Atch G - IHS IEE Representation Form.pdf
PDF 129 KB Posted
- Attached to
- Emergency Room Physicians at PIMC Federal contract opportunity
- Solicitation number
- RFP-22-PHX-09
About this file
This document contains a federal contract opportunity for emergency room physician services. The Indian Health Service is soliciting proposals for non-personal professional emergency room physician services at the Phoenix Indian Medical Center in Phoenix, Arizona. The requirement is set aside for Native American firms under the Buy Indian Act. The North American Industry Classification System code is 621111 for offices of physicians, with a size standard of $12 million. The period of performance is estimated to be from July 15, 2022 to July 14, 2023 with four option years. Proposals are due by July 12, 2022 at 3:00 PM Eastern Time. The solicitation includes rate schedules, statements of work, and representations for Indian Economic Enterprises. The contract type will be firm fixed price.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| RFP-22-PHX-09 Questions and Answers.pdf | ||
| Questions ER PHY HHCC.pdf | ||
| 75H71222R00045 ER PHY PIMC Approved REV 23 Jun 22.pdf | ||
| Continuation SF 1449 REV 23 June 2022.pdf | ||
| 75H71222R00044 Approved REV.pdf | ||
| Continuation SF 1449 rev 23 Jun 22.pdf | ||
| Atch A - Rate Schedule ER Physician Services.xlsx | XLSX spreadsheet | |
| 75H71222R00045 ER PHY PIMC Approved.pdf | ||
| Atch F- Wage Determination 2015-5469 dtd 15 Mar 2022.pdf | ||
| Atch E - Timesheet for Contract Service.xlsx | XLSX spreadsheet | |
| Atch D- Statement of Work ER Physician REV2.pdf | ||
| Continuation SF 1449.pdf | ||
| Atch B - Business Associate Agreement.pdf | ||
| Atch C - 2022 Tax Exemption.pdf |
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Text version
DEPARTMENT OF HEALTH & HUMAN SERVICES
Indian Health Service
Office of Management Services Division of Acquisition Policy (DAP)
5600 Fishers Lane Rockville, MD 20857
INDIAN HEALTH SERVICE
BUY INDIAN ACT
INDIAN ECONOMIC ENTERPRISE
REPRESENTATION FORM
SOLICITATION/SOURCES SOUGHT/RFI #: _________________________________________________
PROJECT TITLE: ________________________________________________________
DATE: ___________________________________________________________________
In accordance with 25 U.S.C. 47 the Buy Indian Act, the signature below constitutes self-certification that the Offeror meets the definition of an “Indian Economic Enterprise” (HHSAR 326.601) in response to this Sources Sought Notice, Request for Information (RFI) or Solicitation and resultant contract.
The enterprise must meet the definition of “Indian Economic Enterprise” throughout the following time periods:
(1) At the time an offer is made in response to this solicitation;
(2) At the time of contract award; and
(3) During the full term of the contract performance period. At any point during these periods, if the Contractor no longer meets the eligibility requirements, the contractor must provide immediate written notification to the Contracting Officer.
Individual Contracting Officers may require documentation of eligibility before awarding a set-aside or sole source contracts under the Buy Indian Act and awards may be subject to protest if the eligibility of the successful Offeror is in question. In addition to the self-certification requirements, successful Offerors must also be registered with the System of Award Management (SAM).
Any false or misleading information submitted by an enterprise when submitting an offer in consideration of an award set-aside under the authority of the Buy Indian Act is a violation of the law and punishable under 18 U.S.C. 1001.
False claims submitted as part of contract performance are subject to the penalties enumerated in 31 U.S.C. 3729 to 3731 and 18 U.S.C. 287.
REPRESENTATION
The Offeror represents as part of its offer that it does _____, does not _____ meet the definition of an “Indian Economic Enterprise” with “Indian Ownership” under the authority of the Buy Indian Act.
Name of the 51% owner of IEE Firm
Certifying Signature
Print Name
Name of Federally Recognized Tribal Entity
Business Name
DUNS Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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