Attachment 1 - MCP 11-212.pdf

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Attached to
Q514--SFVAHCS Otolaryngology/ENT Physician Service 5-Year: 11/01/2023-10/31/2028
Solicitation number
36C26323Q1107
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This document contains a clinic cancellation request form and instructions. The form requires providers requesting a clinic cancellation to specify the date, name of clinic, purpose of cancellation such as annual leave or sick leave, and hours being cancelled. It also includes a clinic cancellation triage form that must be completed to certify all patients have been triaged, medications reviewed, and directions given for rescheduling patients based on clinical indication. Identification of wait times is critical as it may determine patient eligibility for community care services.

The related federal contract opportunity is a five-year solicitation from the Department of Veterans Affairs for otolaryngology/ENT physician services at the San Francisco Veterans Affairs Health Care System from November 1, 2023 to October 31, 2028.

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File Type Posted
Attachment 4 - Contractor Rules of Behavior.pdf PDF
S02 - 36C26323Q1107 - Onsite Otolaryngology (ENT).pdf PDF
Attachment 3 - Organizational Conflict of Interest.pdf PDF
36C26323Q1107_1.docx DOCX document
Attachment 2 - Quality Assurance Surveillance Plan (QASP).pdf PDF
Attachment 6 - Past Performance.pdf PDF
Attachment 5 - Immigration and Nationality Act Certification.pdf PDF
Attachment 7 - 11-100 Reporting Diagnostic Test and Critical Results.pdf PDF

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October 30, 2020

Clinic Cancellation Request

When completed, route this request, patient list, and attachment A to the appropriate Supervisor.

1. Date of request:

2. Name of clinic:

3. Provider Name:

Cancellation Date:

Hours being cancelled:

4. Purpose of Clinic Cancellation: Mark all that apply:

Annual Leave □ Sick Leave □ Conference

Schedule □ Training □ Emergency Adjustment

Other

MCP 11-212

APPENDIX A

A-1

January 31, 2020 MCP 11-212

APPENDIXB

Clinic Cancellation Triage Form must be COMPLETED.

• Completion of this form certifies all patients have been triaged, medications have been reviewed, and directions for rescheduling the patients has occurred based on clinical indication.

• Identification of wait times is critical as it may drive the patient's eligibility for community care services.

• Do not say to schedule to next available without giving the date of the next available.

Thank you for your cooperation. Unfortunately, requests cannot be processed without this information. Incomplete requests will be returned to the requesting provider without approval.

Clinic Cancellation Triage Form

It is the clinical staff's responsibility to triage the patients being rescheduled.

Patients who need to be overbooked or rescheduled urgently should be included on this list with explicit directions. If you have reordered medications for a patient, please indicate when this was completed.

Appointment Med Refill Date to Current Wait Projected Wait

Patient ID time after Date Completed Reschedule Time cancellation

Provider's Signature Date

Service Line Director or Designee Date

Chief of Staff or Designee Date

B-1

Patient ID Med Refill Completed

Additional Space, If Needed Projected Wait

Time After Cancellation

Current Wait Time

Date to RescheduleAppointment Date

11-212 Clinic Cancellation Policy - Fillable
asfasd
Sheet1
Date13_af_date:
Text9:
Text10:
Text11:
Text12:
Check Box1: Off
Check Box2: Off
Check Box3: Off
Check Box4: Off
Check Box5: Off
Check Box6: Off
Check Box7: Off
Projected Wait time after cancellationRow1:
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Date16_af_date:
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Patient IDRow1:
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Date to RescheduleRow1:
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