Medicaid Amendment 0005 to Revise County Lists 36C26320R0126.pdf

5. PROJECT NUMBER (if applicable)

CODE7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER3. EFFECTIVE DATE

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO. 1. CONTRACT ID CODE

FACILITY CODECODE

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:

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

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office.is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

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 letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

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

15A. NAME AND TITLE OF SIGNER 16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30 PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243

(Type or print) (Type or print)

(Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code)

(If other than Item 6)

(Specify type of modification and authority)

(such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

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

0005 None

36C263

Department of Veterans Affairs

NETWORK 23 CONTRACTING OFFICE

316 Robert Street N. STE. 506 St. Paul MN 55101

To all Offerors/Bidders

9A. AMENDMENT OF SOLICITATION NUMBER

36C26320R0126

X 05 March 2021

X

VISN 23 Open and Continuous Nursing Home Solicitation: Medicaid-based:

This amendment updates the Eligible County lists found in the original solicitation at section E.1 in order to to include new counties available for potential awards.

Please see following pages for the updated lists.

Counties added via this amendment are indicated in bold text.

All other terms and conditions remain unchanged.

29 November 2022

1 5

29 November 2022

Matthew Dale Contracting Officer

X

County State Homes Needed

Boone IA 1 Cerro Gordo IA 1 Dalls IA 1 Franklin IA 1 Hamilton IA 2 Hancock IA 1 Hardin IA 1 Marion IA 1 Marshall IA 1 Monrole IA 1 Pocahontas IA 1 Polk IA 4 Story IA 1 Warren IA 2

County Solicitation List VA Medical Health Care System:

Central Iowa (Des Moines)

36C26320R0126 A0005 // Revised Eligible County Lists // Effective from 29 November 2022

Page 2/5

Barnes ND 1 Becker MN 2 Beltrami MN 1 Big Stone MN 1 Burleigh ND 3 Cass ND 3 Clay MN 1 Dunn ND 1 Eddy ND 1 Grand Forks ND 1 Hettinger ND 1 Hubbard MN 1 Marshall MN 1 Nelson ND 1 Norman MN 1 Ottertail MN 3 Polk MN 1 Stark ND 1 Stutsman ND 1 Traill ND 1

County Solicitation List VA Medical Health Care System:

Fargo

Page 3/5

Adams IL 1 Benton IA 1 Blackhawk IA 4 Clayton* IA 2 Des Moines IA 1 Dubuque IA 1 Fayette* IA 1 Henry IA 1 Johnson IA 1 Knox IL 1 Linn IA 1 Louisa** IA 1 Mustatine** IA 1 Rock Island IL 2 Scott IA 2 Wapello IA 1 Whiteside IL 2 *only one (1) facility is needed in EITHER of Clayton or Fayette counties

** only one (1) facility is needed in EITHER of Louisa or Muscatine counties

County Solicitation List VA Medical Health Care System:

Iowa City

Page 4/5

Bon Homme SD 1 Brookings SD 1 Brown SD 1 Charles Mix SD 1 Cherokee IA 2 Clay SD 2 Codington SD 1 Cottonwood MN 1 Davison SD 1 Day SD 1 Dickinson SD 1 Douglas SD 1 Edmunds SD 1 Emmet IA 1 Grant SD 1 Hamlin SD 1 Hutchinson SD 1 Jackson SD 1 Jerauld SD 1 Kingsbury SD 1 Lac Qui Parle MN 1 Lincoln SD 2 Martin SD 1 McCook SD 2 Minnehaha SD 3 Minor SD 1 Moody SD 1 O'Brien IA 1 Osceola IA 1 Plymouth IA 1 Sioux IA 1 Spink SD 1 Turner SD 2 Union SD 1 Woodbury IA 2 Yellow Medicine MN 1

County Solicitation List VA Medical Health Care System:

Sioux Falls

Page 5/5

Blank Page