09. Exhibit A-4-b.xlsx

55 KB Posted

Attached to
Enhanced Provider Network Auditing Program
Solicitation number
ITN-11303
Issued by
Leon County, Florida

About this file

Written by GovTribe AI ·

This is a compliance history template (Exhibit A-4-b) for ITN 002-24/25 from the Agency for Health Care Administration (AHCA). The template is designed to capture detailed compliance history information from respondents, specifically focusing on three main areas: fines and penalties, sanctions, and Corrective Action Plans (CAPs).

The template includes sections for documenting up to 100 instances each of fines/penalties, sanctions, and CAPs, requiring details such as dates imposed and amounts imposed. Additionally, there is a Contract Terminations section with space for 30 entries, requiring comprehensive information including contract name, type, termination type, date of action, client information, and reason for termination. The template also requires disclosure of information about respondent affiliates, subsidiaries, parent organization, and the parent organization's affiliates and subsidiaries.

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Other files

File Type Posted
04. Exhibit A-2 - Transmittal Letter.docx DOCX document
10. Exhibit A-5.xlsx XLSX spreadsheet
05. Exhibit A-3.docx DOCX document
07. Exhibit A-4.docx DOCX document
10. Exhibit A-5.xlsx XLSX spreadsheet
AHCA ITN 002-2425_Addendum No.1.pdf PDF
10. Exhibit A-5.xlsx XLSX spreadsheet
AHCA ITN 002-24.25.pdf PDF
06. Exhibit A-3-a.docx DOCX document
04. Exhibit A-2 - Transmittal Letter.docx DOCX document
AHCA ITN 002-24.25.pdf PDF
11. Exhibit A-6.doc DOC document
05. Exhibit A-3.docx DOCX document
07. Exhibit A-4.docx DOCX document
AHCA ITN 002-24.25.pdf PDF
06. Exhibit A-3-a.docx DOCX document
11. Exhibit A-6.doc DOC document
03. Exhibit A-1 - Questions Template.xlsx XLSX spreadsheet
04. Exhibit A-2 - Transmittal Letter.docx DOCX document
05. Exhibit A-3.docx DOCX document
06. Exhibit A-3-a.docx DOCX document
03. Exhibit A-1 - Questions Template.xlsx XLSX spreadsheet
11. Exhibit A-6.doc DOC document
03. Exhibit A-1 - Questions Template.xlsx XLSX spreadsheet
09. Exhibit A-4-b.xlsx XLSX spreadsheet
07. Exhibit A-4.docx DOCX document
09. Exhibit A-4-b.xlsx XLSX spreadsheet
AHCA ITN 002-24.25 Addendum No. 2.pdf PDF
AHCA ITN 002-2425_Addendum No.1.pdf PDF
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Instructions

Template Instructions

&"-,Bold"&14EXHIBIT A-4-b

SRC #10 - COMPLIANCE HISTORY TEMPLATE

&"Arial,Bold"&10AHCA ITN 002-24/25, Attachment A, Exhibit A-4-b, Page 1 of 1

Fines-Sanctions-CAPs

Enter Respondent Name Below

Fines and Penalties
#Fines and PenaltiesDetailDate ImposedAmount Imposed
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#SanctionsDetailDate ImposedAmount Imposed
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#CAPsDetailDate ImposedAmount Imposed
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&"-,Bold"&14EXHIBIT A-4-b

SRC #10 - COMPLIANCE HISTORY TEMPLATE

&"Arial,Bold"&10AHCA ITN 002-24/25, Attachment A, Exhibit A-4-b, Page &P of 10

Contract Terminations

Contract Terminations
#Contract NameContract TypeTermination TypeDate of ActionClient/Other Party NameClient/ Other Party AddressClient/ Other Party Phone NumberReason for TerminationRespondent AffiliatesRespondent SubsidiariesParent OrganizationParent Organziation's AffiliatesParent Organization's Subsidiaries
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&"Arial,Bold"&14EXHIBIT A-4-b

SRC #10 - COMPLIANCE HISTORY TEMPLATE

&"Arial,Bold"&10AHCA ITN 002-24/25, Attachment A, Exhibit A-4-b, Page &P of 1 image1.png

File details come from the government source that posted it. Updated .