Atch G - IHS IEE Representation Form.pdf
PDF 129 KB Posted
- Solicitation number
- RFP-22-PHX-07
About this file
This document contains a solicitation notice and statement of work for emergency room physician services. The Indian Health Service seeks a firm fixed price contract for non-personal professional emergency room physician services at the Hopi Health Care Center in Polacca, Arizona. The performance period is estimated from August 1, 2022 to July 31, 2023 with four optional one-year extensions. The North American Industry Classification System code is 621111 for offices of physicians and the size standard is $12 million. Electronic proposals shall be submitted to Michele.Lodge@ihs.gov by the deadline and include the rate schedule, technical proposal, past performance data and amendments. The solicitation is set aside for Native American firms under the Buy Indian Act and provides the opportunity for teaming arrangements and subcontracting.
The statement of work specifies emergency room physician services will be provided at the Hopi Health Care Center located at P.O. Box 4000 in Polacca, Arizona. The contractor must be registered in the System for Award Management and the government will award to the responsible and conforming offeror providing the best value based on price and other factors. Attachments include rate schedules, business associate agreements, tax exemption letters, statements of work and other requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| Questions ER PHY HHCC.pdf | ||
| Atch A - Rate Schedule ER Physicians.xls | XLS spreadsheet | |
| Atch F - Wage Determination 2015-5477 dtd 14 Mar 22.pdf | ||
| Continuation SF 1449.pdf | ||
| Atch D - Statement of Work ER Physicians REV2.pdf | ||
| 75H71222R00044 Approved.pdf | ||
| Atch E - Timesheet for Contract Service HHCC.xlsx | XLSX spreadsheet | |
| 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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