0002_Amendment_FBO_15B10218R00000001.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

11 . CONTRACT ID CODE IPA~E OF PAGES

I ~

2. AMENDMENT/MODIFICATION NUMBER 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQUISITION NUMBER 15. PROJECT NUMBER (If applicable)

0002 01/30/2018

6. ISSUED BY CODE FAO 7. ADMINISTERED BY (If other than Item 6) CODE IBASH

US Department of Justice-Federal Bureau of Prisons FBOP-FCI ASHLAND Field Acquisitions Office (FAO) Federal Bureau of Prisons US Armed Forces Dr. FCI Ashland State Route 716 Grand Prairie, TX 75051 Ashland , Kentucky 41105

I

8. NAME AND ADDRESS OF CONTRACTOR (Number, street, county, State and ZIP Code) ~ 9A. AMENDMENT OF SOLICITATION NUMBER

D 15B10218R00000001

9B. DATED (SEE ITEM 11)

01/30/2018

10A MODIFICATION OF CONTRACT/ORDER NUMBER

D

10B. DATED (SEE ITEM 13)

CODE jFACILITY CODE

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

[8J The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers [8J is extended. 0 is not extended.

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended , by one of the following methods:

(a) By completing items 8 and 15, and returning 1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE

RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NUMBER AS DESCRIBED IN ITEM 14.

CHECK ONE IA THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER

NUMBER IN ITEM 10A

D D

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

D C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor 0 is not 0 is required to sign this document and return ____ _ copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

The RFP15B10218R00000001 amendment 0002 is issued to correct the following:

1.The correct wage index for CBSA code 26580, is 0.8461 (See Corrected Attachment) .

2. The care levels are in Attachment 2, not in Attachment 1 as stated , (See Corrected Attachment 2 on page 45) .

3. The schedule of items are to be placed in numerical order see pages 3-6 of the schedule of items (See Attachment)

4. In Output #1 the cross reference pricing categories 1 c was added . (See page 8 attached)

5. In Output #1 in invoice definitions 2b was added See (attached page 11)

6. The Deadline for Proposals has changed to 02/15/2018 @2 p.m. Central Time. See Attached SF-1449 Except as provided herein, all terms and conditions of the document referenced in Item 9A or 1 OA, as heretofore changed, remains unchanged and in full force and effect.

15A NAME AND TITLE OF SIGNER (Type or print) 16A NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

15B. CONTRACTOR/OFFEROR 15C. DATE SIGNED I 16B. UNITED STATES OF AMERICA 16C. DATE SIGNED

(Signature of person authorized to sign)

Previous edition unusable

(Signature of Contracting Officer)

STANDARD FORM 30 (REV.11/2016)

Prescribed by GSA FAR (48 CFR) 53.243

Attachment l Computation of Basic MS-DRG Payments

(i.e., Operating Federal Rate) CBSA 26580- Huntington-Ashland, Kentucky

15810218R00000001

Calculation of the Operating Federal Rate:

Step 1:

Step 2:

Step 3:

Step 4:

Step 5:

Select the applicable average standardized amount for the full update

Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area

For hospitals in Alaska and Hawaii, multiply the non-labor-related portion of the standardized amount by the applicable cost-of-living adjustment factor

Add the amount from Step 2 and the non-labor-related portion of the standardized amount (adjusted, if applicable, under Step 3)

Multiply the final amount from Step 4 by the relative weight corresponding to the applicable MS-DRG

Index Figures: Obtained from the Centers of Medicare and Medicaid services for discharges on or after October 1, 2017

Table lA, National Adjusted Operating Standardized Amount:

Labor-related:

Non-labor-related:

$3454.97 $2117 .56

Table 4A, Wage Index for Ashland Kentucky: 0.8461 Table, Cost of Living Adjustment Factor: Not applicable

Table 5, MS-DRG Relative Weight (MS-DRG 76, Viral Meningitis w/o CC/MCC): 0.9615

Application for MS-DRG 076 (example):

Step 1: $3454.97 Step 2: $ 3454.97 X 0.8461= $2,923.25 Step 3: Not applicable= Step 4: $2,923.25 + 2117.56= $5040.81 Step 5: $5040.81x 0.9615 = $4,846.73 Payment for MS-DRG 076 under the contract would be $4,846.73 plus or minus any premium or discount established as the contract rate.

Page 1 ofl

Instructions for Preparation of Technical Proposal

The offerer's technical proposal will be an important consideration in the award of the resulting contract;

therefore, it should be specific and complete. The technical proposal shall set forth in detail an offerer's conceptual approach to, and interpretation of the following: stated contract goals; proposed work plan for achieving contract objective; proposed methodology and techniques of performing the contract; and the technical resources, experience and background, as well as unique or specialized skills and expertise of both the offerer and proposed subcontractors.

The offerer's proposal should be prepared simply and economically, providing straight-forward, concise delineation of capabilities to perform satisfactorily the contract being sought. The technical proposal should therefore be practical, legible, clear, and coherent . Unnecessarily elaborate brochures or other presentations beyond those sufficient to present a complete and effective response to this solicitation are not desired. Elaborate art work and expensive paper, bindings, and presentation aids are neither necessary nor wanted. The technical evaluation criteria stated within this solicitation will be used by the technical panel in evaluating proposals; therefore, each technical proposal must contain enough specificity to address each evaluation factor and the terms and conditions of the Performance Work Statement. Each offerer shall complete Attachment 7 entitled Technical Proposal Summary Sheets by Hospital Network and include such with the offerer's technical proposal. In order that an evaluation may be accomplished strictly on the merit of the material submitted, the technical proposal shall not make reference to pricing data.

Proposals which merely paraphrase the requirements of the Government's Performance Work Statement or parts thereof or use such phrases as "will comply" or "standard techniques will be employed" and/or cut and paste information from a proposed subcontractor's website will not be acceptable. The offeror must submit an explanation of the proposed technical approach in conjunction with the tasks to be performed in achieving the required output.

Instructions for Preparation of Past Performance Proposal

The proposal must describe the experience of the offerer that is relevant to this contract:

- Experience providing health care to a diverse inmate population;

- Experience establishing and maintaining relationships with a large and diverse number of health care providers and/or organizations;

- Experience receiving and disseminating medical records to and from multiple health care providers.

The following information shall be included in each Past Performance Proposal:

1. A list of a total of three (3) of the offerer's most recently awarded relevant contracts with a period of performance of at least twelve (12) months. The listing shall include all items listed below:

a. Name of contracting activity;

b. Contract number;

c. Date of Award;

d. Estimated Awarded Amount;

e. Contract Performance Period;

f. Name, Mailing Address, telephone number, fax number, and email address of the Contracting Officer, Program Manager, and Administrative Contracting;

g. Relevancy: Describe the relevancy of the past or present contract to this RFP.

Relevancy discussion could include a comparison to providing health care to an inmate population of a similar care level as identified in Attachment 2

h. Provide any other information the offerer deems important to understand the past performance of the contracts, the offerer's ability to deliver quality medical services, meet schedule/performance requirements, and achieve customer satisfaction.

Optometrist : Session Duration - 4 hours (Approximate) Session Quantity- 12 per performance period (Estimated)

Urologist : Visit Duration - 4 hours (Approximate) Visit Quantity - 12 per performance period (Estimated)

Note: Session priced items, sessions which exceed the established session or are less than a full session shall be prorated to the nearest quarter hour.

Offerors shall complete the following Schedule of Items. All proposed pricing will be evaluated in accordance with FAR 52.212-2, "Evaluation--Commercial Items" and "Evaluation of Proposals" in Section 5-2 of this solicitation .

Date of Award (DOA) through 12 months

SCHEDULE OF ITEMS-BASE YEAR

Offerors shall complete the following Schedule of Items. All proposed pricing will be evaluated in accordance with FAR 52 .212-2, "Evaluation--Commercial Items" and "Evaluation of Proposals" in Section 5-2 of this solicitation .

Date of Award (DOA) through 12 months la . Inpatient Facility Services:

lb. Outpatient Facility Services:

le. Long Term Care Services :

2a . Inpatient Physician Services :

2b. Outpatient Physician Services :

2c. Outpatient Institution Services/ Other Physicians:

1. Mobile MRI :

2. Optometrist :

3. Mobi le Ultrasound/Echo:

Sessions= lhour

Discount or+ Premium to Medicare Part A ---

Discount or+ Premium to Medicare Part B - --

Discount or+ Premium to Medicare Part A ---

Discount or+ Premium to Medicare Part B ---

Discount or+ Premium to Medicare Part B ---

Discount or+ Premium to Medicare

Per Session

Per Session

Per Session

NOTE: IF OFFERING A VARIANCE FROM THE BENCHMARK MEDICARE RATE, INSERT APPLICABLE"-/+"

PERCENTAGE. IF NO VARIANCE, ENTER "O".

OPTION YEAR 1

13 through 24 months la . Inpatient Facility Services: Discount or+ ___ Premium to Med icare Part A

lb. Outpatient Facility Services: Discount or+ _ __ Premium to Med icare Part B

le. Long Term Care Services : Discount or+ Premium to Medicare Part A

2a. Inpatient Physician Services : Discount or+ Premium to Medicare Part B

2b. Outpatient Physician Services :

2c. Outpatient Institution Services/

Other Physicians:

1. Mobile MRI :

2. Optometrist :

3. Mobile Ultrasound/Echo:

Sessions = lhour

Discount or+ ___ Premium to Medicare Part B

Discount or+ Premium to Medicare ---

$ Per Session

$ Per Session

$ Per Session

NOTE: IF OFFERING A VARIANCE FROM THE BENCHMARK MEDICARE RATE, INSERT

APPLICABLE "/+"PERCENTAGE. IF NO VARIANCE, ENTER "O".

25 through 36 months

la. Inpatient Facility Services :

lb. Outpatient Facility Services:

le. Long Term Care Services :

2a . Inpatient Physician Services:

2b. Outpatient Physician Services:

2c. Outpatient Institution Services/

Other Physicians:

1. Mobile MRI :

2. Optometrist :

3. Mobile Ultrasound/Echo:

Sessions= lhour

OPTION YEAR 2

Discount or+ Premium to Medicare Part A ---

Discount or+ Premium to Medicare Part B ---

Discount or+ Premium to Medicare Part A ---

Discount or+ Premium to Medicare Part B ---

Discount or+ Premium to Medicare Part B ---

Discount or+ Premium to Medicare

$ Per Session

$ Per Session

$ Per Session

NOTE: IF OFFERING A VARIANCE FROM THE BENCHMARK MEDICARE RATE, INSERT APPLICABLE"-/+"

PERCENTAGE. IF NO VARIANCE, ENTER "O".

OPTION YEAR 3

37 through 48 months

la. Inpatient Facility Services : Discount or+ ___ Premium to Medicare Part A

lb. Outpatient Facility Services : Discount or+ ___ Premium to Medicare Part B

le. Long Term Care Services : Discount or+ ___ Premium to Medicare Part A

2a . Inpatient Physician Services :

2b. Outpatient Physician Services:

2c. Outpatient Institution Services/

Other Physicians:

1. Mobile MRI:

2. Optometrist:

3. Mobile Ultrasound/Echo:

Sessions= lhour

Discount or+ ___ Premium to Medicare Part B

Discount or+ ___ Premium to Medicare Part B

___ Discount or+ Premium to Medicare

$ Per Session

$ Per Session

$ Per Session

NOTE: IF OFFERING A VARIANCE FROM THE BENCHMARK MEDICARE RATE, INSERT APPLICABLE

"/+"PERCENTAGE. IF NO VARIANCE, ENTER "O".

OPTION YEAR 4

49 through 60 months from DOA

la. Inpatient Facility Services:

lb. Outpatient Facility Services :

le. Long Term Care Services:

2a . Inpatient Physician Services :

2b. Outpatient Physician Services :

2c. Outpatient Institution Services/

Other Physicians:

1. Mobile MRI :

2. Optometrist :

3. Mobile Ultrasound/Echo:

Sessions= lhour

Discount or+ Premium to Medicare Part A ---

Discount or+ Premium to Medicare Part B ---

Discount or+ Premium to Medicare Part A ---

Discount or+ Premium to Medicare Part B ---

Discount or+ Premium to Medicare Part B ---

Discount or+ Premium to Medicare

Per Session

Per Session

Per Session

OPTION TO EXTEND SERVICES AS AUTHORIZED BY FAR 52.217-8

Six Month Extension as Authorized by FAR 52.217-8 la . Inpatient Facility Services : Discount or+ ___ Premium to Medicare Part A

lb. Outpatient Facility Services : Discount or+ ___ Premium to Medicare Part B

le. Long Term Care Services : Discount or+ Premium to Medicare Part A

2a. Inpatient Physician Services : Discount or+ ___ Premium to Medicare Part B

2b. Outpatient Physician Services :

2c. Outpatient Institution Services/ Other Physicians:

1. Mobile MRI :

2. Optometrist:

3. Mobile Ultrasound/Echo:

Sessions= lhour

Discount or+ ___ Premium to Medicare Part B

___ Discount or+ Premium to Medicare

$ Per Session

$ Per Session

$ Per Session

NOTE: IF OFFERING A VARIANCE FROM THE BENCHMARK MEDICARE RATE, INSERT APPLICABLE"/+"

PERCENTAGE. IF NO VARIANCE, ENTER "O".

All offerers are hereby advised that the successful offerer's unit pricing (to include discount percentage from or premium percentage to the benchmark Medicare rate) for the base year and all options is public information, in accordance with Federal Acquisition Regulation FAR 15.503(b)(l)(iv) . Accordingly, all successful unit pricing will be released to unsuccessful offerers with the notification of award as well as to the general public when requested .

Any party who objects to the release of their own unit pricing information, should they be awarded a contract in response to this solicitation, should not submit proposal in response to the solicitation.

Sub-Contract Certification:

This contract does [_] does not [_) provide for subcontracting possibilities.

If answer is in the affirmative, offerer will submit[_] a sub-contracting plan in accordance with the requirements of FAR 52.219-9.

2-2 PERFORMANCE WORK STATEMENT

I. Background The Federal Bureau of Prisons (BOP) was established in 1930 to provide more progressive and humane care for

Federal inmates, to professionalize the prison service, and to ensure consistent and centralized administration.

Today, the BOP is responsible for the custody and care of approximately 219,000 Federal offenders. The Federal prison system is a nationwide system of prisons and detention facilities for the incarceration of inmates who have been sentenced to imprisonment for Federal crimes and the detention of individuals awaiting trial in Federal court.

It is the mission of the Federal Bureau of Prisons to protect society by confining offenders in the controlled environments of prisons and community-based facilities that are safe, humane, cost-efficient, and appropriately secure, and that provide work and other self-improvement opportunities to assist offenders in becoming law abiding citizens.

As an agency under the Executive Branch of the United States Government, the BOP receives an annual appropriation of funds to accomplish its assigned mission. The public trust demands that this annual appropriation be prudently managed. Thus, dollars spent to maintain the health of the inmate population must reflect the agency's best efforts to obtain cost-effective health care consistent with community standards.

In meeting the health care needs of a growing inmate population, the BOP provides essential medical, dental, and mental health services to Federal inmates with BOP resources. When a medical need arises which cannot be

Output#1:

Output#2:

Output#3:

Output#4:

Output#S:

Provide inpatient, outpatient and long term care facility services which conform to community standards and all local, state and Federal laws and regulations applicable to the delivery of health care to members of the general public. (Cross-reference pricing categories la, lb and le)

Provide professional services which conform to community standards and all local, state and Federal laws and regulations applicable to the delivery of health care to members of the general public. (Cross-reference pricing categories 2a, 2b, 2cl, 2c.2, 2c.3, and 2c.4)

Submit properly-priced invoices for services rendered .

Manage medical record information in a manner which promotes continuity of care while observing restrictions on the release of information.

Maintain open avenues of communication, facilitating the exchange of information between the contract provider, contract facility, and the Government regarding the contract services.

IV. Compliance with Contract Requirements

The Contractor's efforts under this contract shall be monitored to ensure that the required output is achieved. The

Government reserves the right to inspect and evaluate in a reasonable manner all services rendered during the performance of this contract. The Contractor's performance will be measured by the Government utilizing the outcome measure indicators provided in Attachment 3.

The Contractor is responsible for all management and quality control actions necessary to meet the quality standards set forth by this contract. Prior to commencing performance, the Contractor shall develop and submit a quality control plan (QCP) for the FCl's approval. Once the QCP is approved by the FCI the Contractor shall utilize the QCP to guide and rigorously document the implementation of the required management and quality control actions to achieve the specified output.

V. Specific Requirements

Output#1: Provide inpatient and outpatient facility services which conform to community standards and all local, state and Federal laws and regulations applicable to the delivery of health care to members of the general public.

Output #1 is an optional deliverable. However, if the offeror proposes to provide these services, the following minimum requirements apply. Throughout the performance of this contract, the Contractor shall not utilize any provider that appears on the List of Excluded Individuals/Entities (LEIE) maintained by the Department of Health and Human Services.

If proposed, the Contractor shall provide facility services on an as-needed basis in a manner which adheres to community standards of quality and cost-effective medical care. The services required to satisfy Output #1 may include inpatient facility and outpatient facility, including emergency room services. Inpatient visits for non-emergency services shall require private room accommodations with available space for up to three armed or unarmed guards per inmate.

It is the FCl 's preference to obtain the services of facilities that are accredited by the Joint Commission. Offerers utilizing facilities which maintain accreditation by the Joint Commission shall submit a copy of the current accreditation certificate as part of the offerer's technical proposal. If an offeror intends to utilize a facility which is accredited or certified by any other recognized professional accrediting body, the offeror shall submit documentation validating this accreditation or certification as a part of its proposal.

Overview. Upon completion of a treatment encounter, the Contractor shall prepare and submit proper invoices for services rendered under this contract. For the purpose of this contract, a specific definition for what documentation constitutes an invoice is provided below. A proper invoice shall include the information specified in FAR clause 52.212-4, Contract Terms and Conditions - Commercial Items, paragraph (g) . Services shall be invoiced in accordance with the terms and conditions of the contract, including the payment rate structures specified in the contract.

Invoice/Medical Claims Adjudication. The FCI will employ a process of invoice/medical claims adjudication to ensure, at a minimum, that the services billed by the Contractor were properly authorized and ordered by the FCI, are appropriately coded in compliance with Medicare coding policies (where applicable), are properly priced in accordance with the terms and conditions of the contract, and do not represent duplicate billings for payments already made. In addition, the FCI may utilize the services of a third-party medical claims adjudicator to review medical claims submitted by the Contractor under this contract . When requested by the FCI, the Contractor shall comply with all reasonable requests for additional invoice/medical claim/medical record documentation. All invoice payments shall be made by the FCI and any disagreements regarding the paid amount of any invoice shall be resolved directly with the FCI.

Invoice Definitions. Line Items la - Inpatient Facility Services, lb - Outpatient Facility Services lc.-Long Term

Care Services and 2a.- Inpatient Physician Services, 2b.-Outpatient Physician Services and 2c1. - Outpatient

Institution Services - Other Physicians: At the outset of this contract, an invoice for services rendered under Line

Items la, lb, le, 2a, 2b, and 2c.1 shall be a paper version of an invoice containing not more than 50 individual medical claims. Each invoice shall be supported with paper copies of Universal Billing (UB) 92 forms or Centers for

Medicare and Medicaid Services (CMS) 1500 forms, as applicable, for each medical claim included in the invoice.

Following written notification to the Contractor by the Contracting Officer that a third-party medical claims adjudication service will be utilized by the FCI, an invoice for services rendered under Line Items la, lb,lc, 2a, 2b, and 2c.l shall be a paper invoice detailing not more than 50 individual medical claims which have been electronically transmitted to the BOP's medical claims adjudicator via American National Standards Institute (ANSI)

837 format that also conforms to Medicare and Health Insurance Portability and Accountability Act of 1996

(HIPAA) electronic billing standards. For each medical claim included on the invoice, the Contractor shall reference, at a minimum, the following information : YREGDOC number, inmate name and register number date of service, provider of service, billed code, and contract amount billed. Medical claims detailed in the invoice shall be listed first in descending order by the YREGDOC number, second in alphabetic order by the inmate's last name, and third by ascending date of service (i.e., earliest to latest) when more than one medical claim is present for the same inmate within the same invoice.

If the Contractor's proposal encompasses the provision of Oral surgery and/or dental procedures, only those medical claims which represent adjunctive dental care will be submitted by the Contractor to the medical claims adjudication contractor for processing. Oral Surgery and/or dental procedures which are not considered to be adjunctive dental care will be submitted to the FCI for verification .

The Contractor shall not submit a medical claim for processing that the Contractor knows, or has reason to believe contains inaccurate, incomplete, or misleading information. Medical claims which contain inaccurate, incomplete, or misleading information shall be held by the Contractor and not submitted until such time as all lines are deemed to be accurate and complete. At that time, the Contractor may proceed with submitting the medical claim for processing and invoicing the FCI for all services represented by that medical claim .

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE 1 OF

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

2. CONTRACT NO. 3. AWARD/EFFECTIVE 4. ORDER NUMBER 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE

DATE DATE

15810218R00000001 12/22/2017

a. NAME b. TELEPHONE NUMBER (No collect B. OFFER DUE DATE/

7. FOR SOLICITATION

calls) LOCAL TIME

INFORMATION CALL: 02/15/2018

TARYN JONES TSJONES@BOP.GOV 972-352-4506 2:00 pm C.T.

9. ISSUED BY CODE BFAO 10. THIS ACQUISITION IS [8}.JNRESTRICTED OR lJsETASIDE: % FOR:

Federal Bureau of Prisons Field Acquisition Office 0SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS ---

D(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

U .S . Armed Forces Reserve Complex 346 Marine Forces DHUBZONE SMALL SMALL BUSINESS PROGRAM NAICS:

Drive BUSINESS EDWOSB 622110 Grand Prairie , TX 75051 aERVICE-DISABLED o

ETERAN-OWNED SIZE STANDARD:

SMALL BUSINESS Os (A) 38.5 Million

11 . DELIVERY FOR FOB DESTINA- 12. DISCOUNT TERMS 13b. RATING

TION UNLESS BLOCK IS

NET 30 013a. THIS CONTRACT IS A

MARKED RATED ORDER UNDER

DPAS (15 CFR 700) 14. METHOD OF SOLICITATION

OsEE SCHEDULE IRFa n1FB f'XRFP

15. DELIVER TO CODE BASH 16. ADMINISTERED BY CODE I

Federal Bureau of Prisons Federal Bureau of Prisons

FCI Ashland State Route 716 FCI Ashland State Route 716 Ashland , Kentucky 41105 Ashland , Kentucky 41105 17a. CONTRACTOR/ CODE! I FACILITY 1Ba. PAYMENT WILL BE MADE BY CODE I

Ut-t-t::KUK vUUt:

Federal Bureau of Prisons Federal Bureau of Prisons

FCI Ashland State Route 716 FCI Ashland State Route 716 Ashland, Kentucky 41105 Ashland, Kentucky 41105

I

TELEPHONE NO.

17b. CHECK IF REMITIANCE IS DIFFERENT AND PUT SUCH ADDRESS IN 1 Bb. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 1 Ba UNLESS BLOCK

D OFFER BELOW IS CHECKED D SEE ADDENDUM

19. 20. 21 . 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

COMPREHENSIVE MEDICAL SERVICES AT

FCI ASHLAND

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

[8) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1 , 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATIACHED. ADDENDA

D 27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATIACHED. ADDENDA

[81 ARE D ARE NOT ATIACHED

DARE DARE NOT ATIACHED

D 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN D 29. AWARD OF CONTRACT: REF. OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND ---

DATED . . YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR

30b. NAME AND TITLE OF SIGNER (Type or print)

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

30c. DATE SIGNED

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

31 b. NAME OF CONTRACTING OFFICER (Type or print) 31c. DATE SIGNED

TARYN JONES, CONTRACTING OFFICER

STANDARD FORM 1449 (REV. 212012)

Prescribed by GSA- FAR (48 CFR) 53.212

19. 20. 21 . 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

001 Comprehensive Medical Services Located at FCI 12 MO Ashland, Kentucky Base Year: Date of Award D.O.A through 12 months from D.O.A Ashland, Kentucky Option Year 1 :13 Months

I 002 Comprehensive Medical Services Located at FCI 12 MO

Ashland , Kentucky Option Year 1:13 Months through 24 months from D.O.A

003 Comprehensive Medical Services Located at FCI 12 MO Ashland, Kentucky Option Year 2:25 Months through 36 months from D.O.A

004 Comprehensive Medical Services Located at FCI 12 MO Ashland , Kentucky Option Year 3:37 Months through 48 months on D.O.A

005 Comprehensive Medical Services Located at FCI 12 MO Ashland, Kentucky Option Year 4:49 Months through 60 months from D.O.A

006 Comprehensive Medical Services Located at FCI 6 MO

I Ashland, Kentucky (6) months extension as authorized by the Federal Acquisition Regulation (FAR) 52.217-8 Option to Extend Services

32a. QUANTITY IN COLUMN 21 HAS BEEN

D RECEIVED D INSPECTED D ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32b. SIGNATURE OF AUTHORIZED GOVERNMENT 32c. DATE 32d . PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELPHONE NUMBER OF AUTHORZED GOVERNMENT REPRESENTATIVE

329. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

33. SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED 36. PAYMENT 37. CHECK NUMBER

CORRECT FOR

0PARTIAL 0FINAL 0COMPLETE 0PARTIAL 0FINAL

38. SIR ACCOUNT NO. ~. ~RVOUCHERNUMBER 40. PAID BY

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 42a. RECEIVED BY (Print)

41 b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42b. RECEIVED AT (Location)

42c. DATE REC'D (YYIMM/00) 142d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV. 212012) BACK