Certification_Statement_-_ED_FY20.pdf
PDF 93 KB Posted
- Attached to
- Emergency Medicine Physician Services Federal contract opportunity
- Solicitation number
- 020-G48-20-0047
About this file
This document is a combined synopsis and solicitation for emergency medicine physician services. The Indian Health Service is seeking board certified or board eligible emergency medicine physicians to provide services at the Gallup Indian Medical Center in Gallup, New Mexico. The base period of performance is from the date of award through December 31, 2019 with option periods to extend through March 31, 2020. Offerors must submit pricing schedules, candidate profiles including resumes and licenses, certification statements, and proof of medical liability insurance by November 14, 2019. The award will be made to the responsible offeror whose proposal represents the best value and results in the lowest cost based on price, past performance, and candidate qualifications.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| PWS_No._GIMC-19-002.pdf | ||
| FY20_Pricing_Schedule_-_NONPSC.pdf | ||
| GIMC_ED_Description.pdf |
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Text version
are prescribed in 18 U.S.C. 1001.
Print Name of Provider
1. I currently [ ] meet [ ] do not meet the experience required by PWS #GIMC-19-002, paragraph 6.1 - Experience.
If the experience requirement is met, attach a summary detailing employment history and job duties for the last 24 months.
2. License to practice [ ] has [ ] has not been restricted, terminated, suspended, or revoked.
If your license has been restricted, terminated, suspended, or revoked, provide a copy of the State Board of Physician document pertaining to each occurrence.
3. I currently hold the following active, unrestricted medical license as required by PWS #GIMC-19-002, paragraph 6.2 - License (list all license):
4. I currently hold the following inactive medical license (list all license):
5. I have taken [ ] have not taken [ ] the Emergency Medicine Boards. If not taken, I meet [ ] not meet [ ] eligibility.
6. I currently hold the following certifications as identified by the PWS #GIMC-19-002, paragraph 6.3 - Certifications
Certification Expiration Certification Expiration Certification Expiration BLS ATLS Cert. Wound Care
ACLS Fetal Monitoring
PALS BCLS
7. I meet the requirements of the PWS #GIMC-19-002, paragraph 6.4.1 - Medical Evaluation.
My most recent medical evaluation was completed on:
8. I meet the requirements of the PWS #GIMC-19-002, paragraph 6.4.2 - Immunization.
The dates of my immunizations are as follows:
Date Immunizations Completed:
Date Date
a. Immunity to Rubella, Mumps, Measles MMR#1 MMR#2
b. Immunity to Hepatitis B HEP B#1 HEP B#2
HEP B#3 declination
c. History of chicken pox (varicella) disease or positive titer positive titer disease
d. Tdap vaccine (Tdap) within the last 5 years Tdap
e. Documentation of receiving a TB Mantoux skin test PPD chest x-ray within the past 12 months or chest x-ray
f. Date of Influenza Vaccine:
9. I currently [ ] meet [ ] do not meet the language requirements of the PWS #GIMC-19-002, paragraph 6.5 - Language Requirements and Cultural Awareness initial
10. I currently [ ] meet [ ] do not meet the information technology skill requirements required by PWS #GIMC-19-002, paragraph 6.6 - Information Technology Skills initial
11. I am aware of the orientation requirements of the PWS #GIMC-19-002, paragraph 6.7 - Orientation initial
12. I am aware of the background check required by PWS #GIMC-19-002, paragraph 6.8 - Background Checks initial
13. I am aware of the Work Schedule requirements of the PWS #GIMC-19-002, paragraph 5.2 - Work Schedule initial
State License No. Expiration Date
DateLegal Signature of Provider
Certification Statement for Performance Work Statement (PWS) No. GIMC‐19‐002 Emergency Room Physician Services
State License No. Expiration Date
I hereby certify the below statements are full, accurate, and complete. The penalties for making false statements
Recommended
(must be current) Date
Date
Mandatory Mandatory
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