Atch H - IEE Representation Form.pdf
PDF 129 KB Posted
- Attached to
- Emergency Department NP and PA Services at PIMC
- Solicitation number
- RFP-22-PHX-01
About this file
This document contains a Request for Proposal for emergency department nurse practitioner and physician assistant services at the Phoenix Indian Medical Center. The solicitation is set aside for Native American firms in accordance with the Buy Indian Act of 1910, with no opportunities for joint ventures, teaming arrangements, or subcontracting. Services are required from August 1, 2022 through July 31, 2023 with four optional one-year extensions. The contract type will be firm fixed price. Proposals are due by May 16, 2022 and the contract is expected to be awarded by June 15, 2022. The North American Industry Classification System code is 621399 with a size standard of $7.5 million. The place of performance is the Phoenix Indian Medical Center located in Phoenix, Arizona. The solicitation incorporates FAR provisions and clauses in effect through FAC 2022-06.
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Other files
| File | Type | Posted |
|---|---|---|
| Atch A - Rate Schedule ER NP.PA PIMC 2022.xlsx | XLSX spreadsheet | |
| Atch G - Clauses.Terms and Instructions.pdf | ||
| Atch C - 2022 Tax Exemption.pdf | ||
| Atch D - SOW Emergency NP-PA 26 May 2022.pdf | ||
| Atch B - Business Associate Agreement.pdf | ||
| Atch E - Timesheet for Contract Service.xlsx | XLSX spreadsheet | |
| Atch F- Wage Determination 2015-5469 dtd 15 Mar 2022.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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