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 Florida Agency for Health Care Administration (AHCA) related to their Enhanced Provider Network Auditing Program. The template is designed to collect detailed information about respondents' past performance and compliance history.

The template consists of four main sections: 1) Fines and Penalties, with space for up to 100 entries including details, dates, and amounts imposed; 2) Sanctions, also allowing for 100 entries with similar fields; 3) Corrective Action Plans (CAPs), with space for 100 entries; and 4) Contract Terminations, with space for 30 entries including contract name, type, termination type, date of action, client information, reason for termination, and information about respondent affiliates, subsidiaries, parent organizations and their affiliates and subsidiaries.

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Other files

File Type Posted
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
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
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
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
05. Exhibit A-3.docx DOCX document
07. Exhibit A-4.docx DOCX document
09. Exhibit A-4-b.xlsx XLSX spreadsheet
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
Show all 29

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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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CAPs
#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

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