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FBO DAILY - FEDBIZOPPS ISSUE OF AUGUST 16, 2013 FBO #4283
SOLICITATION NOTICE

Q -- Dental Assistant - F2X4A23211AG01

Notice Date: 8/14/2013
Notice Type: Combined Synopsis/Solicitation
NAICS: 621210 — Offices of Dentists
Contracting Office: Department of the Air Force, Air Education and Training Command, Maxwell AFB Contracting Squadron, 50 LeMay Plaza South, Bldg 804, Maxwell AFB, Alabama, 36112-6334
ZIP Code: 36112-6334
Solicitation Number: F2X4A23211AG01
Archive Date: 10/1/2013
Point of Contact: Eldrae A. Perdue, Phone: 334-953-4745, Kimberly Knott, Phone: 334-953-8552
E-Mail Address: eldrae.perdue@us.af.mil, kimberly.knott.1@us.af.mil
(eldrae.perdue@us.af.mil, kimberly.knott.1@us.af.mil)
Small Business Set-Aside: Total Small Business
Description: QUALITY ASSURANCE SURVEILLANCE PLAN FOR DENTAL ASSISTANT GENERAL INFORMATION The 42nd Contracting Squadron, 50 LeMay Plaza, Bldg 804, Maxwell AFB, AL has a requirement to purchase items as described in this document. This is a streamlined combined synopsis/solicitation for commercial items prepared in accordance with the format in FAR Subpart 12.6 as supplemented with additional information included in this notice. This announcement constitutes the only notice. A written solicitation will not be issued. This requirement is issued as a request for proposal (Reference-Number F2X4A23211AG01). The solicitation document and incorporated provisions and clauses are those in effect the Federal Acquisition Circular 2005-69 and Defense Acquisition Circular 20130808 effective date 08 August 2013. A Firm Fixed Priced Award will be made in accordance with the following: NAICS Code: 621210, size standard $7.0 Million The Defense Priorities and Allocations System rating is S10. "Notice to Offeror(s)/Supplier(s): Funds are not presently available for this effort. No award will be made under this solicitation until funds are available. The Government reserves the right to cancel this solicitation, either before or after the closing date. In the event the Government cancels this solicitation, the Government has no obligation to reimburse an offeror for any costs." NATURE OF ACQUISITION: Maxwell AFB has a requirement to purchase the below listed services. This procurement will be awarded under Simplified Acquisition Procedures. All inquiries/responses to this notice must be received by 16 September 2013, 16:00 hrs CST. Period of Performance (PoP): 01 Oct 13 - 30 Sep 14 (base year) with four (4) one-year options. SCHEDULE OF SUPPLIES/SERVICES: The contractor shall provide the service listed below, which is to be performed on Maxwell, AFB. CLIN 0001: Dental Assistant at the Maxwell Ambulatory Healthcare Center in accordance with (IAW) all local, state and federal laws and the requirements of the Performance Work Statement (PWS) Base Period PoP: 1 October 2013 - 30 September 2014 $_________ CLIN 1001 Option Year 1 PoP: 1 October 2014 - 30 September 2015 $_________ CLIN 2001 Option Year 2 PoP: 1 October 2015 - 30 September 2016 $_________ CLIN 3001 Option Year 3 PoP: 1 October 2016 - 30 September 2017 $_________ CLIN 4001 Option Year 4 PoP: 1 October 2017 - 30 September 2018 $_________ Total: $_________ *All work is to be performed in accordance with (IAW) the attached Performance Work Statement (PWS). PROPOSAL PREPARATION INSTRUCTIONS To ensure timely and equitable evaluation of proposals, offerors must comply with instructions contained herein. Proposals must be complete, self-sufficient, and respond directly to the requirements of this RFP. a. The offeror must submit dated proposal on company letterhead with unit prices and extended prices in response to this solicitation. In doing so and without taking any exception to the requirements of this synopsis/solicitation, including specification, "Schedule of Supplies/Services" and terms and conditions, the offeror accedes to all solicitation requirements. Offerors may submit proposals by email as responses to this solicitation. E-mail proposals are subject to the same rules as paper proposals. Typing shall be double spaced, in Times New Roman, and not be less than 12 pitch. Offerors must clearly identify any exception to the solicitation terms and conditions and provide complete accompanying rationale. b. If offerors ORCA Representations and Certifications are not current, then they must include a completed copy of the provisions at FAR 52.212-3, and Alternate I, Offeror Representations and Certifications - Commercial Items c. Interested parties capable of providing the requirement must submit a written proposal to include discount terms, tax identification number, cage code, and DUNS. d. To be eligible to receive an award resulting from this RFP, contractors must be registered in the DoD Systems for Award Management database, no exceptions. To register, please visit http://www.sam.gov or by calling 1-866-606-8220. IMPORTANT NOTE: This Dental requirement is a 100% small business set-aside. Neither multiple Offerors nor Multiple Awards will be considered. A single award will be made in the resultant contract. BASIS FOR AWARD Award will be based on technical acceptability and price. An offer will be determined technically acceptable if the offeror: a) submits a dated proposal on company letterhead with unit prices and extended prices in response to this solicitation. b) takes no exception to the requirements of this synopsis/solicitation, including specification, "Schedule of Supplies/Services" and terms and conditions CONTRACT TERMS AND CONDITIONS: The following provisions and clauses apply: By reference: The following provisions are included: 52.204-7, System for Award Management 52.212-1, Instructions to Offerors- Commercial Items 52.212-2, Evaluation - Commercial Items 52.212-3 and Alt 1, Offeror Representations and Certifications - Commercial Items 52.217-5, Evaluation of Options 252.204-7004 Alt A, System for Award Management 252.209-7999 Representation by Corporations Regarding an Unpaid Delinquent Tax Liability or a Felony Conviction under any Federal Law The following clauses are included: 52.203-3, Gratuities 52.204-9, Personal Identity Verification of Contractor Personnel 52.204-13, System for Award Management Maintenance. 52.212-4, Contract Terms and Conditions-Commercial Items. 52.212-5, Contract Terms and Conditions Required to Implement Statutes Or Executive Orders-Commercial Items The following FAR Clauses cited in this clause also applies: 52.203-6, Restrictions on Subcontractor Sales to the Government 52.204-10, Reporting Executive Compensation and First-Tier Subcontract Awards 52.209-6, Protecting the Government's Interest when Subcontracting with Contractor's Debarred, Suspended, or Proposed for Debarment. 52.219-6, Notice of Total Small Business Set-Aside 52.219-8, Utilization of Small Business Concerns 52.219-13, Notice of Set-Aside on Orders 52.219-14, Limitations on Subcontracting 52.219-28, Post Award Business Program Representation 52.222-3, Convict Labor 52.222-21, Prohibition of Segregated Facilities 52.222-26, Equal Opportunity 52.222-35, Equal Opportunity for Veterans 52.222-36, Affirmative Action for Workers with Disabilities 52.222-37, Employment Reports on Special Disabled Veterans, Veterans of the Vietnam Era, and Other Eligible Veterans 52.222-40, Notification of Employee Rights under the National Labor Relations Act 52.222-50, Combating Trafficking in Persons 52.222-53, Exemption from Application of the Service Contract Act to Contracts for Certain Services-- Requirements 52.223-18, Contractor Policy to Ban Text Messaging While Driving 52.225-13, Restriction on Certain Foreign Purchases 52.232-33, Payment by Electronic Funds Transfer 52.233-3, Protest After Award 52.233-4, Applicable Law for Breach of Contract Claim. 52.222-17, Non-Displacement of Qualified Workers 52.228-5, Insurance -- Work on a Government Installation 52.232-18, Availability of Funds 52.237-2, Protection of Government Buildings, Equipment, and Vegetation. DFARS Clauses: 252.203-7000, Requirements Relating to Compensation of Former DOD Officials 252.203-7002, Requirement to Inform Employees of Whistleblower Rights 252.204-7000, Disclosure of Information 252.232-7003, Electronic Submission of Payment Requests 252.225-7012, Preference for Certain Domestic Commodities 252.237-7010, Prohibition on Interrogation of Detainees by Contractor Personnel 252.243-7002, Requests for Equitable Adjustment By Full Text: Clause 52.217-8 Option to Extend Services (Nov 1999) The Government may require continued performance of any services within the limits and at the rates specified in the contract. These rates may be adjusted only because of revisions to prevailing labor rates provided by the Secretary of Labor. The option provision may be exercised more than once, but the total extension of performance hereunder shall not exceed 6 months. The Contracting Officer may exercise the option by written notice to the Contractor within 15 Days. Clause 52.217-9 Option to Extend the Term of the Contract (Mar 2000) (a) The Government may extend the term of this contract by written notice to the Contractor within 15 days provided that the Government gives the Contractor a preliminary written notice of its intent to extend at least 30 days before the contract expires. The preliminary notice does not commit the Government to an extension. (b) If the Government exercises this option, the extended contract shall be considered to include this option clause. (c) The total duration of this contract, including the exercise of any options under this clause, shall not exceed 66 months. 52.252-1, Solicitation Provisions Incorporated by Reference (Feb 1998) This solicitation incorporates one or more solicitation provisions by reference, with the same force and effect 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 this/these address(es): http://farsite.hill.af.mil/ 52.252-2, Clauses Incorporated by Reference (Feb 1998) This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this/these address(es): http://farsite.hill.af.mil/ (End of Clause) AFFARS Clauses: 5352.201-9101 OMBUDSMAN (NOV 2012) (a) An ombudsman has been appointed to hear and facilitate the resolution of concerns from offerors, potential offerors, and others for this acquisition. When requested, the ombudsman will maintain strict confidentiality as to the source of the concern. The existence of the ombudsman does not affect the authority of the program manager, contracting officer, or source selection official. Further, the ombudsman does not participate in the evaluation of proposals, the source selection process, or the adjudication of protests or formal contract disputes. The ombudsman may refer the party to another official who can resolve the concern. (b) Before consulting with an ombudsman, interested parties must first address their concerns, issues, disagreements, and/or recommendations to the contracting officer for resolution. Consulting an ombudsman does not alter or postpone the timelines for any other processes (e.g., agency level bid protests, GAO bid protests, requests for debriefings, employee-employer actions, contests of OMB Circular A-76 competition performance decisions). (c) If resolution cannot be made by the contracting officer, concerned parties may contact the Center/MAJCOM or AFISRA ombudsmen, Primary: Mr. David Jones, Deputy Chief, Contracting Division, HQ AETC/PK; Alternate: Mr. Stephen Smith, Chief, Acquisition Support Branch, HQ AETC/PKA; Address: 2035 First Street West, Ste 1, Randolph AFB TX 78150-4324; Telephone Numbers: (210) 652-7907 or (210) 652-7075; Facsimile Number: (210) 652-8344; and E-mail Addresses: david.jones.3@us.af.mil or stephen.smith@us.af.mil. Concerns, issues, disagreements, and recommendations that cannot be resolved at the MAJCOM/DRU or ARISRA level, may be brought by the concerned party for further consideration to the Air Force ombudsman, Associate Deputy Assistant Secretary (ADAS) (Contracting), SAF/AQC, 1060 Air Force Pentagon, Washington DC 20330-1060, phone number (703) 588-7004, facsimile number (703) 588-1067. (d) The ombudsman has no authority to render a decision that binds the agency. (e) Do not contact the ombudsman to request copies of the solicitation, verify offer due date, or clarify technical requirements. Such inquiries shall be directed to the Contracting Officer. (End of clause) AF 5352.223-9001 HEALTH AND SAFETY ON GOVERNMENT INSTALLATIONS (JUN 1997) (a) In performing work under this contract on a Government installation, the contractor shall: (1) Comply with the specific health and safety requirements established by this contract; (2) Comply with the health and safety rules of the Government installation that concern related activities not directly addressed in this contract; (3) Take all reasonable steps and precautions to prevent accidents and preserve the health and safety of contractor and Government personnel performing or in any way coming in contact with the performance of this contract; and (4) Take such additional immediate precautions as the contracting officer may reasonably require for health and safety purposes. (c) The contracting officer may, by written order, direct Air Force Occupational Safety and Health Standards (AFOSH) and/or health/safety standards as may be required in the performance of this contract and any adjustments resulting from such direction will be in accordance with the Changes clause of this contract. (d) Any violation of these health and safety rules and requirements, unless promptly corrected as directed by the contracting officer, shall be grounds for termination of this contract in accordance with the Default clause of this contract. (End of clause) 5352.242-9000 CONTRACTOR ACCESS TO AIR FORCE INSTALLATIONS (AUG 2007) (a) The contractor shall obtain base identification and vehicle passes, if required, for all contractor personnel who make frequent visits to or perform work on the Air Force installation(s) cited in the contract. Contractor personnel are required to wear or prominently display installation identification badges or contractor-furnished, contractor identification badges while visiting or performing work on the installation. (b) The contractor shall submit a written request on company letterhead to the contracting officer listing the following: contract number, location of work site, start and stop dates, and names of employees and subcontractor employees needing access to the base. The letter will also specify the individual(s) authorized to sign for a request for base identification credentials or vehicle passes. The contracting officer will endorse the request and forward it to the issuing base pass and registration office or security police for processing. When reporting to the registration office, the authorized contractor individual(s) should provide a valid driver's license, current vehicle registration, valid vehicle insurance certificate, and to obtain a vehicle pass. (c) During performance of the contract, the contractor shall be responsible for obtaining required identification for newly assigned personnel and for prompt return of credentials and vehicle passes for any employee who no longer requires access to the work site. (d) When work under this contract requires unescorted entry to controlled or restricted areas, the contractor shall comply with citing the appropriate paragraphs as applicable. (e) Upon completion or termination of the contract or expiration of the identification passes, the prime contractor shall ensure that all base identification passes issued to employees and subcontractor employees are returned to the issuing office. (f) Failure to comply with these requirements may result in withholding of final payment. (End of clause) 5352.242-9001 COMMON ACCESS CARDS (CACs) FOR CONTRACTOR PERSONNEL (NOV 2012) (a) For installation(s)/location(s) cited in the contract, contractors shall ensure Common Access Cards (CACs) are obtained by all contract or subcontract personnel who meet one or both of the following criteria: (1) Require logical access to Department of Defense computer networks and systems in either: (i) the unclassified environment; or (ii) the classified environment where authorized by governing security directives. (2) Perform work, which requires the use of a CAC for installation entry control or physical access to facilities and buildings. (b) Contractors and their personnel shall use the following procedures to obtain CACs: (1) Contractors shall provide a listing of personnel who require a CAC to the contracting officer. The government will provide the contractor instruction on how to complete the Contractor Verification System (CVS) application and then notify the contractor when approved. (2) Contractor personnel shall obtain a CAC from the nearest Real Time Automated Personnel Identification Documentation System (RAPIDS) Issuing Facility (typically the local Military Personnel Flight (MPF)). (c) While visiting or performing work on installation(s)/location(s), contractor personnel shall wear or prominently display the CAC as required by the governing local policy. (d) During the performance period of the contract, the contractor shall: (1) Within 7 working days of any changes to the listing of the contract personnel authorized a CAC, provide an updated listing to the contracting officer who will provide the updated listing to the authorizing government official; (2) Return CACs in accordance with local policy/directives within 7 working days of a change in status for contractor personnel who no longer require logical or physical access; (3) Return CACs in accordance with local policy/directives within 7 working days following a CACs expiration date; and (4) Report lost or stolen CACs in accordance with local policy/directives. (e) Within 7 working days following completion/termination of the contract, the contractor shall return all CACs issued to their personnel to the issuing office or the location specified by local policy/directives. (f) Failure to comply with these requirements may result in withholding of final payment. (End of clause) SPECIAL INSTRUCTION 45 REQUIRED INSURANCE Reference FAR clause 52.228-5 entitled "Insurance..." the Contractor shall, at its own expense, procure and thereafter maintain the following kinds of insurance with respect to performance under the contract. a. Workmen's Compensation and Employers Liability Insurance as required by law except that if this contract is to be performed in a State which does not require or permit private insurance, then compliance with the statutory or administrative requirements in any such State will be satisfactory. The required Workmen's Compensation insurance shall extend to cover employer's liability for accidental bodily injury or death and for occupational disease with a minimum liability limit of $100,000. b. General Liability Insurance. Bodily injury liability insurance, in the minimum limits of $500,000 per occurrence shall be required on the comprehensive form of the policy. c. Automobile Liability Insurance. The insurance shall be required on the comprehensive form of policy and shall provide bodily and property damage liability covering the operation of all automobiles used in connection with the performance of the contract. At least the minimum limits of $200,000 per person and $500,000, per occurrence for bodily injury and $20,000 per occurrence for property damage shall be required. This insurance shall cover the operation of automobiles by Contractor employees and authorized Government employees and third parties. SPECIAL INSTRUCTION 119 WAWF-ELECTRONIC SUBMISSION OF INVOICE Reference DFARS Clause 252.232-7003 "ELECTRONIC SUBMISSION OF PAYMENT REQUESTS." Invoices shall be submitted and accepted using Wide Area Workflow (WAWF) web-based system at https://wawf.eb.mil. For information on WAWF including web-based training, visit the web-site and click on "About WAWF". The web-site also contains detailed instructions for setting up your computer to achieve the best results with the system. If you have additional questions contact the WAWF-RA Customer Helpdesk at (866) 618-5988, Option 2 The following information codes will be required to submit your invoices correctly through WAWF: SELECT TYPE OF INVOICE: Contract Specialist/Administrator selects only one (1) of the following: 1 Invoice and Receiving Report (Combo) (Creates two documents, an Invoice and a Receiving Report, within one data entry session (Combo). Creating both documents at the same time, rather than separately, is recommended. 0 Construction Invoice (Creates a Construction Payment Invoice from a contract for construction. Both an Inspector and a Contracting Officer must review and accept). Contract Number: Block 2 of the SF1449 Form (If this is a GSA Delivery Order award, enter the GSA NUMBER) Delivery Order: Block 4 of (Order Number) of SF1449 No Dashes - (if applicable) Pay DoDAAC: Block 16a (Payment will be made by) of SF1449 - Pay DoDAAC code is used to route documents to the Defense Finance Accounting office responsible for payment. The accounts payable mailing address can be located in Block 18a of SF1449. You can easily access payment information using the DFAS web site at http://www.dod.mil/dfas. Your contract/purchase order number or invoice will be required to inquire status of your payment. Issue by DoDAAC: Block 9 (Issued by) of SF1449. Contracting office that issued your contract - WAWF uses the code to route the document to the base. Admin DoDAAC: Block 16 (Administered by) of SF1449) Ship-To Code: Block 15 (Deliver To) of SF1449 - This is a crucial piece of information. It will be different for almost every contract issued. Ship-From Code: Not a required field for Air Force contracts. Inspected by DoDAAC: Block 15 (Deliver to) of SF1449 - If an inspection is called for in the document, then you must provide the DoDAAC/Ext this code identifies the inspector. Service Acceptor: Block 15 (Deliver to) of SF1449 - It is used to route documents to receiving service acceptor in WAWF. LPO DoDAAC/Ext: Not a required field for Air Force contracts. ADDITIONAL E-MAIL NOTIFICATIONS: The VENDOR and the DFAS Office will automatically receive a notice; after clicking SUBMIT WAWF will prompt for additional email submissions. The following E-Mail addresses MUST be input in order to prevent delays in processing: Receiver/Acceptor: david.kimbrough@us.af.mil Contract Specialist: eldrae.perdue@us.af.mil Contracting Officer: kimberly.knott.1@us.af.mil In addition to the requirement of this local clause, the Contractor shall meet the requirements of the appropriate payment clauses in this contract when submitting payment requests. (End of Clause) SPECIAL INSTRUCTION 114 REQUIRED POSTERS Please utilize the following website to access and download as appropriate EEO posters, Service Contract posters, and disability posters required in accordance with 52.222-26, 52.222-41, and 52.222-36 respectively. http://www.dol.gov/osbp/sbrefa/poster/main.htm (End of Clause) Points of Contact: Eldrae Perdue Contracting Specialist Phone (334) 953-4745, Fax (334) 953-3527 eldrae.perdue@us.af.mil Kimberly Knott Contracting Officer Phone (334) 953-8552, Fax (334) 953-3527 kimberly.knott.1@us.af.mil PERFORMANCE WORK STATEMENT (Dental Assistant): Section 1 GENERAL 1. DESCRIPTION OF SERVICES The Contractor shall provide one (1) Full Time Equivalent (FTE) Dental Hygienist/Dental Assistant for the Maxwell Ambulatory Healthcare Center, also referred to as the "Medical Treatment Facility" (MTF) herein. Performance shall be according to the requirements contained in this Performance Work Statement (PWS), the professional standards of the Accreditation Association for Ambulatory Health Care (AAAHC), American Dental Association (ADA), the Air Force Health Services Inspection Agency Office of the Health Service Inspector, and applicable Air Force regulations. Contractor shall administer dental education program; conduct dental examinations and provides dental care for military members with special standards of dental qualification. 1.1. CONTRACTOR STAFFING PLAN: The Contractor shall establish and maintain a staffing plan for staffing vacant positions with fully qualified health care workers from outside of the Government. A copy of the plan shall be forward to the Contracting Officer (CO) prior to contract start date. The plan shall include a timeframe for hiring, credentialing, and if the employee is terminated or quits a re-hiring proposal as part of the proposal as part of the evaluation criteria prior to contract award. 1.2. PERSONNEL. 1.2.1. POINT OF CONTACT. The Contractor shall provide a point of contact that 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 operation of this contract. The Contractor shall designate this individual, in writing, to the Contracting Officer Representative (COR) before the contract start date. 1.2.2. AVAILABILITY. The Contractor shall provide a point of contact that shall be available via telephone five (5) days a week, Monday through Friday, 7:00 AM until 5:00 PM, (defined herein as a "duty day"), excluding Federal Holidays. 1.2.3. ARRANGE FOR REPLACEMENT STAFF. The Contractor shall arrange for pre-credentialed locum tenens coverage when the Contractor will be unable to provide services for four (4) or more consecutive weeks. Locum tenens personnel will have all credentials accepted through the 42d Medical Group before any service is performed within the MTF. 1.2.4. PERSONNEL REQUIREMENTS. 1.2.4.1. ENGLISH LANGUAGE REQUIREMENT. Personnel shall read, understand, speak, and write English well enough to communicate effectively with patients and other healthcare workers. 1.2.4.2. Contractor personnel shall present a neat appearance and be easily recognized as contractor employees. A hospital issued nametag will be provided designating "contractor". 1.2.4.3. United States citizenship 1.2.4.4. Licensure and/or certification as a dental hygienist or dental assistant is required. 1.2.5. CRIMINAL BACKGROUND CHECK REQUIREMENT. 1.2.5.1. Individuals shall have the right to obtain a copy of any background check pertaining to them and to challenge the accuracy and completeness of the information contained in the report. 1.2.5.2. Individuals must obtain a new a background check and shall provide proof of the background check to the MTF COR. 1.2.6. CONFLICT 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 the Department of the Air Force, either military or civilian, unless such person seeks and receives approval in accordance with DoD Directive 5500.7, Standards of Conduct, dated 29 November 2007, and Air Force policy. 1.3. CREDENTIALS REQUIREMENTS 1.3.1. PRIVILEGING. Dental Hygienists are non-privileged healthcare providers and do not have clinical privileges, however they do possess a license, certification, or registration required for this contract. The contractor will be required to provide appropriate Primary Source Verification and documentation for credentials of dental hygienists and/or dental assistants. The credentials of all providers shall be reviewed as outlined in AFI 44-119, Medical Quality Operations. The Contractor is responsible to ensure that proposed staff possesses the requisite credentials to allow for performance of all tasks identified in Section 4 of this PWS. All requirements shall be available to the MTF day one of work in order for performance and payment of services to begin. ATTACHMENT 1 42D MEDICAL GROUP CREDENTIALING PROCEDURES For Contracting Agencies All required credentialing forms can be obtained from: 42d MEDICAL GROUP CREDENTIALS OFFICE / SGHC 300 S. Twining St. Bldg. 760 MAXWELL AFB, AL 36112 (334) 953-5143 loretta.wood@us.af.mil THE PROVIDER MAY NOT REPORT TO THE MTF UNTIL ALL CLINICAL PRIVILEGES DOCUMENTS ARE RECEIVED PLEASE CAREFULLY READ ALL INSTRUCTIONS ON ALL FORMS. IF ANY PART OF THE APPLICATION PACKAGE IS INCOMPLETE OR MISSING, THE ENTIRE PACKAGE WILL BE RETURNED FOR PROPER COMPLETION. PLEASE SAVE EACH DOCUMENT SEPARATELY AS A PDF FILE. PROVIDER: 1. Read, complete and return the following: 0 AF Form 1540, Application for Clinical Privileges 0 AF Form 244, 28XX, Clinical Privileges (Specialty Specific) 0 AF Form 1562, Credentials Evaluation of Health Care Practitioners (2 Forms are Required) 0 Bylaws (AFI44-119): Please ask provider to read at http://www.e-publishing.af.mil 2. AF Form 1540, Application for Clinical Privileges. Complete Section I through IX and sign. Please use MM/DD/YYYY format for all dates. In Section IV, please ensure that ALL facilities where you have EVER been granted privileges since qualifying degree are listed. In Section V, please ensure ALL licenses EVER HELD are listed. 3. Privilege List. Review and complete the privileges list for your specialty by placing a # 1, 2, or 4 in the requested column, according to the instructions at the top of the form. DO NOT use "x's" check marks or initials!!! Also DO NOT use a code 3. Place your signature in the "Provider Signature" space. 4. AF Form 1562. Sign and date the top section of each of the AF Forms 1562, (2 Forms are Required). These will be sent to the individuals you list as references on your application. 5. Provide copies of the following documents if needed for your credentials folder (any training certificates, licenses, etc. listed on your application must be presented before privileges will be awarded): 0 Current BLS and, if required for your specialty, ACLS, PALS, ATLS, NRP certification. 0 DEA certificate, (Must comply with Alabama state license requirements) 0 Photo ID (military ID if available) 0 CE's for the past 3 years or a list of CE's. 0 NPI number (can print page fromhttps://nppes.cms.hhs.gov website) THE PACKET FROM THE CONTRACT COMPANY MUST INCLUDE THE FOLLOWING: 0 All items listed above, as well as 0 Verification of ALL facilities where the provider has EVER been granted privileges (since qualifying degree) A WRITTEN/FAXED verification is PREFERRED. If MUST get a verbal verification, the following information is required: Agency contacted; Phone Number; Date; Time; Name and Title of Person providing verification; What's being verified, Verification Information and who took verification. 0 A List of privileges from each facility where privileges are currently held. If no privileges are currently held, then list of privileges from most recent facility (during past year) 0 Verification of ALL licenses ever held 0 Verification of Board Certification(s) 0 Verification of Professional Education 0 Verification of all training programs (internship/residencies/fellowships, etc.) 0 Proof of malpractice insurance and claims history for the past 10 years. 0 AF Form 1562 from at least two of the professional/peer references listed on the AF Form 1540 a form/letter with comparable information will be accepted. 0 Queries of: 0 NPDB / HIPDB (if available to agency); 0 FSMB (if MD/DO or PA & provider worked prior to ‘95); 0 Inspection General Sanctions; 0 Tricare Sanctions 15 FEB 2013 1.3.1.1. Initial applications for credentials action history, malpractice history, and completed copies of the below listed documents, shall be submitted to the applicable MTF Credentials Committee in accordance with the Contract Staffing Plan in 1.1. Additionally, the Contractor shall make all proposed healthcare providers available for interview by the applicable MTF during the credentialing process. a. Copy of valid, current, applicable state license or certification as a dental hygienist or dental assistant, shall be submitted. Under a personal services contract, have and maintain an unrestricted license or certification as applicable in one of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, or the U.S. Virgin Islands, and be able to practice at the MTF where services are provided. Copies of required certification shall be furnished to the Contracting Officer prior to performance on this contract. Each required document must be sent in PDF form, one document per PDF, to ensure credentialing as soon as possible. Attached credentialing document is what is expected. (See Attachment 1) b. Provider education and training. c. Current Basic Life Support (BLS) based on guidance in AFI 44-102, Medical Care Management. d. A signed consent for release of information. e. Must have an Alabama Dental Hygienist or Dental Assistant license or certification, as appropriate. f. A copy of the proposed contract provider's professional resume (curriculum vitae), 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. g. A list of all states in which contract provider currently holds or has held a license, certification, or registration to practice related services. h. Certification of current physical examination for each employee. The certification shall contain a signed statement by the examining physician stating that the employee is free of any contagious diseases. Physical examination must be current and within the 12 months prior to the application for privileges. 1.3.1.2. Applications for privileges will be screened through the National Practitioners Data Bank, if applicable. 1.3.1.3. Professional staff appointments will be based on review of documents listed in paragraph 1.3.1, in accordance with AFI 44-119, Medical Quality Operations. 1.3.1.4. Applications for replacement contract providers shall be submitted to the applicable MTF Credentials Committee through the COR where services are to be provided, not later than thirty (30) calendar days prior to the provider assuming duty. 1.3.1.5. The Contractor is required to submit a progress report within thirty (30) days of contract award. The progress report will include total numbers of applicants for each position, total number of interviews for each position, hiring limitations if any, and proposed start to work day. 1.3.1.6. The Contractor must submit only complete credentials applications for processing. Incomplete applications (those that do not fully comply with the requirements) will not be accepted by the Government and will be returned without action. 1.3.1.7. The Contractor must take specific action, including Primary Source Verification, to ensure that contract provider applications have the required prerequisites and do not have disqualifying impediments for employment at the applicable MTF. This is a non-delegable responsibility of the Contractor. 1.3.1.8. The Contractor will submit applications for only those contract providers who can reasonably be anticipated to render the actual, substantial performance on the contract. The submission of primary contract providers for credentialing who lack the requisite qualifications, or who will not work at all, is unacceptable and will be considered a failure to perform. 1.4. RELATIONSHIP OF THE PARTIES, PROFESSIONAL LIABILITY RESPONSIBILITY, AND PROCEDURES. 1.4.1. RELATIONSHIP OF THE PARTIES. This is a personal services contract as defined in Federal Acquisition Regulation (FAR) 2.101. The health care provider who furnishes services under this contract is subject to the day-to-day supervision and control of employees of the United States. The COR and applicable Flight Commanders will provide the supervision and control where the services are performed. 1.4.2. PROFESSIONAL LIABILITY RESPONSIBILITY. The healthcare provider's status as a personal servant of the United States entitles it to applicable coverage of the Federal Tort Claims Act as provided in the Medical Malpractice Immunity Act, 10 U.S.C. 1089. Therefore, the healthcare provider shall not be liable for claims of personal injury or death, allegedly caused by the negligence of the healthcare provider, which occur within the scope of work performed by the healthcare provider under this contract, and are not otherwise compensated for, or covered by, private insurance. Such claims will be processed in accordance with the procedures established by those statutes, implementing regulations, and as set out below. The Contractor is not required to maintain dental malpractice liability insurance, and the government will not reimburse or otherwise pay for such insurance should any be purchased. 1.4.3. CLAIMS PROCEDURES. If any suit or action is filed or any claim is made against the health care provider, which occurred as a result of work performed by the healthcare provider under this contract, the healthcare provider shall: 1.4.3.1. Immediately notify the COR and promptly furnish copies of all pertinent papers received; 1.4.3.2. Cooperate with the Government, without further compensation, in the processing, review, settlement or defense of the suit, action or claim; and; 1.4.3.3. Authorize Government representatives to settle or defend the claim and to represent the health care provider in, or take charge of, any litigation involved in such an action. The health care provider may participate, at his own expense, in defense of such claim or litigation. 1.4. DENIAL/TERMINATION OF PRIVILEGES. 1.4.1. Actions to limit, suspend, or revoke clinical privileges shall be in accordance with the procedures outlined in AFI 44-119, Medical Quality Operations. 1.4.2. The CO and the Contractor shall be notified by the COR as soon as possible when the necessity to exercise such authority becomes apparent. The COR will also provide the CO and the Contractor with copies of documentation initiating the revocation process if such actions become apparent. 1.5. EDUCATION AND TRAINING REQUIREMENTS. The Contractor must submit in writing to the MTF commander through the COR any request for waivers to the education and training requirements. The waiver request must explicitly state what requirement the Contractor is requesting be waived. 1.5.1. Provider must have graduated from an approved school of dental hygiene or dental assistant, accredited by ADA and acceptable to the U.S. Air Force Surgeon General. Current Basic Life Support (BLS) course completion is required dependent upon AFI 44-102.Medical Care Management. Contract dental hygienists or dental assistants shall have a minimum of 1 year of experience following graduation from dental hygiene or dental assistant school. Contract dental hygienists or dental assistants shall be capable of performing the full range of dental services commensurate with a degree in Dental Hygiene or Dental Assistance. In addition, each contract dentist hygienist or dental assistant shall have been performing in these duties during 12 of the last 36 months immediately prior to performance on this contract. 1.5.2. The Contractor must submit in writing to the 42 MDG/CC through the COR any request for waivers to the education and training requirements. The waiver request must explicitly state what requirement the Contractor is requesting be waived. The dental hygienist/assistant shall meet the following minimum qualifications: 1.5.3. Knowledge is mandatory of: oral prophylaxis, preliminary periodontal examinations involving diagnostic tests and x-rays, oral health education, preparation of treatment plans for plaque control, and application of topical fluorides and desensitizing agents to the teeth. Additionally, the position requires planning, conducting, and evaluating preventive dental health programs. The position of dental hygienist/assistant requires knowledge of the concepts, techniques, and procedures of dental hygiene/assistant. 1.5.4. Knowledge is mandatory of: Fundamentals of physiology; dental therapeutics; sterile techniques; emergency dental care; oral hygiene; dental materials; instruments; dental treatment room procedures; medicines; systemic diseases; oral prophylaxis techniques; dental health programs; infection control procedures; dental administration; budgeting; equipment maintenance requirements; and physical properties of dental materials. 1.5.5. Experience is mandatory in performing and supervising functions such as taking dental radiographs, maintaining dental equipment, performing oral prophylaxis procedures, and assisting dental officer in patient treatment. 1.6. HEALTH REQUIREMENTS: 1.6.1. PREASSIGNMENT MEDICAL EVALUATION: No contract employee shall perform health care services under this contract unless a pre-assignment medical evaluation has been performed not more than thirty (30) calendar days prior to submission of credentials. The purpose of this medical evaluation is to determine if the individual, from a healthcare standpoint, possesses the minimum physical abilities needed to perform the proposed job without significant risk to personal health or the health and safety of others. As a minimum, the individual shall be free of physical defects or medical conditions which might reasonably be expected to place other workers, patients, or the public at risk. Not later than five (5) days prior to the commencement of performance of health care services under this contract by any employee, the Contractor shall provide to the Public Health (Employee Health) Flight certification that such employees have completed the medical evaluation requirements identified below. This certification shall state the date on which the examination was completed, the doctor's name that performed the examination and a statement concerning the physical health of the individual. Initial documentation is required for: MMR (immunization or titer levels for Rubella and Rubeola), history of chicken pox disease or positive titer (varicella vaccination must be accomplished if lack of immunity), TB Mantoux skin test (IPPD) if positive, minimum requirement will be follow-up with contractors physician and a chest x-ray. A physician must provide documentation of "no active respiratory disease", Hepatitis B vaccination/series are required for all personnel with occupational risk of exposure (declination are not acceptable, this is a condition of employment) and if the employee will be involved in exposure-prone procedures (ex: dentist, dental hygienist) they will have their HbsAg status determined. This is to be done by providing documentation of the HbsAb (if positive they will be referred to the MTF Credentials committee to determine scope of practice). If, in the opinion of the evaluating dental practitioner, the individual is found to be qualified for duty, the medical statement shall include the following wording: "(NAME OF EMPLOYEE) possesses the minimum physical abilities to perform the proposed duties of a (insert job title). He/she has documented proof of immunization against/immunity to rubeola, rubella, and hepatitis B and does not have an active infectious condition which might place others at risk." If, in the opinion of the evaluating medical practitioner, the individual does not possess the minimum capabilities needed to perform the proposed job or does not meet the conditions of employment or will pose a risk to others, the medical statement shall contain the following wording: "For medical reasons, (NAME OF EMPLOYEE) is not qualified for employment as a (insert job title)." Certification shall be provided to the CO, who will forward to the MTF Employee Health Office. 1.6.2. ANNUAL MEDICAL EVALUATION. All contract employees performing health care services under this contract shall complete annual medical evaluations as required by the MTF hospital employee health program. The contractor shall provide to the COR a certificate, as described above, documenting the results of this evaluation. 1.6.3. PREVENTIVE, PROPHYLACTIC, AND FOLLOW-UP PROCEDURES. The contractor shall ensure that his/her employees are in compliance with preventive, prophylactic and follow-up procedures, as well as infection control and employee health program procedures, as established by the MTF. The Government will provide required preventive, prophylactic and follow-up procedures to contract employees in the military MTF. The Contractor shall reimburse payment for these services. If care is received elsewhere, the Contractor shall provide written verification of treatment. 1.7. EMERGENCY HEALTH CARE. The MTF will provide emergency health care for contract personnel for injuries occurring while on duty in the MTF. These services will be billed to the Contractor at the current full reimbursement rate. 1.8. HOURS OF OPERATION. Core patient care hours are 7:00am - 4:00pm, Monday through Friday. Contract employees shall be present during core hours with additional time to complete documentation and manage the empanelled population as required. Expectations are a minimum of 40 hours up to 60 hours average per week. Contract personnel should follow command announcements for reporting to work as it relates to inclement weather or base closures. 1.9. FEDERAL HOLIDAYS/MTF CLOSURE. The Contractor will not provide routine services on federal holidays. The Contractor will not provide routine services during Department of Defense (DOD), AF or Wing-declared down-days, or events which result in dental facility closure. (Some exceptions may apply as directed by the MDG COR staff.) Note: for Squadron functions/emergency base closure, i.e. weather, contractors will not be reimbursed or paid for these events. Also, alternate duty location events will not be reimbursed. 1.10. ON CALL/AFTER DUTY RESPONSE TIME. The contract provider shall not provide on call services. 1.11. SECTION FLEXIBILITY. Contract personnel may be required to work in other dental duty sections. Contract personnel shall be flexible in rotating temporarily, or permanently moving into, other duty sections upon notification of the COR. Contract personnel identified for rotation or temporary move into a new duty section will be required to undergo orientation to new section IAW Para. 1.13 of this PWS. 1.12. DENTAL QUALITY ASSURANCE/RISK MANAGEMENT (QA/RM). 1.12.1. Health care providers shall participate in QA/RM activities to the extent required by AFI 44-119, Medical Quality Operations and the individual MTF QA/RM plan or regulation. This includes, but is not limited to, peer review at a minimum of 10 encounters per month. 1.12.2. The Government will evaluate the provider's professional performance, as differentiated from administrative performance under this contract using quality assurance standards specified in AFI 44-119, Medical Quality Operations. 1.13. ORIENTATION. The Contractor shall ensure that all contract providers participate in the MTF orientation and service/clinic specific orientation prior to furnishing services under this contract. Clinic orientation must occur within five (5) duty days of employment start date. MTF orientation must occur within thirty (30) days of employment start date. 1.14. CONTINUING EDUCATION (CE) DENTAL REQUIREMENTS. Health care providers registered or certified by national/dental associations shall continue to meet the minimum standards for CE to remain current as prescribed in AFI 41-117, Medical Service Officer Education. CE shall be obtained at no additional cost to the Government and shall be reported to the COR and MTF Credentials Committee annually on the first normal duty day in January for the previous calendar year. Periodic CE may be conducted at the MTF and will be available, at no cost, to any healthcare provider desiring to attend. 1.15. ANNUAL TRAINING REQUIREMENTS: All contract employees must complete any mandatory and annual training required IAW DoD, Air Force Instructions, medical facility training requirements, and regulatory agencies (AAAHC, Health Insurance Portability and Accountability Act (HIPAA), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Health Services Inspection (HSI), AF Computer Security Policy, and AF Safety Policy). They must complete any additional training as dictated by facility or work-center. 1.16. MTF PROVIDER DIRECTORY: Contract providers will provide information necessary for paper and web-based MTF provider directory. Credentialed providers will include information such as name, degree, specialty, board status, office telephone and fax number, and licensing information. A picture of the provider is encouraged, but optional. Additional education and training information completed by the provider may also be included. Educational information and links to health information for the provider's patient population is also encouraged. 1.17. GOVERNMENT COMPUTER ACCESS: The contractor will ensure that all Contract employees comply with the requirement to obtain the minimum personnel security investigations as prescribed by DoDD 5200.2,Personnel Security Program and AFI 31-501,Personnel Security Program Management,, paragraphs 3.27.3.7 to 3.27.3.7.2. The contractor will work with the MTF to ensure that the pre-employment screening process for each employee classified as Automatic Data Processing I, II, III (as defined in DoDD 5200.2-R) includes the appropriate investigations and that each contract employees have the appropriate questionnaires and forms to be completed. All completed forms will be reviewed by the contractor and forwarded to the MTF for processing. The contractor understands that, while the MTF Commander may allow contractor personnel to temporarily occupy non-critical sensitive positions pending National Agency Check (NAC), employee will be immediately removed from the position if at any time the NAC receives unfavorable adjudication, or, if other unfavorable information that would affect the NAC becomes known. 1.18. CUSTOMER COMPLAINTS. Any customer complaints will be documented on the Customer Complaint Record (CCR). SECTION 2 SERVICES SUMMARY (SS) Performance Objective PWS Para Performance Threshold Arrange for Replacement Staff 1.2.3. 95% Compliance Work Requirement 4.1.1. thru 4.1.18. 90% Weekly Patient Sensitivity 4.1.9. 95% Compliance Complete paper and electronic dental records within 72 hours of the patient encounter 4.1.17. 95% Compliance SECTION 3.0 GOVERNMENT FURNISHED PROPERTY AND SERVICES 3.1. GENERAL. The Government will provide the following equipment, supplies, and services listed below: 3.1.2. EQUIPMENT/OFFICE FURNITURE. The provider shall have joint use of all available equipment for performing services required by this contract. 3.1.2.1. PAGER. The MTF will provide a cell phone for use by the contract dental hygienist/assistant if required for on-call services. 3.1.2.2. PERSONAL PROTECTIVE EQUIPMENT (PPE). The Government will furnish the provider 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. 3.1.3. FORMS. The MTF will provide required government forms used in the performance of services. 3.1.4. SUPPLIES. The MTF will provide dental and non-dental supplies commonly used in the facility for the care and management of patients. 3.1.5. COMPUTER EQUIPMENT. The MTF will provide computer equipment required to schedule, check in, document, order ancillary services, and maintain appropriate electronic dental information that supports the hard copy dental record. The MTF will provide required training for these systems. The contractor will be required to use the computer systems that are standard for the support of health care delivery at the MTF. 3.2. CONTRACTOR FURNISHED ITEMS AND SERVICES 3.2.1. GENERAL. Except for those items or services specifically stated in Section 3 to be Government furnished, the Contractor shall furnish everything required to perform this contract in accordance with all of its terms and conditions. SECTION 4 SPECIFIC TASKS 4.1. SPECIFIC PROCEDURES FOR WHICH THE CONTRACTOR SHALL BE RESPONSIBLE. The Contractor shall not introduce services other than those required in this PWS without prior recommendation to, and approval of, the Contracting Officer (CO). If the scope of the contract is changed by new services, the Contracting Officer (CO) will incorporate the change into the contract prior to implementation. The contractor shall provide outpatient dental care as scheduled by the Government. Be subject to the same Quality Control standards as those applied to comparable military or civil service providers. 4.1.1. WORK REQUIREMENT. Provider will be required to see minimum of seven (7) patients per day and a minimum of 35 bookable appointments per week, in accordance with the template manager. If the provider drops below this requirement for four (4) consecutive weeks, without adequate justification, the Chief of Dental Services will review whether continued services will be required from this provider. This requirement will apply to newly hired providers only after sixty (60) days of work has been completed. 4.1.1.1. The duties include but are not limited to the following: 4.1.1.2. The Contractor shall not introduce services other than those required in this PWS without prior recommendation to, and approval of, the CO. If the scope of the contract is changed by new services, the change will be incorporated into the contract by the CO prior to implementation. 4.1.1.3. Provide outpatient dental services for patients as scheduled by the Government. 4.1.1.4. Provide comprehensive oral health and dental hygiene treatment to diverse patient groups with assistance from members of the dental service. 4.1.1.5. Be subject to the same Quality Control standards as those applied to comparable military or civil service dental hygienists/assistants 4.1.1.6.The hygienist of assistant shall be able to perform the full range of dental services commensurate with the dental hygienist and assistant specialty. Duties include the following: 4.1.1.7. Patient Evaluation. Complete an evaluation of every patient and formulate a dental hygiene diagnosis and treatment plan, in collaboration with the dentist and patient. Examine patient's oral cavity including mouth, throat, and pharynx. Record conditions of teeth and surrounding areas. Refer patients with abnormalities to the dentist. Clinical hygienists and assistants usually work alone in a treatment room designed to provide preventive, therapeutic and education services, and work under the supervision of a dentist. 4.1.1.8. Assists dental officer with patient treatment. Receives patient, examines dental record, and prepares patient for treatment. Adjusts dental chair, and selects and arranges instruments and medications. Takes and records blood pressure. Assists in managing emergency procedures. Retracts tissues and maintains clear operating field. Prepares syringe for injection of anesthetics. Prepares materials for making impressions and restoring defective teeth. Records entries in individual dental records indicating oral cavity condition and treatment accomplished. 4.1.1.9. Oral Prophylaxis. Includes seating and draping patients, applying disclosing solution to teeth, supra/sub-gingival scaling, polishing, cleaning and polishing removable dental appliances worn by patients; and placing pit and fissure sealants on teeth when indicated. Perform the following procedures: 4.1.1.10. Adult and child Prophylaxis 4.1.1.11. Topical Fluoride, Professional Application, Self-Applied, Group 4.1.1.12. Individual/group Oral Health Counseling 4.1.1.13. Periodontal Scaling 4.1.1.14. Performs dental health duties such as scaling procedures using dental hand instruments and oral hygiene aids. Applies anticariogenic agents and materials. Polishes restorations and instructs patients in dental health maintenance. Assists in planning, developing, and conducting comprehensive dental health programs. 4.1.1.15. Exposes and processes dental radiographs. Adjusts radiographic machine, places film in proper position, and exposes intraoral film. Places patient in proper position for extraoral radiograph and exposes film. Processes, labels, and mounts film. Duplicates dental radiographs. Practices and enforces accepted radiation safety standards. 4.1.1.16. Preventive Treatment and Education. Develops methods and carries out studies for evaluating the effectiveness of the preventive dentistry program. Provide preventive treatment and education to promote the values of oral and general health and wellness to support population health strategies. Common activities include dental prophylaxis, hygiene and tissue indices, tobacco cessation counseling, professional topical fluoride treatment, oral health counseling, and application of pit and fissure sealants. Compiles statistical data and written reports on the participation in the preventive dentistry program. 4.1.1.17 Specialized Treatment. Provide specialized treatment designed to achieve and maintain oral health. Specialized treatment includes scaling and root planning of tooth surfaces, application of local chemotherapeutic agents, control of pain and anxiety, continuous evaluation of the patient's response to therapy, provision of long-term supportive dental care, and management of medical emergencies. 4.1.1.18. Insertions and Restorations. Insert and remove temporary fillings; insert and remove temporary crowns and bridges; irrigate and pack dry sockets. 4.1.1.19. Adjustments and Repairs. Administer smoothing and polishing restorations, cleaning and polishing removable appliances. 4.1.1.20. Surgical Assistance. Assist in surgically related procedures such as removing sutures, placing periodontal packs, controlling bleeding by direct pressure, performing gingival curettage and giving instructions to patients after deep curettage, removing medications from dry sockets, and retracting oral tissues in surgical procedures. 4.1.1.21. Periodontist Assistance. Assist Periodontist with perio patients. 4.1.1.22. Community Oral Health Services. Provide community oral health services in a variety of settings, depending on the local mission, resources, and opportunities for community involvement. Community outreach programs are often associated with special and recurring events such as national children's dental health month, health fairs, oral cancer screening programs, tobacco cessation classes, and prenatal counseling programs. 4.1.1.23. Maintain Dental Records. Maintain dental records in accordance with established clinic procedures. Enter workload, dental readiness information, and appointment scheduling utilizing the Corporate Dental Applications (CDA). 4.1.1.24. Supervision. Dental hygienists and Assistants function under the indirect or general supervision of a dentist, as defined by the American Dental Association. This requires that a dentist shall diagnose conditions to be treated, personally authorize the procedures, and evaluate the performance of the dental hygienist and provide clinical feedback. 4.1.1.25. Indirect supervision requires the dentist to be in the clinic or treatment facility and to be physically available to provide consultation and oversight. General supervision does not require the dentist to remain in the clinic or treatment facility, but the dentist shall be available for consultation by phone while the hygienist/assistant is performing direct patient care activities. 4.1.1.26. The degree of supervision required varies with the nature of the procedure and the medical and dental history of the patient. Appropriate levels of supervision shall be chosen that will not jeopardize the systemic or oral health of the patient. 4.1.1.27. Conducts military unique dental examinations of personnel with special standards of dental care. Examines personnel requiring special dental care standards to determine fitness for special duties, or to recommend continuance, removal, or return to duty status. 4.1.2. REFERRALS AND CONSULTS. The provider shall follow DoD and Air Force regulations and policies when arranging for a referral or consult. The provider shall inform patients of the required referral or consult by indicating the specialty involved. All consults and referrals will adhere to the MTF Referral Management process. 4.1.3. PRESCRIPTIONS. The provider shall use and follow the applicable MTF formulary for prescriptions for all patients that received care at the MTF. The formulary list is approved and maintained by the MTF Pharmacy and Therapeutics Committee. Any drug requested by the contract provider that is not listed on the formulary must be approved by the Chief of the Dental Staff and/or Pharmacy and Therapeutics Committee. 4.1.4. PROCEDURE GUIDANCE. Contractor providers shall perform procedures compatible with the dental service's operating capacity and equipment. New dental procedures/services shall not be introduced without prior recommendation to, and approval of the MTF Commander or authorized representative. The providers shall provide clinic and minor procedure services for patients as scheduled by the Government and credentialed/privileged to perform. 4.1.5. OTHER SUPPORT. Contract personnel shall provide immediate evaluation and management of emergency problems as they occur. The contract provider could also provide consultation in complex cases. Prepare and review case histories and clinical records. Perform and direct diagnostic procedures, including x-ray examinations and clinical laboratory tests. Interpret test results and evaluate examination findings. 4.1.6. TOTAL QUALITY IMPROVEMENT. The contract provider shall assess dental care to assure its quality. All providers shall participate in a continual process of self-evaluation and strive for excellence in the Maxwell Dental Clinic. 4.1.7. RECORDS. The contractor shall be responsible for creating, maintaining, and disposing of only those Government required records, which are specifically cited in this PWS, or as may be required by the provisions of the directive listed in Appendix I of this PWS. If requested by the Government, the Contractor shall provide the original record or a reproducible copy of any such records within five working days of receipt of the request. 4.1.8. PATIENT LISTS. Patient lists, no matter how developed shall be treated as privileged information. Lists and/or names of patients shall not be disclosed to or revealed in any way for any use outside the MTF without prior written permission by the Chief of the Dental Staff. 4.1.9. PATIENT SENSITIVITY. Contract personnel shall respect and maintain the basic rights of patients, demonstrating concern for personal dignity and human relationships. Personnel receiving complaints validated by the COR and Chief of the Dental Staff shall be subject to counseling and, depending on the nature and severity of the complaint, separation from performing services under this contract. 4.1.10. RELEASE OF DENTAL INFORMATION. Contract personnel shall only release dental information obtained during the course of this contract to the patient, legal guardian, or other MTF staff involved in the care and treatment of that individual patient. 4.1.11. JUDGEMENT AND DECISIONS. Educate and counsel patients/families about their potential risk for diseases or injuries; make appropriate recommendations/referrals; conduct education and counseling in 1:1 or group setting as appropriate. 4.1.11.1 Coordinate with appropriate individuals/departments regarding delays in service that may impact quality patient care. 4.1.12. COMMUNICATION. Demonstrate strong customer service skills and foster development of those skills throughout entire MTF. 4.1.12.1. Communicate and collaborate with the appropriate members of the health care team to ensure that needs of assigned patients are met without duplication of effort. 4.1.12.2. Make the dental care and MTF system as responsive to patients' needs as possible. 4.1.12.3. Establish liaisons with case managers. Coordinate services through the continuum of care for complex patients. 4.1.12.4. Establish and maintains good interpersonal relationships with co-workers, families, peers, and other health team members 4.1.13. MEETINGS. Contractor personnel shall attend and participate in meetings, professional staff conferences, and other appropriate professional activities as directed. 4.1.14. INFECTION CONTROL AND SAFETY. The contractor shall comply with all MTF infection control and safety procedures, practices, and standards. 4.1.15. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 2013: All individuals performing services at the MTF are required to complete HIPAA Act of 2013 Privacy Rule training and will be held accountable for complying with the MTF's specific health information privacy and security policies and procedures. 4.1.16. PERFORMANCE EVALUATION MEETINGS. The CO shall require the Contractor or his representative to meet with the CO, contract administrator, COR, and other government personnel at least quarterly, and as often as deemed necessary. The Contractor may request a meeting with the CO when he deems such necessary. Meetings will be documented in the contract file with written minutes signed by the contract manager and the CO, or contract administrator. Should the Contractor not concur with the minutes, such non-concurrence shall be provided in writing to the CO within ten (10) calendar days of receipt of the minutes. 4.1.17. DOCUMENTATION. The contractor shall prepare all documentation to meet or exceed established standards of the MTF to include but not limited to: timeliness (within 72 hours of the patient encounter), legibility, accuracy, content and signature. Only MTF and Air Force approved abbreviations may be used to document of care in the health care record. Contract personnel shall ensure complete patient identifying information is on all documentation that is to become part of the health care record. Contract dentists may be required to review military dentist dental records for quality assurance, accuracy and compliance with the standard of care. Corrections will be made by the Government or under the direction of the government representative. 4.1.18. SUPPORT DURING MILITARY TRAINING. Contract personnel may periodically be required to continue clinical operations while DoD employees attend mandatory training or other DoD-specific activities. SECTION 5 SECURITY REQUIREMENTS FOR UNCLASSIFIED SERVICES 5.1 Contractor Notification Responsibilities: The contractor shall notify the 42d Air Base Wing Information Protection Office within 30 days before on-base performance of the service. The notification shall include: a. Name, address, and telephone number of contractor representatives. b. The contract number and contracting agency. c. The reason for the service (i.e., work to be performed). d. The location(s) of service performance and future performance, if known. e. The date service performance begins. f. Any change to information previously provided under this paragraph. 5.2 Security Manager Appointment: The contractor shall appoint a security manager for on-base service performance. The security manager may be a full-time position or an additional duty position. The security manager shall provide employees with training required by DoDM 5200.01, DoD Information Security Program, Volume 3, Enclosure 5, and AFI 31-401, Information Security Program Management. The contractor will provide 42d Air Base Wing Information Protection Office with name and telephone number of the security manager. 5.3. Visit Request: Contractors participating in the National Industrial Security Program are authorized to use Joint Personnel Adjudication System (JPAS) in lieu of sending Visitor Authorization Letters (VALs) for classified visit to Department of Defense facilities and military installations. VALs are only required if the contractor isn't using JPAS or if contractor personnel whom access level and affiliation are not accurately reflected in JPAS. However, some agencies may still require VALs to be submitted for access to their facilities. 5.4. Obtaining and Retrieving Identification Media: As prescribed by the AFFARS 5352.242-9000, Contractor access to Air Force installations, the contractor shall comply with the following requirements: a. The contractor shall obtain base identification for all contractor personnel who make frequent visits to or perform work on the Air Force installation(s) cited in the contract. Contractor personnel are required to wear or prominently display installation identification badges or contractor-furnished identification badges while visiting or performing work on the installation. b. The contractor shall submit a written request on company letterhead to the contracting officer listing the following: contract number, location of work site, start and stop dates, and names of contractor employees needing access to the base. The letter will also specify the contractor individual(s) authorized to sign requests for base identification credentials. The contracting officer will endorse the request and forward it to the issuing base pass and registration office for processing. When reporting to the base pass and registration office for issue of military identification credentials for access to the installation, contractor individual(s) will need a valid state or federal issued picture identification. To operate a vehicle on base contractor individual(s) will need to provide a valid driver's license, current vehicle registration, and a valid vehicle insurance certificate. c. During performance of the service, the contractor shall be responsible for obtaining required identification for newly assigned personnel and for prompt return of credentials for any employee who no longer requires access to the work site. d. Upon completion or termination of the service or expiration of the identification passes, the contractor shall ensure that all base identification passes issued to contractor employees are returned to the issuing office. The issuing office will verify all base identification passes have been returned and/or accounted for. The issuing office will forward a memorandum to the contractor individual authorized to sign request for base identification credentials indicating the badges have been turned in. The DD Form 577 (signature card) for the contractor authorized requestor will be destroyed and the individual will not long be authorized to sign DD Form 1172 (Application for Uniform Services Identification Cards). e. Failure to comply with these requirements may result in withholding of final payment. 5.5. Pass and Identification Items: The service shall ensure the following pass and identification items required for service performance are obtained for employees: a. DD Form 1172, Application for Uniformed Services Identification Card (AFI 36-3026, Identification Cards For Members of The Uniformed Services, Their Family Members, and Other Eligible Personnel, and AETC Instruction 36-3001, Issue and Control of AETC Civilian Identification (ID) Cards). b. DoD Common Access Card (CAC), (AFI 36-3026). c. DBIDS card/pass (AF Form 75 may be used only if DBIDS is inoperable). d. AF Form 1199, USAF Restricted Area Badge, or locally developed badge, if required. 5.6. Computer and Network Access Requirements: Contractor personnel that required access to unclassified government computers and operations systems (Automated Information Systems - AIS) will be designated as AIS-III - Nonsensitive Positions. Contractor personnel must submit a National Agency Check with Inquiries (NACI) and the NACI be favorability adjudicated before operating government furnished computer workstations or systems that have access to Air Force e-mail systems. These investigations shall be submitted by the government at no additional cost to the contractor. The contractor shall comply with the DoD 5200.2-R, Personnel Security Program, and AFI 33-119, Air Force Messaging, requirements, AFMAN 33-282, Computer Security; AFSSI 7700, Emission Security (EMSEC) Program; and applicable AFKAGs, AFIs, and AFSSIs for Communications Security (COMSEC); and AFI 10-701, Operations Security (OPSEC) Instructions. 5.7. Unescorted Entry to Restricted Areas: Contractor personnel requiring unescorted entry to restricted areas designated by the installation commander shall comply with base access requirements; AFI 31-101, Integrated Defense, DoD 5200.2-R, and AFI 31-501, Personnel Security Program Management, as applicable. Contractor personnel shall be the subject of a favorably adjudicated National Agency Check with Inquiries (NACI) investigation to qualify for unescorted entry to a restricted area. The Air Force shall submit NACI investigations for contractor employees at no additional cost to the contractor. Contractor personnel must contact the unit security manager to obtain the required paperwork for NACI and restricted area badges. 5.8. Entry Procedures to Controlled/Restricted Areas: The contractor shall comply and implement local base procedures for entry to Air Force controlled and restricted areas. 5.9. Freedom Of Information Act Program (FOIA): The contractor shall comply with DoD Regulation 5400.7-R/Air Force Supplement, DoD Freedom of Information Act Program, requirements. The regulation sets policy and procedures for the disclosure of records to the public and for marking, handling, transmitting, and safeguarding For Official Use Only (FOUO) material. The contractor shall comply with AFI 33-332, Air Force Privacy Act Program, when collecting and maintaining information protected by the Privacy Act of 1974 authorized by Title 10, United States Code, section 8013. The contractor shall maintain records in accordance Air Force manual (AFMAN) 33-363, Management of Records; and disposed of in accordance with Air Force Records Information Management System (AFRIMS) Records Disposition Schedule (RDS) located at https://www.my.af.mil/gcss-af61a/afrims/afrims/. 5.10. Reporting Requirements: The contractor shall comply with AFI 71-101, Volume-1, Criminal Investigations, and Volume-2, Protective Service Matters, requirements. Contractor personnel shall report to 42d Air Base Wing Information Protection Office, any information or circumstances of which they are aware may pose a threat to the security of DoD personnel, contractor personnel, resources, and classified or unclassified defense information. Contractor employees shall be briefed by their immediate supervisor upon initial on-base assignment and as required thereafter. 5.11. Physical Security: Areas controlled by contractor employees shall comply with base operations plans/instructions for FPCON procedures, Random Antiterrorism Measures (RAMS) and local search/identification requirements. The contractor shall safeguard all government property, including controlled forms, provided for contractor use. At the close of each work period, government training equipment, ground aerospace vehicles, facilities, support equipment, and other valuable materials shall be secured. 5.12. Internal Operating Instructions: The contractor will adhere to the Air Force activity operating instructions (OI) for internal circulation control, protection of resources, and to regulate entry into Air Force controlled areas during normal, simulated, and actual emergency operations. 5.13. Key Control: The contractor will adhere to the Air Force activity operating instructions control procedures to ensure keys issued to the contractor by the government are properly safeguarded and not used by unauthorized personnel. The contractor shall not duplicate keys issued by the government. All government issued keys will be turned at the end of employment or contract. Lost keys shall be reported immediately to the Air Force activity that issued the keys. The government replaces lost keys or performs re-keying. The total cost of lost keys, re-keying or lock replacement shall be deducted from the monthly payment due the contractor. 5.14. Government Authorization: The contractor shall ensure its employees do not allow government issued keys to be used by personnel other than current authorized contractor employees. Contractor employees shall not use keys to open work areas for personnel other than contractor employees engaged in performance of their duties, unless authorized by the government functional area chief. 5.15. Access Lock Combinations: Access lock combinations are "For Official Use Only" and will be protected from unauthorized personnel. The contractor will adhere to the Air Force activity operating instruction (OI) for ensuring lock combinations are not revealed to unauthorized persons and ensure the procedures are implemented. The contractor is not authorized to record lock combinations without written approval by the government functional director. 5.16. Security Alarm Access Codes: Security alarm access codes are "For Official Use Only" and will be protected from unauthorized personnel. Security alarm access codes will be given contractors employees who required entry into areas with security alarms. Contractor employees will adhere to the Air Force activity operating instructions and will properly safeguard alarm access codes to prevent unauthorized disclosure. Contractor will not record alarm access codes without written approval by the government functional director. 5.17. Traffic Laws: The contractor and their employees shall comply with base traffic regulations. 5.18. Cellular Phone Operation Policy: The use of cellular phones while operating a motorized vehicle is prohibited on Maxwell-Gunter. Although discouraged, drivers are authorized to use devices, i.e. ear bud or ear boom, which allows their cellular phone to be operated hands-free. The device must not cover both ears. This policy applies to everyone driving on Maxwell-Gunter AFB. 5.19. Security Education and Training: The contractor will be required to participate in the government's in-house and web-based security training program under the terms of the contract. The government will provide the contractor with access to Advance Distributed Learning Service (ADLS) web site. Contractor personnel will complete Information Protection and DoD Information Assurance computer base training and other security related training as directed at the ADLS web site. 5.20. Healthcare: Healthcare provided at the local military treatment facility on an emergency reimbursable basis only. 6.0. APPENDICES Appendix I Applicable Publications Appendix II Definitions Appendix III HIPAA Privacy and Security Business Associate Contract Language (June 20, 2013) Appendix I PUBLICATIONS Publications and forms applicable to the PWS are listed below. The Contractor is obligated to follow these publications. These publications are available at http://www.e-publishing.af.mil/ and maintained by AF publishing. The government has coded publications as mandatory (M) or advisory (A). The contractor shall follow those publications coded as mandatory to the extent (that is, the specific procedure in a paragraph, section, chapter or volume) specified in the PWS. The contractor shall be guided by those coded advisory to the extent necessary to meet requirements in this PWS. The government may issue supplements or amendments to listed publications from any organizational level during the life of the contract. It is the responsibility to use the most current version of all publications. The contractor shall immediately implement those changes in publications that result in a decrease or no change in the contract price. Before implementing any such revision, supplement, or amendment that will result in an increase in contract price, the contractor shall submit to the CO a price proposal for approval. Price proposals shall be submitted within thirty (30) calendar days from the date the contractor receives notice of the revision, supplement, or amendment giving rise to the increase in cost of performance. The government will consider changes in the contract price due to supplements and amendments shall be considered under the FAR 52.212-4 "Contract Terms and Conditions-Commercial Items" clause. The government will continue to supply the government forms needed for daily operations. Upon completion of the contract, the contractor shall return to the government all issued publications and unused forms. M = Mandatory Guidance, A = Advisory or Supplemental Information The following documentation will provide all needed background to offer insight and direction. Reference Number Title (and Website, if applicable) Date M/A Applicable Paragraph AETCI 36-3001 Issue and Control of AETC Civilian ID Cards 30 Sep 1999 M All AFI 10-701 Operations Security (OPSEC) Instructions 8 Jun 2011 M All AFI 31-401 Information Security Program Management 1 Nov 2005 M All AFI 31-501 Personnel Security Program Management 27 Jan 2005 M All AFI 31-601 Industrial Security Program Management 29 Jan 2005 M All AFI 36-3026 Identification Cards for Members of the Uniformed Service, Their Family Members, and Other Eligible Personnel 29 Jul 1999 M All AFI 41-117 Medical Service officer Education 19 Oct 2011 M All AFI 44-102 Medical Care Management 29 Jan 2012 M All AFI 44-119 Medical Quality Operations 26 Aug 2011 M 3.1-5. DoDD 5220.22 Industrial Security Regulation 24 Sep 2004 M All DoDM 5200.01 Information Security Program 1 Nov 2005 M All DoDD 5200.2-R Personnel Security Program 19 Jan 1993 M All DoDI 1402-5 Criminal History Background Checks on Individuals in Child Care Services 19 Jan 1993 M All DODD 5500.07 Standards of Conduct 29 Nov 2007 M All AFPD 31-6 Industrial Security 1 Apr 2000 M All AFMAN 31-116 Air Force Motor Vehicle Traffic Supervision 9 May 2012 M All APPENDIX II DEFINITIONS GENERAL DEFINITIONS. As used throughout this work statement, the following terms shall have the meaning set forth in accordance with the terms of this PWS and the contract. CLINICAL PRIVILEGES. Those inpatient and ambulatory clinical activities permitted the provider in the granting Medical treatment facility (MTF) after evaluation by the credentials function and approved by the Medical center commander. CONTRACTING OFFICER'S REPRESENTATIVE. Those actions taken by the Government to assure services meet the requirements of the contract. CREDENTIALS. Documents providing evidence of education, training, licensure, experience, board certification and expertise of a health care provider. CREDENTIALS COMMITTEE. The professional body set up to review credentials, make recommendations on clinical privileges for providers, and to promote quality control in professional practice. FULL TIME EQUIVALENT (FTE). Provider: 1.0 (One) FTE represents 1920 hours. All 1,920 hours are productive. The Government does not reimburse physicians as independent contractors for Federal Holidays and vacation/sick time. GOVERNMENT. The federal government of the United States of America. HEALTH CARE PROVIDER. Any contract healthcare professional who, under regulations of a Military Department, is granted clinical practice privileges in a military MTF or Medical Treatment Facility or who is licensed or certified to perform healthcare services by a Governmental board or Agency or professional health care society or organization. MEDICAL TREATMENT FACILITY (MTF). Air Force hospitals or clinics, including all activities providing outpatient and/or in-patient healthcare services for authorized personnel. PERFORMANCE WORK STATEMENT (PWS). A document that accurately describes a service in terms of the output requirements. PREPRIVILEGING. The application of a screening process whereby prospective DoD healthcare providers, required to be privileged to provide patient care within MTFs, have their education, training, and past performance evaluated preliminary to their being considered for an active contractual relationship. PRIVILEGING. Frequently referred to as credentialing. The process whereby the medical center commander, or the major command surgeon general, upon recommendations from the MTF credentials function, grants to individual health care providers the privileges and responsibility of providing specified dental and dental care within the MTF. PROCURING CONTRACTING OFFICER (PCO). A person duly appointed with the authority to enter into, administer, and terminate contracts on behalf of the Government. QUALITY IMPROVEMENT/RISK MANAGEMENT (QI/RM) COMMITTEE. Committee responsible for the execution of the MTF QI/RM plans to include the duties outlined in AFI 44-119. The committee ensures an ongoing assessment of the quality and appropriateness of all dental care and will put in priority sequence suspected problems for evaluation, resolution, and follow-up. QUALITY IMPROVEMENT/RISK MANAGEMENT (QI/RM) PLAN. An organized document that describes the methods of doing QI reviews within the MTF. It designates the areas of responsibility and accountability for the QI program and the mechanisms for monitoring and evaluating patient care. It is consistent with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) monitoring and evaluation (M&E) approach and Air Force risk management (RM) efforts. QUALITY CONTROL (QC). Those actions taken by a Contractor to control the quality of output and to ensure that they conform to contract requirements and reasonable standards of dental care. VALID LICENSE. A grant of permission by an official agency of the District of Columbia, a state, commonwealth, or territory of the United States to provide care independently as a health care professional. Licenses must be current and unrestricted. TECHNICAL DEFINITIONS. Contract Provider - Any healthcare personnel providing dental services at this MTF who are either directly employed by, or who provide services pursuant to a contract with the Contractor. Healthcare worker - A provider. Basic Life Support (BLS) certification (CPR, or cardiopulmonary training). Required every two (2) years for all personnel, including contract personnel, working at the MTF. Primary Source Verification - The verification in writing or by documented telephone conversation from the original dental or nursing school, training or residency program, licensing or certifying boards, etc. The training and credentials claimed by a health care provider and used in the privileging process. &emsp; Appendix III HIPAA Privacy and Security Business Associate Contract Language (June 20, 2013) BAA Contractor Access to DoD Systems The contractor shall contact the COR and COTRs after being awarded a contract if access to a DoD system is required. The contractor is responsible for submitting the SF85P and FD 258 for their respective contractor employees if the Contractor employees are required to gain access to a DoD system for performance of this contract. As such, contractor personnel shall undergo appropriate background investigation (Trustworthiness Determination for Public Trust positions/ADP-IT) or have a security clearance and Information Assurance training if deemed necessary. The Contractor should be prepared for this process to take at least two (2) weeks. Prior to the submission of the SF85P for new contractor employees, the contractor's Facility Security Officer (FSO) shall submit the contract number, contract start date, contract end date, personnel names, and the ADP position designations, to the designated COTRs for verification and approval with a list of personnel being submitted for an ADP/IT Trustworthiness Determination. The Contractor's FSO shall submit all appropriate forms as provided by the COTRs to request a background investigation to the Office of Personnel Management (OPM) and obtain receipt confirmation as a prerequisite for contractor personnel to access DoD systems. The Standard Form 85P is available at: http://www.tricare.osd.mil/tmapivacy/sf85p.pdf. The Contracting company shall ensure all contractor personnel are designated as ADP/IT-I, ADP/IT-II where their duties meet the criteria of the position sensitivity designations. The contractor must notify the COR and COTRs when the security officer has submitted the SF85P user form to OPM for new employees. Upon termination of a contractor employee from the contract, the contractor's FSO must notify the COR and COTRs and OPM of the action, including the termination date. In both cases, the COR or the COTR must notify the Deputy Director, TMA Privacy Office at Pamela.Schmidt@tma.osd.mil. All emails should be sent using CAC encryption. Non-U.S. Citizens - Only United States citizens shall be granted a personnel security clearance, assigned to sensitive duties, or granted access to classified information unless approved by an authority designated in Appendix 6. Exceptions to these requirements shall be permitted only for compelling national security reasons. (DoD 5200.2-R. C2.1.1, AP6.6.1) Non-U.S. citizens are not being adjudicated by any government agency for a trustworthiness determination at this time. Non-U.S. Citizens are not allowed access to any DoD systems/networks. The contractor shall ensure that data, which contains PHI, is continuously protected from unauthorized access, use, modification, or disclosure. The contractor shall comply with all previously stated requirements for HIPAA, Personnel Security, Electronic Security, and Physical Security. Termination of access - Upon termination of a contractor employee the Contractor Point of Contact shall forward a request to have the employee deleted from DoD system access to the COR and COTRs. BAA TMA Privacy Office Standard Contract Language The Contractor shall establish appropriate administrative, technical, and physical safeguards to protect any and all Government data. The Contractor shall also ensure the confidentiality, integrity, and availability of Government data in compliance with all applicable laws and regulations, including data breach reporting and response requirements, in accordance with DFAR Subpart 224.1 (Protection of Individual Privacy), which incorporates by reference DoDD 5400.11, "DoD Privacy Program," May 8, 2007, and DoD 5400.11-R, "DoD Privacy Program," May 14, 2007. The contractor shall also comply with federal laws relating to freedom of information and records management. Health Insurance Portability and Accountability Act (HIPAA) The Contractor shall comply with all requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Pub. L. 104-191), as implemented by the HIPAA Privacy and Security Rules codified at 45 C.F.R. Parts 160 and 164, and as further implemented within the Military Health System (MHS) by DoD 6025.18-R, "DoD Health Information Privacy Regulation," January 24, 2003, and DoD 8580.02-R, "DoD Health Information Security Regulation, July 12, 2007. The Contractor shall also comply with all applicable HIPAA-related rules and regulations as they are published and as further defined by later-occurring Government requirements and DoD guidance, including current and forthcoming DoD guidance implementing applicable HIPAA amendments under the American Recovery and Reinvestment Act of 2009 (ARRA). Any rules and regulations that are published, and/or requirements that are defined after the award date of this contract, and that require expenditure of additional Contractor resources for compliance, may be considered "changes" and will be subject to the "changes" clause under the contract. Breach Response DoD 5400.11-R, "DoD Privacy Program," May 14, 2007, defines a breach as the "actual or possible loss of control, unauthorized disclosure, or unauthorized access of personal information where persons other than authorized users gain access or potential access to such information for other than authorized purposes where one or more individuals will be adversely affected." Within one hour of discovery, the breach must be reported to the US Computer Emergency Readiness Team (US CERT) at https://forms.us-cert.gov/report/ and to the TMA Privacy Office at PrivacyOfficerMail@tma.osd.mil The Contractor shall adhere to the reporting and response requirements set forth in the Office of the Secretary of Defense (OSD) Memorandum 1504-07, "Safeguarding Against and Responding to the Breach of Personally Identifiable Information," June 5, 2009; DoD 5400.11-R, and applicable TMA Privacy Office guidance, including current and forthcoming DoD guidance on ARRA breach notification requirements, available at: http://www.tricare.mil/tmaprivacy/breach.cfm. Systems of Records In order to meet the requirements of 5 U.S.C. 552a, the Privacy Act of 1974, and its implementation within the Military Health System (MHS) under DoD 5400.11-R, " DoD Privacy Program," May 14, 2007, Contractors must identify to the Contracting Officer Representative (COR) systems of records that are maintained or operated for TMA where records of personally identifiable information (PII) collected from individuals are maintained and specifically retrieved using a personal identifier. Upon identification of such systems to the COR, and prior to the lawful operation of such systems, Contractors must coordinate with the TMA Privacy Office at SORmail@tma.osd.mil to complete systems of records notices (SORNs) for submission and publication in the Federal Register as coordinated by the Defense Privacy Office, and as required by DoD 5400.11-R. Following proper SORN publication and Government confirmation of Contractor authority to operate the applicable system(s), Contractors must also comply with the additional systems of records and SORN guidance, in coordination with the TMA Privacy Office, regarding periodic system review, amendments, alterations, or deletions set forth by DoD 5400.11-R, Office of Management and Budget (OMB) Memorandum 99-05, Attachment B, and OMB Circular A-130. Privacy Impact Assessment (PIA) The Contractor shall provide for the completion of a Privacy Impact Assessment (PIA) for any applicable systems that collect, maintain, use or disseminate personally identifiable information (PII) or protected health information (PHI) about members of the public, federal personnel, contractors, or in some cases foreign nationals. To begin the PIA process, Contractors are responsible for the completion of the PIA Determination Checklist. This Checklist provides basic system information to the TMA Privacy Office and ensures that the appropriate decision concerning PIA requirements is made. The Checklist can be downloaded from http://www.tricare.mil/tmaprivacy/downloads/PIADC.121008.pdf. Contractors are responsible for the employment of practices that satisfy the requirements and regulations of: Section 208 of E-Government (E-Gov) Act of 2002, (Pub. L. 107-347); DoDI 5400.16, "DoD Privacy Impact Assessment (PIA) Guidance," February 12, 2009; and, Office of Management and Budget (OMB) Memorandum 03-22, "OMB Guidance for Implementing the Privacy Provisions of the E-Government Act of 2002," September 26, 2003. When completing a PIA, the Contractor is responsible for using the DoD-approved PIA Template, DD Form 2930, available at http://www.dtic.mil/whs/directives/infomgt/forms/eforms/dd2930.pdf. Completed PIA Determination Checklists and DD Form 2930s will be sent to the TMA Privacy Office at piamail@tma.osd.mil. Data Use Agreement (DUA) A Data Use Agreement (DUA) is currently used to request and control the disclosure, use, storage and/or destruction of MHS data that is owned and/or managed by TMA to ensure that applicable privacy and security requirements are followed. In addition, research requests for MHS data that include protected health information (PHI) must be reviewed for HIPAA compliance by the TMA Privacy Board. Under DoD 6025.18-R, "DoD Health Information Privacy Program," January 24, 2003, reasonable steps must be taken to implement appropriate procedural, administrative, technical and physical safeguards to prevent the unauthorized use and/or disclosure of any personally identifiable information (PII) or PHI. Likewise, all uses, disclosures, and destruction of PII and PHI data are generally subject to DoD 5400.11-R, "DoD Privacy Program," May 14, 2007, as well as DoDI 8500.2, "Information Assurance (IA) Implementation," Feb. 6, 2003, and DoD 8580.02-R, "DoD Health Information Security Regulation," July 12, 2007. To begin the DUA request process, the contractor should choose the applicable request form at http://www.tricare.mil/tmaprivacy/List-of-Forms.cfm, or should contact DUAmail@tma.osd.mil. After receiving DUA approval, anyone needing access to information system applications or data sources must contact the responsible system program office. DUAs are active for one year, after which the TMA contractor must submit a renewal request or provide a Certificate of Data Destruction (CDD) to the TMA Privacy Office. Privacy Act and HIPAA Training The Contractor shall ensure that all staff including subcontractors and consultants comply with the training requirements of the Privacy Act of 1974 (5 U.S.C. 552a) and Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Pub. L. 104-191). The training requirements are mandated by OSD Memorandum 15041-07, "Safeguarding Against and Responding to the Breach of Personally Identifiable Information;" DoD 6025.18-R, "DoD Health Information Privacy Regulation," January 24, 2003; and the TMA Workforce Training Policy Memorandum, dated May 28, 2008, on the subject, "Workforce Training Policy Pursuant to the Department of Defense Privacy Act Regulations and the Department of Defense Health Insurance Portability and Accountability Act Privacy and Security Regulations." The Contractor shall ensure that the annual Privacy Act and HIPAA training is completed by all staff assigned to or performing on this Task Order, including subcontractors and consultants. All required Privacy Act and HIPAA training will be conducted online through Military Health System Learn (MHS Learn) at https://mhslearn.csd.disa.mil or the current TMA learning management system (LMS) in place to deliver training to meet the above requirements. The Contractor shall ensure all employees and subcontractors supply a certificate of Privacy Act and HIPAA training completion to the Contracting Officer Representative (COR) within 30 days of being as thereafter. Records Management When creating and maintaining official government records, the Contractor shall comply with all federal requirements established by 44 United States Code (USC), 41 USC, 36 Code of Federal Regulations (CFR), Department of Defense (DOD) Administrative Instruction No. 15 (DOD AI-15), "Records Management, Administrative Procedures and Records Disposition Schedules," and Chapter 2 of the TRICARE Operations Manual. Freedom of Information Act (FOIA) Office TRICARE Freedom of Information Act Service Center procedures require a written request under FOIA to be addressed to the Freedom of Information Officer, TMA, 16401 East Centretech Parkway, Aurora, Colorado 80011-9066. The request shall describe the desired record as completely as possible to facilitate its retrieval from files and to reduce search fees which may be borne by the requestor. No more than ten working days shall elapse after a request has been received by the Freedom of Information Officer before notification is sent that the request has been granted or denied. The administrative time limit for responding to FOIA requests does not begin until the request is received by TMA. In response to requests received by contractors for the release of information, unclassified information, documents and forms which were previously provided to the public as part of routine services shall continue to be made available in accordance with previously established criteria. All other requests from the public for release of TRICARE records and, specifically, all requests that reference the Freedom of Information Act shall be immediately forwarded to TMA, ATTENTION: Freedom of Information Officer, for appropriate action. Direct contact, including interim replies, between TRICARE contractors and such requestors is not authorized. The contractor shall process requests by individuals for access to records about themselves under the Privacy Act procedures when those procedures are more advantageous to the requestor. Department of Defense Standard Contract Clause for Business Associates Introduction In accordance with DoD 6025.18-R "Department of Defense Health Information Privacy Regulation," January 24, 2003, the Contractor meets the definition of Business Associate. Therefore, a Business Associate Agreement is required to comply with both the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security regulations. This clause serves as that agreement whereby the Contractor agrees to abide by all applicable HIPAA Privacy and Security requirements regarding health information as defined in this clause, and in DoD 6025.18-R and DoD 8580.02-R, as amended. Additional requirements will be addressed when implemented. (a) Definitions. As used in this clause generally refer to the Code of Federal Regulations (CFR) definition unless a more specific provision exists in DoD 6025.18-R or DoD 8580.02-R. Individual has the same meaning as the term "individual" in 45 CFR 160.103 and shall include a person who qualifies as a personal representative in accordance with 45 CFR 164.502(g). Privacy Rule means the Standards for Privacy of Individually Identifiable Health Information at 45 CFR part 160 and part 164, subparts A and E. Protected Health Information has the same meaning as the term "protected health information" in 45 CFR 160.103, limited to the information created or received by the Contractor from or on behalf of the Government pursuant to the Contract. Electronic Protected Health Information has the same meaning as the term "electronic protected health information" in 45 CFR 160.103. Required by Law has the same meaning as the term "required by law" in 45 CFR 164.103. Secretary means the Secretary of the Department of Health and Human Services or his/her designee. Security Rule means the Health Insurance Reform: Security Standards at 45 CFR part 160, 162 and part 164, subpart C. Terms used, but not otherwise defined, in this Clause shall have the same meaning as those terms in 45 CFR 160.103, 160.502, 164.103, 164.304, and 164.501. (b) The Contractor shall not use or further disclose Protected Health Information other than as permitted or required by the Contract or as Required by Law. (c) The Contractor shall use appropriate safeguards to prevent use or disclosure of the Protected Health Information other than as provided for by this Contract. (d) The Contractor agrees to use administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits in the execution of this Contract. (e) The Contractor shall, at their own expense, take action to mitigate, to the extent practicable, any harmful effect that is known to the Contractor of a use or disclosure of Protected Health Information by the Contractor in violation of the requirements of this Clause. These mitigation actions will include as a minimum those listed in the TMA Breach Notification Standard Operating Procedure (SOP), which is available at: http://www.tricare.mil/tmaprivacy/breach.cfm (f) The Contractor shall report to the Government any security incident involving protected health information of which it becomes aware. (g) The Contractor shall report to the Government any use or disclosure of the Protected Health Information not provided for by this Contract of which the Contractor becomes aware. (h) The Contractor shall ensure that any agent, including a subcontractor, to whom it provides Protected Health Information received from, or created or received by the Contractor, on behalf of the Government, agrees to the same restrictions and conditions that apply through this Contract to the Contractor with respect to such information. (i) The Contractor shall ensure that any agent, including a subcontractor, to whom it provides electronic Protected Health Information, agrees to implement reasonable and appropriate safeguards to protect it. (j) The Contractor shall provide access, at the request of the Government, and in the time and manner reasonably designated by the Government to Protected Health Information in a Designated Record Set, to the Government or, as directed by the Government, to an Individual in order to meet the requirements under 45 CFR 164.524. (k) The Contractor shall make any amendment(s) to Protected Health Information in a Designated Record Set that the Government directs or agrees to pursuant to 45 CFR 164.526 at the request of the Government, and in the time and manner reasonably designated by the Government. (l) The Contractor shall make internal practices, books, and records relating to the use and disclosure of Protected Health Information received from, or created or received by the Contractor, on behalf of the Government, available to the Government, or at the request of the Government to the Secretary, in a time and manner reasonably designated by the Government or the Secretary, for purposes of the Secretary determining the Government's compliance with the Privacy Rule. (m) The Contractor shall document such disclosures of Protected Health Information and information related to such disclosures as would be required for the Government to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528. (n) The Contractor shall provide to the Government or an Individual, in time and manner reasonably designated by the Government, information collected in accordance with this Clause of the Contract, to permit the Government to respond to a request by an individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528. General Use and Disclosure Provisions Except as otherwise limited in this Clause, the Contractor may use or disclose Protected Health Information on behalf of, or to provide services to, the Government for treatment, payment, or healthcare operations purposes, in accordance with the specific use and disclosure provisions below, if such use or disclosure of Protected Health Information would not violate the HIPAA Privacy Rule, the HIPAA Security Rule, DoD 6025.18-R or DoD 8580.02-R if done by the Government. Specific Use and Disclosure Provisions (a) Except as otherwise limited in this Clause, the Contractor may use Protected Health Information for the proper management and administration of the Contractor or to carry out the legal responsibilities of the Contractor. (b) Except as otherwise limited in this Clause, the Contractor may disclose Protected Health Information for the proper management and administration of the Contractor, provided that disclosures are required by law, or the Contractor obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and the person notifies the Contractor of any instances of which it is aware in which the confidentiality of the information has been breached. (c) Except as otherwise limited in this Clause, the Contractor may use Protected Health Information to provide Data Aggregation services to the Government as permitted by 45 CFR 164.504(e)(2)(i)(B). (d) Contractor may use Protected Health Information to report violations of law to appropriate Federal and State authorities, consistent with 45 CFR 164.502(j)(1). Obligations of the Government Provisions for the Government to Inform the Contractor of Privacy Practices and Restrictions (a) The Government shall provide the Contractor with the notice of privacy practices that the Government produces in accordance with 45 CFR 164.520. (b) The Government shall provide the Contractor with any changes in, or revocation of, permission by Individual to use or disclose Protected Health Information, if such changes affect the Contractor's permitted or required uses and disclosures. (c) The Government shall notify the Contractor of any restriction to the use or disclosure of Protected Health Information that the Government has agreed to in accordance with 45 CFR 164.522. Permissible Requests by the Government The Government shall not request the Contractor to use or disclose Protected Health Information in any manner that would not be permissible under the HIPAA Privacy Rule, the HIPAA Security Rule, or any applicable Government regulations (including without limitation, DoD 6025.18-R and DoD 8580.02-R) if done by the Government, except for providing Data Aggregation services to the Government and for management and administrative activities of the Contractor as otherwise permitted by this clause. Termination (a) Termination. A breach by the Contractor of this clause, may subject the Contractor to termination under any applicable default or termination provision of this Contract. (b) Effect of Termination. (1) If this contract has records management requirements, the records subject to the Clause should be handled in accordance with the records management requirements. If this contract does not have records management requirements, the records should be handled in accordance with paragraphs (2) and (3) below (2) If this contract does not have records management requirements, except as provided in paragraph (3) of this section, upon termination of this Contract, for any reason, the Contractor shall return or destroy all Protected Health Information received from the Government, or created or received by the Contractor on behalf of the Government. This provision shall apply to Protected Health Information that is in the possession of subcontractors or agents of the Contractor. The Contractor shall retain no copies of the Protected Health Information. (3) If this contract does not have records management provisions and the Contractor determines that returning or destroying the Protected Health Information is infeasible, the Contractor shall provide to the Government notification of the conditions that make return or destruction infeasible. Upon mutual agreement of the Government and the Contractor that return or destruction of Protected Health Information is infeasible, the Contractor shall extend the protections of this Contract to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as the Contractor maintains such Protected Health Information. Miscellaneous (a) Regulatory References. A reference in this Clause to a section in DoD 6025.18-R, DoD 8580.02-R, Privacy Rule or Security Rule means the section currently in effect or as amended, and for which compliance is required. (b) Survival. The respective rights and obligations of Business Associate under the "Effect of Termination" provision of this Clause shall survive the termination of this Contract. (c) Interpretation. Any ambiguity in this Clause shall be resolved in favor of a meaning that permits the Government to comply with DoD 6025.18-R, DoD 8580.02-R, the HIPAA Privacy Rule or the HIPAA Security Rule. 7.0. ATTACHMENTS: Attachment 1. 42 MDG Credentialing Procedures
Web Link: FBO.gov Permalink
(https://www.fbo.gov/spg/USAF/AETC/MaxAFBCS/F2X4A23211AG01/listing.html)
Place of Performance: Address: Maxwell Ambulatory Healthcare Center, 42d MEDICAL GROUP, 300 S. Twining St. Bldg. 760, Montgomery, Non-U.S., 36112, United States; Zip Code: 36112
Record: SN03148540-W 20130816/130814235216-f8c3ab57f6b36cdc55ed85753fe4fe15 (fbodaily.com)
Source: FedBizOpps Link to This Notice
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