Exhibit_A-SF1449_(revised).pdf

SEE ADDENDUMIS CHECKED

CODE 18a. PAYMENT WILL BE MADE BY

CODE

FACILITYCODE

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

OFFEROR

Phoenix AZ 85004-4424 Suite 507, Attn: Division of Acquisition Mgmt Two Renaissance Square, 40 North Central Ave Phoenix Area Indian Health Service

CODE 16. ADMINISTERED BYCODE

X

X

X

621512

SIZE STANDARD:

100.00 % FOR:SET ASIDE:UNRESTRICTED OR10

RFPIFB

10. THIS ACQUISITION ISCODE

RFQ

14. METHOD OF SOLICITATION

13b. RATING

NAICS:

SMALL BUSINESS

01/19/2016 1700 MS602-364-5032FELICIA ASPAAS

(No collect calls)

INFORMATION CALL:

FOR SOLICITATION 8. OFFER DUE DATE/LOCAL TIMEb. TELEPHONE NUMBER a. NAME

4. ORDER NUMBER3. AWARD/ 6. SOLICITATION

16-247-SOL-00013

5. SOLICITATION NUMBER

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

1 3 OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

TELEPHONE NO.

17a. CONTRACTOR/

15. DELIVER TO

Phoenix AZ 85004-4450 Suite 507 Attn: Division of Acquisition Mgmt Two Renaissance Square, 40 North Central Ave

9. ISSUED BY

7.

2. CONTRACT NO.

EFFECTIVE DATE

$15.0

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW

ISSUE DATE

DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

11.

SEE SCHEDULE

12. DISCOUNT TERMS

THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13a.

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

8(A)

Phoenix Area Indian Health Service

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

The contractor shall perform teleradiology services and provide Medical Director Physician over-sight for operational issues for the Hopi Health Care Center located in Polacca, Arizona.

1 Teleradiology Services Billed for the following rates per reads;

1. Routine digital radiology (DR)/digital x-ray

(DX) $________

2. Sonograms $________

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

HEREIN, IS ACCEPTED AS TO ITEMS:

X

XX

DATED

VERNA M. KUWANHOYIOMA

. YOUR OFFER ON SOLICITATION (BLOCK 5),

INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER

ARE

ARE

31c. DATE SIGNED

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

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

30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (Type or print)

ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL

SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDEND

26. TOTAL AWARD AMOUNT (For Govt. Use Only)

OFFER

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA - FAR (48 CFR) 53.212

ARE NOT ATTACHED.

ARE NOT ATTACHED.

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

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

30a. SIGNATURE OF OFFEROR/CONTRACTOR

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

25. ACCOUNTING AND APPROPRIATION DATA

29. AWARD OF CONTRACT:

REF.

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32c. DATE 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

40. PAID BY39. S/R VOUCHER NUMBER38. S/R ACCOUNT NUMBER

37. CHECK NUMBER

FINALPARTIAL

36. PAYMENT

FINALPARTIAL

35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER33. SHIP NUMBER

COMPLETE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

42d. TOTAL CONTAINERS42c. DATE REC'D (YY/MM/DD)

42b. RECEIVED AT (Location)

42a. RECEIVED BY (Print)

41c. DATE41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

STANDARD FORM 1449 (REV. 2/2012) BACK

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

3. Multi detector computed tomography (MDCT)

4. Magnetic resonance imaging (MRI) $________

5. Dual Energy X-ray Absorptiometry (DEXA)

6. Training/Certification $________

02/01/2016-01/31/2017

Period of Performance: 02/01/2016 to 01/31/2017

2 OY-1

Teleradiology Services

Billed for the following rates per reads;

1. DR/DX $________

2. Sonograms $________

3. MDCT $________

4. MRI $________

5. DEXA $________

6. Training/Certification $________

02/01/2017-01/31/2018

(Option Line Item)

01/02/2017

Period of Performance: 02/01/2017 to 01/31/2018

3 OY-2

Teleradiology Services

Billed for the following rates per reads;

1. DR/DX $________

Continued ...

32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

3 2 of

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

3 3

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

(A) (B) (C) (D) (E) (F)

16-247-SOL-00013

2. Sonograms $________

3. MDCT $________

4. MRI $________

5. DEXA $________

6. Training/Certification $________

02/01/2018-01/31/2019

(Option Line Item)

01/01/2018

Period of Performance: 02/01/2018 to 01/31/2019

4 OY-3

Teleradiology Services

Billed for the following rates per reads;

1. DR/DX $________

2. Sonograms $________

3. MDCT $________

4. MRI $________

5. DEXA $________

6. Training/Certification $________

02/01/2019-01/31/2020

(Option Line Item)

01/01/2019

Period of Performance: 02/01/2019 to 01/31/2020

5 OY-4

Teleradiology Services

Billed for the following rates per reads;

1. DR/DX $________

2. Sonograms $________

3. MDCT $________

4. MRI $________

5. DEXA $________

6. Training/Certification $________

02/01/2020-01/31/2021

(Option Line Item)

01/01/2020

Period of Performance: 02/01/2020 to 01/31/2021

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)

Sponsored by GSA

FAR (48 CFR) 53.110