Attachment J.16 - Invoice Format Updated.xlsx
XLSX spreadsheet 70 KB Posted
- Solicitation number
- 75D301-22-R-72142
About this file
This document contains an invoice template and budget template for the World Trade Center Health Program Clinical Centers of Excellence contracts. The templates provide guidance on the required format for invoices and budgets to be submitted under the contracts. Expense categories include direct labor, subcontracts, other direct costs, overhead costs, and travel. Labor and expenses must be tracked by activity and work breakdown structure code. The templates also include sections for rent/lease calculations, subcontractor labor reporting, and fee-for-service provider information.
The related federal contract opportunity is a solicitation to establish and operate up to three World Trade Center Health Program Clinical Centers of Excellence to provide healthcare services to 9/11 responders and survivors. Services include contract management, quality assurance, member services and outreach, care coordination and case management, program communications, healthcare administration, benefits coordination, and clinical and operational data collection. The cost-reimbursement contracts are for a period of five to eight years. Proposals will be evaluated using a best value tradeoff methodology. The solicitation number is 75D301-22-R-72142 and was issued by the National Institute for Occupational Safety and Health within the Department of Health and Human Services.
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Text version
SF 1034
| Standard Form 1034 | PUBLIC VOUCHER FOR PURCHASES AND SERVICES | ||||
| OTHER THAN PERSONAL | VOUCHER NO. | ||||
| Revised October 1987 | |||||
| Department of the Treasury | |||||
| TFM 4-2000 | |||||
| 1034-122 | |||||
| U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION | DATE VOUCHER PREPARED | SCHEDULE NO. |
| Centers for Disease Control & Prevention | CONTRACT NUMBER AND DATE | PAID BY |
| Financial Management Office (FMO) | ||
| P. O. Box 15580 | ||
| Atlanta, GA 30333 |
| PAYEE'S | |
| NAME | DATE INVOICE RECEIVED |
| AND | |
| ADDRESS | DISCOUNT TERMS |
PAYEES ACCOUNT NUMBER
SHIPPED FROM TO WEIGHT GOVERNMENT B/L NUMBER
| NUMBER AND DATE OF ORDER | DATE OF DELIVERY OR SERVICE | ARTICLES OR SERVICES | QUANTITY | UNIT PRICE | ||
| (Enter description, item number of contract of Federal supply schedule, and other information deemed necessary) | AMOUNT | |||||
| COST | PER | (1) |
| $ - 0 |
| $ - 0 |
| $ - 0 |
| (Use continuation sheet(s) if necessary) | (Payee must NOT use the space below) | TOTAL | $ - 0 | |||||
| PAYMENT: | Approved for Provisional Payment | EXCHANGE RATE | DIFFERENCES | |||||
| o | PROVISIONAL | Subject to later audit. =$ | =$1.00 | |||||
| o | COMPLETE | BY (2) | ||||||
| o | PARTIAL | |||||||
| o | FINAL | Amount verified correct for payment | ||||||
| o | PROGRESS | TITLE | (Signature or initials) | |||||
| o | ADVANCE | Auditor, Defense Contract Audit Agency | ||||||
| Pursuant to the authority vested in me, I certify that this voucher is correct and proper for payment. |
| (Date) | (Authorized Certifying Officer) | (Title) | |
| ACCOUNTING CLASSIFICATION |
PAID BY CHECK NUMBER ON ACCOUNT OF U.S. TREASURY CHECK NUMBER ON (Name of bank)
| CASH | DATE | PAYEE (3) | ||
| $ | ||||
| 1. When stated in foreign currency, insert name of currency. | PER | |||
| 2. If the ability to certify and authority to approve are combined in one person one signature only is necessary; otherwise the approving officer will sign in the space provided, over his official title. |
3. When a voucher is receipted in the name of a company or corporation, the name of the person writing the company or corporate name, as well as the capacity in which he signs, must appear. For example: "John Doe Company, per John Smith, Secretary:, or "Treasurer", as the case may be. TITLE
| Previous edition usable | NSN 7540-00-900-2234 |
| Privacy Act Statement | |
| The information requested on this form is required under the provisions of 31 U.S.C 82B and 82c, for the purposes of disbursing Federal money. The information requested is to identify the particular creditor and the amounts to be paid. Failure to furnish this information will hinder discharge of the payment obligation. |
SF 1035
Standard Form 1035 (EG) September 1973 4 Treasury FRM 2000
| 1035-110 | PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL | |
| CONTINUATION SHEET | VOUCHER NO. |
| SCHEDULE NO. | |
| SHEET NO. 2 | |
| U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT |
| NUMBER AND DATE OF ORDER | DATE OF DELIVERY OR SERVICE | ARTICLES OR SERVICES | ||||
| (Enter description, item number of contract or Federal supply schedule, and other information deemed necessary) | QUANTITY | UNIT PRICE | AMOUNT | |||
| COST | PER |
| Total | $0 |
| (Transfer to SF1034) |
| TOTAL | $0 |
| (Transfer to SF1034) |
| TOTAL |
| (Transfer to SF1034) |
Designed using Perform Pro, WHS/DIOR, Aug 96
Budget Snapshot
| Date: | 1/1/22 | |
| Total Award Amount: | Summary of Expenses for Option Period: XXXX (xx/xx/xx - xx/xx/xx) |
Contract #: (enter contract number)
| Budget Category | Award Amount | Prior Period Expenses | Current Period Expenses | Cumulative Expenses | Remaining Balance | % of increase/decrease from prior period | % of budget Remaining | % of YR Remaining | Variance | |
| (Enter in the award | ||||||||||
| amount for line item) | (Enter in the prior | |||||||||
| invoice amount) | (Enter in the current expenses) | (Enter in the previous |
cumulative expenses plus current)
| Total Direct Labor | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | 0% |
| Total Sub Contracts Labor | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | 0% |
| Other Direct Costs | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | 0% |
| Total Direct Costs | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | 0% |
| Total Overhead Costs | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | 0% |
| Total CLIN 1 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | 0% |
| Travel CLIN 2 | ||||||
| Total CLIN 1 &2 | ||||||
| Total Billed: | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
Activity & WTC Billing Title
| Activity Code | WTC Billing Labor Category | yes | Categories of expenses |
| 4.1 Contract Management (Directors only for this activity) | Administrative Assistant | no | Cleaning Supplies |
| 4.1.1 Training | Administrative Coordinator | Equipment | |
| 4.1.1.1 Training Reporting | Benefits Coordinator | Information Tech software | |
| 4.1.2 Staffing Requirements | Case Management | Information Tech Supplies | |
| 4.1.2.1 Staffing Report and Wages Report | Claims/Billing Manager | Medical Records | |
| 4.1.3 Coordination and Participation | Claims/Billing Specialist | Medical Supplies | |
| 4.1.4 Change Request (CR), Documentation, and Control Log | Clinic Manager | Office Supplies | |
| 4.1.5 Technical Guidance Document Compliance | Data Analyst | Other | |
| 4.1.6 Records Management | Deputy Director | Postage/Mailings | |
| 4.1.7 Risk and Issue Management | Director | ||
| 4.1.8 Fraud Waste and Abuse Compliance | Finance Specialist | ||
| 4.1.9 Quality Assurance Plan | Information Technology | ||
| 4.1.9.1 Quality Assurance Internal Audit Report | Medical Assistant | ||
| 4.2 Systems | Medical Records Coordinator | ||
| 4.2.1.2 Member Records | Member Services Coordinator | ||
| 4.2.2 Cost Tracking and Invoicing | Member Services Manager | ||
| 4.2.3 Operations Manual | Nurse | ||
| 4.3.1 Member Services | Nurse Manager | ||
| 4.3.2 Member Enrollment and Initial Contact | Pharmacist | ||
| 4.3.3 Member Retention | Physician | ||
| 4.3.4 Transfers | Physician Assistant | ||
| 4.3.5 Disruptive member and Member in Crisis Protocol | Project Coordinator | ||
| 4.3.6 Benefits Counseling | Psychiatrist | ||
| 4.3.6.1 Social Benefits Functions | Psychologist | ||
| 4.3.6.2 Assistance with Workers Compensation and other Healthcare Benefits | Pulmonologist | ||
| 4.3.7 Communication | Quality Assurance | ||
| 4.3.7.1 Translation and Interpretive Services | Revised Title | ||
| 4.3.7.2 Retention Activities for Current Members | Social Worker | ||
| 4.3.7.3 Outreach and Education for Prospective Members | |||
| 4.3.7.4 Establish Formal Mechanism for Consulting with Representative of Eligible Populations | |||
| 4.3.8 Administering Health Benefits | |||
| 4.3.8.1 Responsibilities of the Medical Director | |||
| 4.3.8.1.1 External Providers | |||
| 4.3.8.2 Responsibilities of the Mental Health Director | |||
| 4.3.8.3 Monitoring and Initial Health Evaluations | |||
| 4.3.8.3.1 Initial Health Evaluations | |||
| 4.3.8.3.2 Annual Monitoring Exam | |||
| 4.3.8.3.3 General Administration for AME/IHE | |||
| 4.3.8.4 Diagnostic Services | |||
| 4.3.8.6 Cancer Screening | |||
| 4.3.8.7 Certifications | |||
| 4.3.9 Medical Treatment for Certified Conditions | |||
| 4.3.9.1 Authorization of Services | |||
| 4.3.9.3 Prior Authorization] | |||
| 4.3.9.4 CCE Medical Reviews | |||
| 4.3.9.5 Medical Appeals | |||
| 4.3.9.6 Telehealth Services | |||
| 4.3.9.7 Disaster Preparedness and Public Health Emergencies | |||
| 4.4 Comprehensive Care Management (do not use, select sub-category) | |||
| 4.4.1 Case Management and Care Coordination | |||
| 4.4.1.1 Intensive Case Management | |||
| 4.4.2 Utilization Management | |||
| 4.4.3 Inpatient Hospital stays | |||
| 4.4.4 Lifestyle Medicine | |||
| 4.5 Claims submission and Payment | |||
| 4.5.1 Legally allowable fee schedule | |||
| 4.5.2 Billing for Health Plan Benefits | |||
| 4.5.3 Claims Appeals | |||
| 4.5.4 Coordination of Benefits (Survivor Cohort Only) | |||
| 4.6 Pharmacy Services | |||
| 4.6.1 Member Education | |||
| 4.6.2 Covered Medication and Restrictions | |||
| 4.6.3 Review of Data | |||
| 4.6.4 Compliance with State and Federal Law | |||
| 4.6.5 Retrospective Reviews and Reporting | |||
| 4.6.6 Pharmacy Benefits Quality Assurance and Reporting | |||
| 4.7.1 Provider Network | |||
| 4.7.2 Licensing and Insurance | |||
| 4.8 Transitioning Out | |||
| 5.1 Data Management Plan | |||
| 5.2 Data Transfer | |||
| 6 Performance Metrics | |||
| 6.1 Quality Assurance Surveillance Plan | |||
| 9 Deliverables | |||
| 10 Subcontracting | |||
| 11 HIPAA COMPLIANCE AND BUSINESS ASSOCIATE AGREEMENT | |||
| 12 Information Security | |||
| 12.1 Adequate Security | |||
| 12.2 Cyber Incident Reporting Requirement | |||
| 12.3 Cyber Incident Report | |||
| 12.4 Media Preservation and Protection | |||
| 12.5 Audit and Accountability (information security) | |||
| 12.6 Information Security Continuous Monitoring | |||
| 12.7 Access to Additional Information or Equipment Necessary for Forensic Analysis | |||
| 12.8 Cyber Incident Damage Assessment Activities | |||
| 12.9 CDC/NIOSH Safeguarding and Use of Contractor Attributional/Proprietary Information (do not use) | |||
| 12.1 Use and Release of Contractor Attributional/Proprietary Information Not Created By or For CDC/NIOSH (Do not use) | |||
| 12.11 Use and Release of Contractor Attributional/Proprietary Information Created By or For CDC/NIOSH (do not use) | |||
| 12.12 Use and Release of Contractor Attributional/Proprietary Information Created By or For CDC/NIOSH (do not use) | |||
| 12.13 Other Safeguarding or Reporting Requirements | |||
| 12.14 Subcontracts |
Direct Labor Labor Data for Option Period: XXXX (xx/xx/xx - xx/xx/xx) Contract #: (enter contract number)
| Facility | WTC Billing Labor Category | Employee Name | Hourly Rate (Salary/1880hrs) | Hours Worked | Monthly Labor | Fringe Rate | Total cost | Comments |
| Finance Specialist | john doe | 50 | 160 | 8000 | 25 | 200000 | ||
| Finance Specialist | sally doe | 50 | 160 | 8000 | 25 | 200000 | ||
| Finance Specialist | ||||||||
| Finance Specialist | ||||||||
| Finance Specialist |
"Labor Data for Option Period: XXXX (xx/xx/xx - xx/xx/xx) Contract #: (enter contract number) "
Subcontract Labor Subcontract Labor Data for Option Period: XXXX (xx/xx/xx - xx/xx/xx) Contract #: (enter contract number) Facility WTC Billing Labor Category Employee Name Hourly Rate (Salary/1880hrs) Hours Worked Monthly Labor Fringe Rate Total cost Comments
ODC
Other Direct Costs (ODC) for Option Period: XXXX (xx/xx/xx - xx/xx/xx) Contract #: (enter contract number)
| All items must have been on proposal or approved in a change request. All receipts to be attached | |||
| Invoice/Receipt # | Category of expenses | Amount | Description |
| $ - 0 | |||
| $ - 0 | |||
| $ - 0 | |||
| $ - 0 | |||
| $ - 0 | |||
| $ - 0 | |||
| $ - 0 |
Total Direct Costs $ - 0
Rent - Lease Rent/Lease for Option Period: XXXX (xx/xx/xx - xx/xx/xx) Contract #: (enter contract number) Provide how Rent/Lease is calculated - Include supporting documentation on original invoice and with each change
Overhead Overhead for Option Period: XXXX (xx/xx/xx - xx/xx/xx) Contract #: (enter contract number)
| Note: G&A, F&A, Fees, and Indirect Rates are to be defined and calculated here. | |
| Allowable Expense Categories: | |
| Facilities Expenses (see attachment 23) | |
| Total Expenses | 0 |
| Overhead Rate | |
| Total Overhead | 0 |
Travel
| Travel Expenditures Contract #: (enter contract number) |
| All items must have been on proposal or approved in a change request. |
Travel requires pre approval documentation.
All items over $5,000 require a receipt.
All travel requires invoices/receipt.
Fee for service Providers with Fee for Service Claims and Labor being billed for Option Period: XXXX (xx/xx/xx - xx/xx/xx) Contract #: (enter contract number)
| Providers Name | % of Labor Billed | |
| for the Month | % of Labor spent on fee for service | Dates of Fee for Service |
File details come from the government source that posted it. Updated .