25-AP-3943 PPR 656 LIMB Winkley-112436.pdf
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- 36C26325P1047
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PROSTHETIC APPLIANCES AND SENSORY AIDS:Prosthetic Procurement Request Document Page of Revised: 08March2017 PURPOSE: To ensure standardization of the submission process for all prosthetic appliances and sensory aids over the micro-purchase threshold; the document below is required to be completed and uploaded into the Electronic Contract Management System (eCMS) Planning Module. For access to the eCMS Planning Module, please contact the Network Contracting Office (NCO) eCMS Coordinator. Select this link to identify a local/regional eCMS/Application Coordinator.
This procurement request document is designed to be a complete compilation of all information required by the NCO to process the requested prosthetic item(s)/service(s). NOTE: Patient consults are prohibited in eCMS and ALL Patient Health Information MUST be redacted from all documents before uploading into the eCMS Planning Module.
Click the hyperlinks to open the eCMS Planning Module or a SharePoint page to assist in locating contact personnel for eCMS Application Coordinators.
A. Contact Information: Prosthetics Point of Contact Provide the following information B. Item Information: Accounting and Appropriation Data C. Detailed Procurement Information:
D. eCMS Procurement Package Completion Instructions:
Verify each item by checking the adjacent box.
Patient Information MUST be redacted prior to loading into eCMS Planning Module.
E. Justification & Approval (J&A):
ONE of the following four items MUST be selected to populate page three appropriately.
A Justification and Approval Document is required when a Sole Source is requested due to Emergency/Urgent and Compelling circumstances where only One Source can provide the item or service, or for USC 8123 Requests.
Link to J&A templates for open market items ≥ 150k - see attachments a-m. Selecting >150 results in a statement at the bottom of page three indicating the page was intentionally left blank and open the VHA PM to the relevant informational areas.
Check ONE of the Following ONE of the following four items MUST be selected to populate page three appropriately.
Link to J&A templates for open market items ≥ 150k - see attachments a-m. Selecting >150 results in a statement at the bottom of page three indicating the page was intentionally left blank and open the VHA PM to the relevant informational areas.
Is this an EMERGENCY Procurement?
Emergency/Urgent Requests: An e-mail with subject line "Emergency" is to be transmitted to notify the NCO Prosthetics Manager of the emergency request by PSAS. PSAS should verify receipt of the order by the Prosthetics Team Lead and that action is being taken. All emergencies shall be received by Procurement no later than 2:00 PM for same day action. Any emergencies that arrive after the 2:00 PM same day cutoff will be executed by 10:00 AM the following business day. In the event no confirmation is received by 2:30 PM the PSAS requestor shall notify the NCO PSAS email Group.
Time Zones: For same day processing through distributors in varying time zones, be cognizant of time differences; emergency orders placed in Pacific time zones that require processing through VA offices located in Eastern time zones are to be placed with Procurement Activity prior to 11AM Pacific time for same day processing.
Purchase Order Line Item Information
4. Demonstration that the Contractor's Unique Qualifications or Nature of the Procurement Requires the Use of the Authority Cited Above (Applicability of Authority):
This area is UNEDITABLE. Text here is determined by selection of item above.
5. Approvals in Accordance with VHA PM Volume Six, Chapter VI:
DoC/Designee (for non-delegated approval authorities) OR Contracting Officer's Certification (required): I certify that the foregoing justification is accurate and complete to the best of my knowledge and the order represents the best value to the government. I also certify that the justification meets requirements for other than full and open competition.
PSAS J&A Templates Requests < $250k - FSS (FAR Part 8) - Or - Open Market (FAR Part 13/FAR 16.505(b)(2)) Toggle check box selections to add or remove narrative text in 4 below.
Pick the right side box to insert narrative text for that item. Deselect the narrative by checking the left side box of that item. Pick only one, the narratives overlay and become difficult to read.
3. Statutory Authority Permitting Other than Full and Open Competition: Include narrative for ONLY ONE item below.
This Page Intentionally Left BLANK.
When NO J&A or >650k is selected on page two, the "This Page Intentionally Left Blank" will appear in the footer. To insert a J&A, return to Page 2 and select appropriate checkbox.
Kelly, Kristine E.
10.0.2.20120224.1.869952 Prosthetic limb components are specified by the clinical team to meet the unique and comprehensive needs of each Veteran with amputation.
The J&A is to support the award of a contract or purchase order on a sole source basis for the purchase of a prosthetic limb component from a single source per medical determination of need.
The prescribed item will be purchased from the Vendor identified because they are able to meet the Veteran's immediate need. The item was prescribed by the Veteran's attending Physician who has the authority to prescribe the method of treatment to best satisfy the medical condition of his/her patient. The physician has determined this item as the best device to treat the patient's medical condition and functional limitations. Substituting another device other than that specifically prescribed is beyond the role, competency, and professional functions of the Contract Specialist and would be detrimental to the treatment of the Veteran patient.
| CurrentPage: |
| PageCount: |
| Normally, folks can find user names, etc, by their eMail address fairly readily. : SAMANTHA.GOULET@VA.GOV |
| What is the total funding amount that has been verified by the Prosthetics POC for this action? : $63,706.04 |
| The Station Code field will allow for more than the three characters displayed. : 656 |
| Enter your own unique value by typing in the box. : 2692 |
| Provide a little more detailed description of the item to be procured here. : New ATK PROSTHESIS |
| txtfldConsultID: 112436 |
| To what address on file should the item be delivered? If OTHER is selected an additional prompt will appear to input the delivery information. : Other |
| By what date is this item required? : 2025-08-12 |
| Resets ENTIRE FORM. : |
| Provide the IFCAP/VISTA Vendor ID number here. : 11219 |
| Provide the Vendor's Name here. : WINKLEY |
| If OTHER is selected from the Delivery Information drop down, provide details here. : Veteran will pick up |
| Provide the number or email address to which documents should be submitted. : P: 763-546-1177 F: 763-847-9508 |
| Provide the Vendor's POC's contact information here. : Customer Service |
| Select One. : New |
| Select one. Attach additional pages if more than six items are to be listed. : Attached (Wheelchairs, Limbs, Stock) |
| Provide the IFCAP/VISTA Vendor ID number here. : 6248975 |
| If charges exceed $250, a Bill of Lading is REQUIRED. : $0.00 |
| Total ALL items with shipping. Field is calculated based on sum of Funding and Shipping charges. No override available. : $63,706.04 |
| ddServiceConnStat: Service Connected (SC) |
| Provide the number or email address to which documents should be submitted. : See Template |
| List any FSS, National, or Local Contracts that can be utilized to fulfill this need. : |
| List any Mandatory Sources required to fulfill this need. : 1 |
| Enter your own unique value by typing in the box. : 932 |
| ddSAMExclusion: No |
| By using the HCPC Code, later reference to HCPC in the IGCE section is possible. : |
| Indicate quantity of this item required. : |
| Provide the serial number for this item. : |
| Indicate price of the item required. : |
| Provide the billing item number for this item. : |
| Brief Item description. : |
| Add another row to insert another item. : |
| Delete an unused or incorrectly listed item. : |
| Indicate any Discounts on this item. : |
| ddDiscountINPrice: |
| Indicate any Discounts on this item. : |
| Provide the billing item number for this item. : |
| Consults contain PII and other Patient Information- verify consults are NOT loaded into eCMS by checking here. : 1 |
| All Patient Information MUST be redacted...verify this has been completed by checking here. : 1 |
| Check here when all Supporting Documentation has been loaded into eCMS. : 1 |
| Verify that Vendor Quotes are loaded into eCMS by checking here. : 1 |
| Verify that identification sequences are specifically identified within the eCMS Planning module by checking here. : 1 |
| Verify that Implant Forms have been loaded into eCMS where applicable by checking here. : 0 |
| Verify any other supporting documentation has been loaded into eCMS by checking here. : 1 |
| with the Requesting Provider if there is any uncertainty regarding FDA approval. : 1 |
| Selecting less than 150k Open Market J&A adds a J&A option to page three for completion.: |
| Selecting NO results in a statement at the bottom of page three indicating the page was intentionally left blank. : |
| Link is to the OTFOC SOP in the VHAPM. A separate J&A is required for sole source actions over $150K IAW FAR 6.303-2. Contact your NCO for assistance with initiating the sole source J&A.: |
| Clicking YES will produce a narrative with additional instructions to process the EMERGENCY. : |
| No, this is NOT an emergency. : |
| Click here to attach this request (WITHOUT A J&A) to an emergency eMail to Procurement Staff. : |
| cbAddlLineItemsForm: 0 |
| Keep in mind- this J&A MAY also require a QA review. All fields up to and including this signature field are locked upon executing this signature. : |
| Text here is determined by selection of item above. : |
| Text here is determined by selection of item above. : |
| Select ONE Item from list below. To change selection, simply re-select a different item. : |
| PrintButton1: |
| By Signing this Form, ALL data entry fields are LOCKED to editing. : |
| Selecting the right button inserts this item's narrative text in section 4 below. : |
| Selecting the right button inserts this item's narrative text in section 4 below. : |
| Selecting the right button inserts this item's narrative text in section 4 below. : |
| Selecting the right button inserts this item's narrative text in section 4 below. : |
| Selecting the right button inserts this item's narrative text in section 4 below. : |
| Exception language applies to Pacemaker/ICD/Implantable Loop Recorder national contracts. Selecting the right button inserts this item's narrative text in section 4 below. : |
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