RFP_Submission_Checklist.pdf

Document Submission Checklist

Request for Proposal (RFP: 17-242-SOL-00018)

Professional Physician and Other Ambulatory Health Care Services

The following checklist is to assist you in ensuring that the acceptable minimum documents are submitted with your proposal and signed by an official authorized to bind your organization.

Document Requirement Number of Copies

1. Standard Form 1449, Solicitation/Contract/ 1 Copy with Original Order for Commercial Items Signature (Page 1) (Complete blocks 17a and 30a-30c) *Cite DUNS# in block 17a of the Standard Form 1449*

2. Paragraph B-1.b. (General/Purpose of Contract) 1 Copy Enter in Type of Professional Health Care Service

(Page 5)

3. Paragraph B-5.b.1.-5. (Fee Schedule/Pricing) 1 Copy Enter Discount/Offer/No-Show Fee

(Page 5)

4. Paragraph C-3 (FAR 52.212-3 Offeror 1 Copy Representation and Certifications –

Commercial Items (JAN 2017) Complete Pages 17 and 18, paragraphs (c)1- (c)10 and (d)1- (d)2 (Page 16, only b(2) if Annual Reps & Certs are up to date in SAM.gov)

5. Paragraph C-3 (FAR 52.212-3 Offeror 1 Copy Representation and Certifications –

Commercial Items (JAN 2017) Complete Page 22 and 23, paragraphs (l)3- (l)5, (n)2, (q)2 (Page 16, only b(2) if Annual Reps & Certs are up to date in SAM.gov)

6. Appendix D-2: Business Associate Agreement 1 Copy Complete Fillable items in I and IIA.

7. Attachment D-6: Provider Contract Summary Sheet 1 Copy with Original Complete Fillable items and sign. Signature

8. Attachment D-7: Provider Certification 1 Copy with Original Complete Fillable items and sign. Signature

9. Copies of Certifications, Licenses, Medical Malpractice Insurance 1 Copy and Specialty Training for each provider (if applicable).

Note: Please retain a copy of the RFP package for your reference.