75H70621D00025-Award_FtYatesND_Dentist.pdf

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

2. CONTRACT NO.

I 3.AWARD/ r· ORDER NUMBER

75H70621D00025 EFFECTIVE DATE

7. FOR SOLICITATION

► 18

.NAME

INFORMATION CALL: WENDA WRIGHT

9. ISSUED BY CODE

Aberdeen Area Indian Health Servic Federal Building 115 Fourth Ave, SE Aberdeen SD 57401

11. DELIVERY FOR FOB DESTINA--

TION UNLESS BLOCK IS

MARKED

KJ SEE SCHEDULE

15. DELIVER TO

IHSFTYATES

010 N RIVER RD PO

FT YATES ND 58538

17a. CONTRACTOR/ CODE

OFFEROR

12. DISCOUNT TERMS

IHS NET

BOX J

1519349

15P

CODE

I IHSFTYATES

I

FACILITY!

CODE

DAX SAFETY & STAFFING SOLUTIONS, LLC 1519349

DAX SAFETY & STAFFING SOLUTIONS, LL

3219 NE 153RD TER

SMITHVILLE MO 640896801

TELEPHONE NO.

□ 17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

19. 20.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES

Firm Fixed-Price, Non-Personal Healthcare Service, Commercial Item, Indefinite Delivery/Indefinite Quantity, Contract for Dentist to provide Dental Services for the Standing Rock IHS Service Unit, Fort Yates, Dakota or the McLaughlin IHS Health Center,

1. REQUISITION NUMBER

I

PAG

OF

I 7

5- SOLICITATION NUMBER

ISSUE DATE

r· SOLICITATION

I

b. TELEPHONE NUMBER (No collect calls)

8. OFFER DUE DATE/LOCAL TIME

605-226-7724

10. THIS ACQUISITION IS □ UNRESTRICTED OR IBJ SET ASIDE: %FOR:

iZJ SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

□ (WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

□ HUBZONE SMALL SMAI I RLJSIN!=SS PRO�RAM

NAICS: 621210

BUSINESS □ EDWOSB

□ SERVICE-DISABLED □ 8(A) $8.00 VETERAN-OWNED SIZE STANDARD:

SMALL BUSINESS

13b. RATING D 13a. THIS CONTRACT IS A

RATED ORDER UNDER 14. METHOD OF SOLICITATION

DPAS (15 CFR 700)

□RFQ

16. ADMINISTERED BY

Aberdeen Area Indian Health Federal Building 115 Fourth Ave, SE Aberdeen SD 57401

18a. PAYMENT WILL BE MADE BY

IHSGREATPLAINS AREA

Great Plains Area IHS

115 4TH AVENUE SE

ABERDEEN SD 57401-4301

□ IFB □ RFP

CODE

Servic

CODE

IIHSGREATPLAINS l

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW

IS CHECKED □SEE ADDENDUM

21. 22. 23. 24.

QUANTITY UNIT UNIT PRICE AMOUNT

a

North

McLaughlin, South Dakota. Period of Performance:

7/15/2021 through 7/14/2022.

Period of Performance:

Base Year: July 15, 2021 through July 14, 2022

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 126. TOTAL AWARD AMOUNT (For Govt. Use Only)

See schedule $0.00

□ 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212- 1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA □ ARE □ ARE NOT ATTACHED.

□ 27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA □ ARE □ ARE NOT ATTACHED.

□ 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER

ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL

SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

30a. SIGNATURE OF OFFEROR/CONTRACTOR

30b. NAME AND TITLE OF SIGNER (Type or print)

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

I 30c. DATE SIGNED

□ 29. AWARD OF CONTRACT: __ _ _ _ _ __ _ _ __ OFFER

DATED _ _ _ _ _ __ . YOUR OFFER ON SOLICITATION (BLOCK 5),

INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

HEREIN, IS ACCEPTED AS TO ITEMS:

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

31b. NAME OF CONTRACTING OFFICER (Type or print)

CRAIG J. WELLS I

31c. DATE SIGNED

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA- FAR (48 CFR) 53.212

Brent Fraizer / Vice President 7/15/21

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

Option Year One (1): July 15, 2022 through July

14, 2023

Option Year Two (2): July 15, 2023 through July

14, 2024

Option Year Three (3): July 15, 2024 through July

14, 2025

Option Year Four (4): July 15, 2025 through July

14, 2026

Period of Performance: 07/15/2021 to 07/14/2026

Base Year: July 15, 2021 through July 14, 2022

Dentist Services - Fort Yates, ND or McLaughlin, SD

1872 Hours X $140.00/Hour, totaling $262,080.00

Obligated Amount: $0.00

Delivery: 07/14/2022

Option Year One (1): July 15, 2022 through July

14, 2023

Dentist Services - Fort Yates, ND or McLaughlin, SD

1872 Hours X $140.00/Hour, totaling $262,080.00

Amount: $262,080.00(Option Line Item)

07/15/2022

Delivery: 07/14/2023

Continued ...

32a. QUANTITY IN COLUMN 21 HAS BEEN

21. 22.

QUANTITY UNIT

0 RECEIVED 0 INSPECTED 0 ACCEPTED AND CONFORMS TO THE CONTRACT EXCEPT AS NOTED·

23.

UNIT PRICE

24.

AMOUNT

0.00

32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE I

32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

33. SHIP NUMBER �- VOUCHER NUMBER 35. AMOUNT VERIFIED 36. PAYMENT 37. CHECK NUMBER

CORRECT FOR

0 COMPLETE □ PARTIAL 0 FINAL

0 PARTIAL 0 FINAL

38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID BY

41 a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 42a. RECEIVED BY (Print)

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42b. RECEIVED AT (Location)

42c. DATE REC'D (YY/MMIDD) 142d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV. 2/2012) BACK

REFERENCE NO. OF DOCUMENT BEING CONTINUED

CONTINUATION SHEET 75H70621D00025

NAME OF OFFEROR OR CONTRACTOR

DAX SAFETY & STAFFING SOLUTIONS, LLC 1519349

ITEM NO.

(A)

SUPPLIES/SERVICES

(B)

Option Year Two (2): July 15, 2023 through July

14, 2024

Dentist Services - Fort Yates, ND or McLaughlin, SD

1872 Hours X $144.00/Hour, totaling $269,568.00

Amount: $269,568.00(Option Line Item)

07/15/2023

Delivery: 07/14/2024

Option Year Three (3): July 15, 2024 through July

14, 2025

Dentist Services - Fort Yates, ND or McLaughlin, SD

1872 Hours X $148.00/Hour, totaling $277,056.00

Amount: $277,056.00(Option Line Item)

07/15/2024

Delivery: 07/14/2025

Option Year Four (4): July 15, 2025 through July

14, 2026

Dentist Services - Fort Yates, ND or McLaughlin, SD

1872 Hours X $152.00/Hour, totaling $284,544.00

Amount: $284,544.00(Option Line Item)

07/15/2025

Delivery: 07/14/2026

This contract does not obligate funds; funds must be obligated prior to starting performance through a delivery/task order. FAR 52.216-18

Ordering, FAR 52.216-19 Ordering limitations and

FAR 52.216-22 Indefinite Quantity. Orders may be placed against this contract by issuing task orders and may be submitted electronically by e-mail, facsimile or mailed by hard copy.

The "Unit Price" is an all-inclusive cost. All

"inclusive cost" is defined to include travel, lodging, per diem, fringe benefits, i.e., life insurance, social security, federal, state, and local taxes, plus all other costs pertinent to the performance of this contract.

Attachments:

Continued ...

NSN 7540--01-152-8067

QUANTITY UNIT

(C) (D)

UNIT PRICE

(E)

PAGE OF

3 7

AMOUNT

(F)

OPTIONAL FORM 336 (4-86)

Sponsored by GSA

FAR (48 CFR) 53.110

0.00

0.00

0.00

CONTINUATION SHEET

?SH70621D0002S

NAME OF OFFEROR OR CONTRACTOR

DAX SAFETY & STAFFING SOLUTIONS, LLC 1519349

ITEM NO.

(A)

SUPPLIES/SERVICES

(B)

- Quote

- Statement of Work

- Clauses incorporated by Reference and in

Full-Text

- HHS Residual Standards of Conduct

- Business Associate Agreement

- Workplace Violence

- Courtesy and Respect in the Workplace Policy

- Mandatory Seasonal Influenza Immunizations for the Civilian Health Care Personnel

- Standards of Conduct

A security pre-clearance must be performed for any employees referred to IHS through this contract.

Fingerprints must be completed and adjudicated prior to services being performed under this contract.

No contract award shall be made to any vendor or provider listed on the OIG Exclusion List http://exclusions.oig.hhs.gov throughout the duration of the contract. It shall be the responsibility of the contractor to notify the acquisition official if there is a change in provider.

Performance of this contract will require routine access by employees of the Contractor or its subcontractors to facilities or systems controlled by the Indian Health Service (I.H.S.).

Before starting work requiring routine access to

I.H.S. facilities or systems each person must complete a FBI National Criminal History Check

(Fingerprint Check) adjudicated by an I.H.S.

employee using the Office of Personnel Management

Personnel Investigations Processing System.

Contractors shall allow five business days for

I.H.S. processing of fingerprints taken electronically at an I.H.S. site and thirty business days for non-electronic processing of fingerprints using FBI Form FD-258. A list of

I.H.S. sites with electronic fingerprint capability is available from the Contracting

Officer.

Continued

NSN 7540--01-152-8067

QUANTITY UNIT

(C) (D)

UNIT PRICE

(E)

PAGE OF

4 7

AMOUNT

(F)

OPTIONAL FORM 336 (4-86)

Sponsored by GSA

FAR (48 CFR) 53.110

CONTINUATION SHEET

?SH70621D0002S

NAME OF OFFEROR OR CONTRACTOR

DAX SAFETY & STAFFING SOLUTIONS, LLC 1519349

ITEM NO.

(A)

SUPPLIES/SERVICES

(B)

In addition, no Contractor or subcontractor employee shall be permitted to perform work under this contract if listed on the HHS Office of

Inspector General List of Excluded

Individuals/Entities (LEIE), http://exclusions.oig.hhs.gov. As soon as practicable prior to the start of work, the performance of the work the Contractor shall provide to the Contracting Officer the names of all individuals to be used in performance of work for screening against the LEIE. During the performance, the Contractor shall provide the

Contracting Officer the names of any additional or substitute employees for screening before they begin work.

The Contractor is responsible for conducting security preclearance investigations in sufficient depth to ensure that each Contractor or subcontractor employee referred to I.H.S. is not on the LEIE and can obtain a favorable fingerprint clearance. Each security preclearance shall be conducted sufficiently in advance of the start of performance to avoid delays caused by denial of access. If this is a

Time and Materials, Labor-Hour or Cost

Reimbursement contract, the contractor shall not charge for or be reimbursed for labor hours or other costs incurred for employees who are unable to perform due to denial or access or the excess time required to resolve and clear unfavorable security clearance findings. If this is a Fixed

Price contract, denial of access due to security clearance findings shall not be a basis for excusable delay or an increase to the contract amount.

Government will pay for the cost to process the contractors suitability clearances. However, multiple investigations for the same position may, at the Contracting Officers discretion, lead to reduction(s) in the contract price of no more than the cost of the extra investigation(s).

Employees that DO NOT have access to LMS, contractors, volunteers, or IHS employees with

IPA's or MOA's to tribal organizations please, Continued ...

NSN 7540--01-152-8067

QUANTITY UNIT

(C) (D)

UNIT PRICE

(E)

PAGE OF

5 7

AMOUNT

(F)

OPTIONAL FORM 336 (4-86)

CONTINUATION SHEET 75870621D00025

NAME OF OFFEROR OR CONTRACTOR

DAX SAFETY & STAFFING SOLUTIONS, LLC 1519349

ITEM NO.

(A)

SUPPLIES/SERVICES

(B) click here IHS Sexual Abuse Prevention website.

When the contractors have completed and passed the training, please have them send a copy of the last page of the training with Name, Date, and

Time to their Supervisor, COR, and Kimmen LeBeau, e-mail: Kimmen.LeBeau@ihs.gov

INVOICE SUBMISSION AND PAYMENT:

The contractor shall submit a signed and approved invoice to request payment on at least a monthly basis.

A. The contractor shall submit an original invoice to:

The Great Plains Area Indian Health Service

Attn: Accounts Payable

115 4th Avenue SE, Room 309

Federal Building

Aberdeen, South Dakota 57401

The contractor shall submit a copy of the invoice to:

Attn: Michael Candreva, COR II

010 North River Rd

PO Box J

Fort Yates, North Dakota 58538

Phone: 701-854-8248 michael.candreva@ihs.gov

B. The contractor shall include the following information on each invoice in accordance with the prompt payment act (5 CFR Part 1315.9(b)):

1. Contractor's name

2. Invoice number and date

3. Entire award number or other authorization number for delivery of goods or services

4. Description (including dates of service), price and quantity of goods and services rendered

5. Shipping and payment terms

6. Duns number and taxpayer identifying number

Continued ...

NSN 7540--01-152-8067

QUANTITY UNIT

(C) (D)

UNIT PRICE

(E)

PAGE OF

6 7

AMOUNT

(F)

OPTIONAL FORM 336 (4-86)

CONTINUATION SHEET 75870621D00025

NAME OF OFFEROR OR CONTRACTOR

DAX SAFETY & STAFFING SOLUTIONS, LLC 1519349

ITEM NO.

(A)

SUPPLIES/SERVICES

(B)

(TIN)

7. Contact name (where practicable), title and telephone number

Payment shall be made by the Great Plains Area

Financial Management Branch, 115 4th Avenue SE, Room 309, Federal Building, Aberdeen, South

Dakota 57401.

The Government reserves the right to accept or reject services, if the level of performance is unacceptable.

"Dentist(s) will arrive on a Business Day ONLY to complete all Orientation and Background procedures. The Clinical Director or Designee will ensure all Orientation and Background procedures have been completed and an email will be sent to the Contracting department to state as such. The Dentist(s) will NOT see patients until

Background/Fingerprints have been cleared."

"The standards of medical practice and duties of the Contractor through its Dentist(s) shall be determined pursuant to the bylaws of the Service

Unit. The regulations of the hospital, applicable provisions of law, other rules and regulations of any and all governmental authorities relating to licensure and regulation of physicians and hospitals must be followed.

Also the standards and recommendations of Centers for Medicare and Medicaid Services (CMS) or the

Accreditation Organization must be adhered to.

The Contract Dentist(s) shall be required to participate in a quality improvement program, which is consistent with current requirements for ongoing monitoring and evaluation of the quality and appropriateness of care."

The total amount of award: $1,355,328.00. The obligation for this award is shown in box 26.

NSN 7540--01-152-8067

QUANTITY UNIT

(C) (D)

UNIT PRICE

(E)

PAGE OF

7 7

AMOUNT

(F)

OPTIONAL FORM 336 (4-86)