18-242-SOL-00038_-_Amendment.pdf

(x)

18-242-SOL-00038

x x copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted ; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT 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 telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

x

Albuquerque NM 87110 4101 Indian School Rd NE, Suite 225 Albuquerque Indian Health Service

05/14/2018000001

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

12. ACCOUNTING AND APPROPRIATION DATA (If required) is not extended.is extended, Items 8 and 15, and returning

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

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

FACILITY CODE CODE

10B. DATED (SEE ITEM 13)

10A. MODIFICATION OF CONTRACT/ORDER NO.

9B. DATED (SEE ITEM 11)

9A. AMENDMENT OF SOLICITATION NO.

CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code)

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

PAGE OF PAGES

4. REQUISITION/PURCHASE REQ. NO.3. EFFECTIVE DATE2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO. (If applicable)

1. CONTRACT ID CODE

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

05/14/2018

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

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority) appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

E. IMPORTANT: Contractor is not, is required to sign this document and return __________________ copies to the issuing office.

ORDER NO. IN ITEM 10A.

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

Amendment No. One is hereby issued to make the following corrections to the original solicitation for two part-time dentists to provide services at the Albuquerque Indian

Dental Clinic (AIDC)

Correction Albuquerque Indian Dental Clinic (AIHC) should read Albuquerque Indian Dental

Clinic (AIDC).

Page 7:

Continued ...

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

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

(Signature of person authorized to sign) (Signature of Contracting Officer)

GENEVIEVE L. MONK

STANDARD FORM 30 (REV. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

NSN 7540-01-152-8070

Previous edition unusable

Except as provided herein, all terms and conditions of the document referenced in Item 9 A or 10A, as heretofore changed, remains unchanged and in full force and effect .

Electronically Signed 05/23/2018

X

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 3

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

18-242-SOL-00038/000001

Responsibility Factors:

Take out: 2. Contractor must be a graduate of an accredited residency program in endodontic dentistry.

Correction: 4. Contractor must be licensed in a state of the United States or its territories in order to practice endodontic dentistry. Should read: 4. Contractor must be licensed in a state of the United States or its territories in order to practice general dentistry.

Page 14: Full text of Privacy Act Violation

Notification

Privacy Act Violation Notification

Pursuant to the section of the Privacy Act entitled, "Civil Remedies", a Federal employee or contractor can be required to pay up to $5,000 if,

(a) A Federal employee or Contractor, who knows that certain types of releases of information about a patient are prohibited, willfully discloses the information to a person not entitled to receive it.

(b) A Federal employee or contractor keeps information about individual people and does not make public notice of it as required by the

Privacy Act of 1997, or;

(c) Any person or organization asks for or gets a copy of an individual's record under false pretense.

The Privacy Act of 1974 was designed to establish and protect certain rights of people served by the employees of the Federal Government or their contractors. The Contractor shall ensure that each Contract employee is aware that he/she can be subject to criminal penalties for violations of the Act to the same extent as a Federal employee.

Questions concerning the Privacy Act Procedures may be directed to:

Joel McIntosh, Area Privacy Act Coordinator

Continued ...

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

Sponsored by GSA

FAR (48 CFR) 53.110

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)

18-242-SOL-00038/000001

Address: Albuquerque Area Indian Health Services

4101 Indian School Road NE

Albuquerque, New Mexico 87110

Telephone (505) 256-6817

Page 15:

Correction:

My license to practice psychology ( ) has ( ) has not been terminated, suspended, or revoked, in any State, the District of Columbia, Puerto Rico, or a Territory of the U.S.

Should Read: My license to practice general dental services ( ) has ( ) has not been terminated, suspended, or revoked, in any State, the District of Columbia, Puerto Rico, or a

Territory of the U.S.

All other terms and conditions of the original solicitation remain unchanged by reason of this amendment.

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

Sponsored by GSA

FAR (48 CFR) 53.110