RQ_Submission_Checklist.pdf

Rate Quotation Agreement Checklist

Solicitation#: 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 rate quotation and signed by an official authorized to bind your organization.

Document Requirement Number of Copies

1. Rate Quotation For Professional Health Care Services 1 Copy with Original (Pages 1 -8) Signature o Complete all applicable sections and sign o Please attach a detailed Fee Schedule if pricing will not be based on a percentage of the Medicare Fee Schedule (see bottom of Page 2).

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

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

4. Signed SF-30, Amendment of Solicitation, (Amendment 0003) 1 Copy with Original Effective Date 01/06/2020 Signature

5. Copy of W-9, Request for Taxpayer Identification Number and 1 Copy faxed to Certification; please fax if not sending via US Mail. 505-256-6848

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

Note2: Electronic signatures will be accepted,