14_Ex_H_-_Licensing_Compliance_Summary.xlsx

This is a Licensing Compliance Summary spreadsheet template for Staff Medical Monitoring Services from the California Department of Corrections and Rehabilitation (CDCR), Bid Number 6000001895. The document provides a detailed sample format for contractors and subcontractors to submit their licensing information, including facility addresses, type of medical service provider (clinic, mobile clinic, or laboratory), employed physicians, and various required licenses and certifications. The template requires documentation of California Medical Board Physician and Surgeon Licenses, Clinical Laboratory Improvement Amendments (CLIA) Certificates, and California Department of Health Services Laboratory Field Services (LFS) Clinical Laboratory Licenses.

The document specifies location requirements stating that facilities must be within 45 miles of the institution/facility/office they serve, with an exception of 100-mile radius for Avenal State Prison (ASP), High Desert State Prison (HDSP), and California Correctional Center (CCC). The sample data shows multiple medical service providers serving various CDCR institutions, including CCI, FSP, SAC, LAC, VSP, CEN, CHCF, KVSP, NKSP, and SQ, with various license expiration dates throughout 2013 and 2014. The template includes space for additional pages and specific instructions for listing contractor headquarters and additional locations under the subcontractor section.