36C79118R0022-011.xls
XLS spreadsheet 47 KB Posted
- Attached to
- FY19 Dialysis National Contract - Trinity Dialysis Clinic Inc. Federal contract opportunity
- Solicitation number
- 36C79118R0022
About this file
This document contains a federal contract solicitation template and opportunity notice. The template provides instructions for offerors to list dialysis facilities and related contact and payment information on a spreadsheet. Offerors must indicate whether authorizations and payments will be centralized or handled at each facility. The opportunity notice seeks nationwide dialysis services for veterans, including center and home-based hemodialysis, peritoneal dialysis, and home training. Interested contractors must have CMS ESRD certification. The Department of Veterans Affairs intends to issue a solicitation on October 18, 2018 for these services under VISN 19.
36C79118R0022 Attachment 2 - Facility List - FY19.xls
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Text version
INSTRUCTIONS
| Purpose: This spreadsheet will be used by the VA Medical Centers to place authorizations and make payments as well as display the number of facilities under the contract, treatment modalities, and available chairs. |
| Instructions: Offerors must indicate on this spreadsheet whether the process for placing authorizations and making payments will be centralized or sent directly to the facility providing services and fill out the information in this spreadsheet accordingly. If the contact information for placing an authorization differs from the facility information, then offerors must fill out the authorization contact information. If the remittance address is different from the facility address then offerors must fill out the remittance information. The Government reserves the right to verify the number of chairs proposed by any offeror. |
| Column P- CMS Certification Column is formatted to save as "text", please ensure this is entered as text and not another number format. |
Column S- Modality Treatments Offered- Please list any and all Modalities offered (For example- Center HD, Home HD, Center PD, Home PD, Home Training)
FACILITY LISTING
| FACILITY INFORMATION | Authorization Point of Contact/Information | Remittance Information | |||||||||||||||||||||||||||||
| Network | VISN | Facility Name | Address1 | Address2 | City | State | Zip Code (+4) | Phone Number | Fax Number | Point of Contact (Business Hours) | Email Address | Point of Contact (After Hours) | After Hours Phone # | Provider Tax ID | CMS Certification Number | Facility NPI | Modality Treatments Offered | Number of Chairs | Shifts | Current Utilization | Authorization Address | Authorization City | Authorization State | Authorization Zip Code (+4) | Authorization Phone Number | Authorization Fax Number | Remittance Address | Remittance City | Remittance State | Remittance Zip Code (+4) | Remittance Phone Number |
&CFACILITY LISTING
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