705-571 1 if located within the United States; or (ii) If located outside the United States, by contacting the local Dun and Bradstreet office. The offeror should indicate that it is an offeror for a U.S. Government contract when contacting the local Dun and Bradstreet office. (2) The offeror should be prepared to provide the following information: (i) Company legal business name. (ii) Tradestyle, doing business, or other name by which your entity is commonly recognized. (iii) Company physical street address, city, state and ZIP Code. (iv) Company mailing address, city, state and ZIP Code (if separate from physical). (v) Company telephone number. (vi) Date the company was started. (vii) Number of employees at your location. (viii) Chief executive officerlkey manager. (ix) Line of business (industry). (x) Company Headquarters name and address (reporting relationship within your entity). (End of provision) 52.204-8 Annual Representations & Certifications As prescribed in 4.1202, insert the following provision: ANNUAL REPRESENTATION & CERTIFICATIONS (JAN 2006) (a)(l)The North American Industry Classification System (NAICS) code for this acquisition is (insert NAICS code). (2)The small business size standard is (insert size standard). (3). The small business size standard for a concern which submits an offer in its own name, other than on a construction or service contract, but which proposes to furnish a product which it did not itself manufacture, is 500 employees. (b)(l)If the clause at 52.204-7, Central Contractor Registration, and the offeror is currently registered in CCR, and has completed the ORCA electronically, the offeror may choose to use paragraph (c) of this provision instead of completing the corresponding individual representations and certifications in the solicitation. The offeror shall indicate which option applies by checking one of the following boxes: (J (i)Paragraph (c) applies (J(ii)Paragraph (c) does not apply and the offeror has completed the individual representations and certifications in the solicitation. (c) The offeror has completed the annual representations and certifications electronically via the Online Representations and Certifications Applications (ORCA) website at http://orca.bpn.gov. After reviewing the ORCA database information, the offeror verifies by submission of the offer that the representations and certifications currently posted electronically have been entered or updated within the last 12 months, are current, accurate, complete, and applicable to this solicitation (including the business size standard applicable to the NAICS code referenced for this solicitation), as of the date of this offer and are incorporated in this offer by reference (see FAR 4.120l);except for the changes identified below (offeror to insert changes, identifying change by clause number, title, date). These amended representations(s) and /or certifications(s) are also incorporated in this offer and are current, accurate, and complete as of the date of this offer. FAR CLAUSE # TITLE DATE CHANGE Any changes provided by the offeror are applicable to this solicitation only, and do not result in an update to the representations and certifications posted on ORCA. (End of Provision) 52.219-1 Small Business Program Representations As prescribed in 19.308(a)(l), insert the following provision: Small Business Program Representations (MAY 2004) (a)(l) The North American Industry Classification System (NAICS) code for this acquisition is -1. (2) The small business size standard is (insert size standard). (3) The small business size standard for a concern which submits an offer in its own name, other than on a construction or service contract, but which proposes to furnish a product which it did not itself manufacture, is 500 employees. (b) Representations. (1) The offeror represents as part of its offer that it [ ] is, [ ] is not a small business concern. (2) (Complete only if the offeror represented itself as a small business concern in paragraph (b)(l) of this provision.) The offeror represents, for general statistical purposes, that it [ ] is, [ ] is not, a small disadvantaged business concern as defined in 13 CFR 124.1002. (3) (Complete only if the offeror represented itself as a small business concern in paragraph (b)(l) of this provision.) The offeror represents as part of its offer that it [ ] is, [ ] is not a women-owned small business concern. (4) [Complete only if the offeror represented itself as a small business concern in paragraph (b)(l) of this provision.] The offeror represents as part of its offer that it [ ] is, [ ] is not a veteran-owned small business concern. (5) [Complete only if the offeror represented itself as a veteran-owned small business concern in paragraph (b)(4) of this provision.] The offeror represents as part of its offer that it [ ] is, [ ] is not a service-disabled veteran-owned small business concern. (6) [Complete only if the offeror represented itself as a small business concern in paragraph (b)(l) of this provision.] The offeror represents, as part of its offer, that-- (i) It [ ] is, [ ] is not a HUBZone small business concern listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration, and no material change in ownership and control, principal office, or HUBZone employee percentage has occurred since it was certified by the Small Business Administration in accordance with 13 CFR part 126; and (ii) It [ ] is, [ ] is not a joint venture that complies with the requirements of 13 CFR part 126, and the representation in paragraph (b)(6)(i) of this provision is accurate for the HUBZone small business concern or concerns that are participating in the joint venture. [The offeror shall enter the name or names of the HUBZone small business concern or concerns that are participating in the joint venture:-- ----] Each HUBZone small business concern participating in the joint venture shall submit a separate signed copy of the HUBZone representation. (c) Definitions. As used in this provision-- Service-disabled veteran-owned small business concern-- (I) Means a small business concern-- (i) Not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 5 1 percent of the stock of which is owned by one or more service-disabled veterans; and (ii) The management and daily business operations of which are controlled by one or more servicedisabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran. (2) Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined in 38 U.S.C. lOl(16). Small business concern means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding on Government contracts, and qualified as a small business under the criteria in 13 CFR part 121 and the size standard in paragraph (a) of this provision. Veteran-owned small business concern means a small business concern-- (1) Not less than 5 1 percent of which is owned by one or more veterans (as defined at 38 U.S.C. 101 (2)) or, in the case of any publicly owned business, not less than 5 1 percent of the stock of which is owned by one or more veterans; and (2) The management and daily business operations of which are controlled by one or more veterans. Women-owned small business concern means a small business concern-- (1) That is at least 5 1 percent owned by one or more women; or, in the case of any publicly owned business, at least 5 1 percent of the stock of which is owned by one or more women; and (2) Whose management and daily business operations are controlled by one or more women. (d) Notice. (1) If this solicitation is for supplies and has been set aside, in whole or in part, for small business concerns, then the clause in this solicitation providing notice of the set-aside contains restrictions on the source of the end items to be furnished. (2) Under 15 U.S.C. 645(d), any person who misrepresents a firm's status as a small, HUBZone small, small disadvantaged, or women-owned small business concern in order to obtain a contract to be awarded under the preference programs established pursuant to section 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal law that specifically references section 8(d) for a definition of program eligibility, shall-- (i) Be punished by imposition of fine, imprisonment, or both; (ii) Be subject to administrative remedies, including suspension and debarment; and (iii) Be ineligible for participation in programs conducted under the authority of the Act. (End of provision) Alternate I (OCT 2002). As prescribed in 19.307(a)(2), add the following paragraph (b)(7) to the basic provision: (7) [Complete if offeror represented itself as disadvantaged in paragraph (b)(2) of this provision.] The offeror shall check the category in which its ownership falls: ---- Black American. ---- Hispanic American. ---- Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians). ---- Asian-Pacific American (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru). ---- Subcontinent Asian (Asian-Indian) American (persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands, or Nepal). ---- IndividuaVconcern, other than one of the preceding. [60 FR 48264, Sept. 18,1995, as amended at 61 FR 67422, Dec. 20, 1996; 62 FR 238, Jan. 2,1997; 63 FR 9069, Feb. 23,1998; 63 FR 35725, June 30,1998; 63 FR 70274, Dec. 18,1998; 64 FR 10533, Mar. 4, 1999; 64 FR 32749, June 17, 1999; 64 FR 5 1832, Sept. 24,1999; 65 FR 46058, July 26,2000; 65 FR 60546, Oct. 1 1,2000; 66 FR 21 34, Jan. 10,2001 ; 67 FR 13066, Mar. 20,2002; 69 FR 25279, May 5,2004; 69 FR 76358, Dec. 20, 20041 52.219-2 Equal Low Bids As prescribed in 19.308(c), insert the following provision: Equal Low Bids (OCT 1995) (a) This provision applies to small business concerns only. (b) The bidder's status as a labor surplus area (LSA) concern may affect entitlement to award in case of tie bids. If the bidder wishes to be considered for this priority, the bidder must identify, in the following space, the LSA in which the costs to be incurred on account of manufacturing or production (by the bidder or the first-tier subcontractors) amount to more than 50 percent of the contract price. (c) Failure to identify the labor surplus areas as specified in paragraph (b) of this provision will preclude the bidder from receiving priority consideration. If the bidder is awarded a contract as a result of receiving priority consideration under this provision and would not have otherwise received award, the bidder shall perform the contract or cause the contract to be performed in accordance with the obligations of an LSA concern. (End of provision) 11. Department of Health and Human Services Acquisition Regulations (HHSAR) (49 Chapter 3) Clauses No. HHSAR Citation Clause Title Clause Date 1. HHSAR 352.224-70 Confidentiality of Information March 2005 2. HHSAR 352.270-2 Indian Preference April 1984 HHSAR 352.224-70 Confidentiality of Information The following clause is covered by the policy set forth in subpart 324.70 and is to be used in accordance with the instructions set forth in 324.7704. CONFIDENTIALITY OF INFORMATION (MAR 2005) (a) Confidential information, as used in this clause, means (I) information or data of a personal nature about an individual, or (2) proprietary information or data submitted by or pertaining to an institution or organization. (b) In addition to the types of confidential information described in (a)(l) and (2) above, information which might require special consideration with regard to the timing of its disclosure may derive from studies or research, during which public disclosure of preliminary unvalidated findings could create erroneous conclusions which might threaten public health or safety if acted upon. (c) The Contracting Officer and the Contractor may, by mutual consent, identify elsewhere in this contract specific information andlor categories of information which the Government will furnish to the Contractor or that the Contractor is expected to generate which is confidential. Similarly, the Contracting Officer and the Contractor may, by mutual consent, identify such information from time to time during the performance of the contract. Failure to agree will be settled pursuant to the "Disputes" Clause. (d) If it is established elsewhere in this contract that information to be utilized under this contract, or a portion thereof, is subject to the Privacy Act, the Contractor will follow the rules and procedures of disclosure set forth in the Privacy Act of 1974,5 U.S.C. 552a, and implementing regulations and policies, with respect to systems of records determined to be subject to the Privacy Act. (e) Confidential information, as defined in (a)(l) and (2) above, that is information or data of a personal nature about an individual, or proprietary information or data submitted by or pertaining to an institution or organization, shall not be disclosed without the prior written consent of the individual, institution, or organization. (f) Written advance notice of at least 45 days will be provided to the Contracting Officer of the Contractor's intent to release findings of studies or research, which have the possibility of adverse effects on the public or the Federal agency, as described in (b) above. If the Contracting Officer does not pose any objections in writing within the 45-day period, the Contractor may proceed with disclosure. Disagreements not resolved by the Contractor and the Contracting Officer will be settled pursuant to the "Disputes" clause. (g) Whenever the Contractor is uncertain with regard to the proper handling of material under the contract, or if the materials in question is subject to the Privacy Act or is confidential information subject to the provisions of this clause, the Contractor should obtain a written determination from the Contracting Officer prior to any release, disclosure, dissemination, or publication. (h) Contracting Officer determinations will reflect the results of internal coordination with appropriate program and legal officials. (i) The provisions of paragraph (e) of this clause shall not apply when the information is subject to conflicting or overlapping provisions in other Federal, State or local laws. (End of clause) HHSAR 352.270-2 Indian Preference The following clause shall be used as prescribed in 370.202(a): INDIAN PREFERENCE (APR 1984) (a) The Contractor agrees to give preference in employment opportunities under this contract to Indians who can perform required work, regardless of age (subject to existing laws and regulations), sex, religion, or tribal affiliation. To the extent feasible and consistent with the efficient performance of this contract, the Contractor further agrees to give preference in employment and training and opportunities under this contract to Indians who are not fully qualified to perform regardless of age (subject to existing laws and regulations) sex, religion, or tribal affiliation. The contractor also agrees to give preference to Indian organizations and Indian-owned economic enterprises in the awarding of any subcontracts to the extent feasible and consistent with the efficient performance of this contract. The Contractor shall maintain statistical records as are necessary to indicate compliance with this paragraph. (b) In connection with the Indian employment preference requirements of this clause, the Contractor shall provide opportunities for training incident to such employment. Such training shall include on-the job, classroom or apprenticeship training which is designed to increase the vocational effectiveness of an Indian employee. (c) If the Contractor is unable to fill its employment and training opportunities after giving full consideration to Indians as required by this clause, those needs may be satisfied by selection of persons other than Indians in accordance with the clause of this contract entitled "Equal Opportunity." (d) If no Indian organizations or Indian-owned economic enterprises are available under reasonable terms and conditions, including price, for awarding of subcontracts in connection with the work performed under this contract, the Contractor agrees to comply with the provisions of this contract involving utilization of small business concerns, small business concerns owned and controlled by socially and economically disadvantaged individuals, or labor surplus area concerns. (e) As used in this clause: (1) "Indian" means a person who is a member of an Indian Tribe. If the Contractor has reason to doubt that a person seeking employment preference is an Indian, the Contractor shall grant the preference but shall require the individual to provide evidence within thirty (30) days from the Tribe concerned that the person is a member of that Tribe. (2) "Indian Tribe" means an Indian Tribe, pueblo, band, nation, or other organized group or community, including any Alaska Native village or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688; 43 U.S.C. 1601) which is recognized as eligible for the special programs and services provided by the United State s to Indians because of their status as Indians. (3) "Indian organization" means the governing body of any Indian Tribe or entity established or recognized by such governing body in accordance with the Indian Financing Act of 1974 (88 Stat. 77; 25 U.S.C. 1451); and (4) "Indian-owned economic enterprise" means any Indian-owned commercial, industrial, or business activity established or organized for the purpose of profit, provided that such Indian ownership shall constitute not less than 5 1 percent of the enterprise, and that ownership shall encompass active operation and control of the enterprise. (f) The Contractor agrees to include the provisions of this clause, including this paragraph (f), in each subcontract awarded at any tier under this contract. (g) In the event of noncompliance with this clause the Contracting Officer may terminate the contract in whole or in part or may impose any other sanctions authorized by law or by other provisions of the contract. (End of clause)
 

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Place of Performance

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Zip Code: 57770
 

Record

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