Attachment 4 - Letter of Intent Attachments 1-4.pdf

LETTER OF INTENT ATTACHMENT 1

DEFENSE HEALTH AGENCY

Manual of the Medical Department 3 December 2024

Subj: Off-duty Remunerative Professional Employment (Regulatory)

1. General. Outside (Off-duty) remunerative professional civilian employment, including self-employment (hereto referred to as off-duty employment) of all health care providers, is subject to policies herein stated by the Defense Health Agency (DHA), and policies applicable by the Secretary of the Defense (DoD Manual 6025.13). For purposes of this article, a health care provider is any military or Federal civilian health care professional who is eligible for, or who has been granted, clinical practice privileges to provide health care services in a military medical or dental treatment facility.

2. Guideline

(a) Commanding officers may authorize off-duty employment upon written request of Federal health care providers when such activities do not interfere with provision of health care services or mission accomplishment.

Commanding officers should consider factors such as hours per week, work site proximity, travel time, potential training opportunities and skills maintenance that would benefit the DHA, and impact on civilian communities and providers when reviewing such requests.

(b) Permission to engage in off-duty employment must be documented in writing and may be withdrawn at any time by the commanding officer.

(c) Personnel enrolled in graduate training programs will not be authorized to engage in off-duty employment.

(d) If approved, employment will normally not exceed 16 hours per week and there must be at least 8 hours between the end of the off-duty employment and the start of military duties. Periods in excess of 16 hours per week can be authorized only if the commanding officer finds that special circumstances exist which indicate that no conflict with military or civilian duties will occur, notwithstanding the additional hours. Health care providers on leave may be exempt, by the commanding officer, or as delegated, from the 16 hours per week, 8 hours between work periods, and 2-hour travel time restrictions.

(e) The site of off-duty employment must be located within 2 hours travel time, by land, of the site of military duties unless in a leave status or otherwise authorized by the commanding officer.

(f) A health care provider engaged in off-duty employment must not assume primary responsibility for the care of any critically ill person on a continuing basis as this will inevitably result in compromise of responsibilities to the patient or the primacy of military obligations. Military health care providers must be available to provide patient care to military beneficiaries at all times. Their military duty takes precedence. Similarly, civilian health care providers must be available to perform their Government duties during prescribed working hours.

(g) No health care provider will request or be granted administrative absence for the primary purpose of conducting off-duty employment.

(h) Off-duty employment will not be conducted on military premises, involve expense to the Federal government, or involve use of military equipment, personnel, or supplies.

(i) Off-duty employment must not interfere, or be in competition with local civilian practitioners in the health professions. Off-duty employment local impact must be assessed by the requesting practitioner’s officer. The commanding officer should consider items such as assessment statements from the employer, local medical or dental society, and practitioner when deciding level of impact.

(j) Health care providers are responsible for complying with all applicable licensing requirements to practice in the civilian community such as State licensure, Drug Enforcement Administration (DEA) certification, and medical malpractice coverage. The fee-waived DEA certification is not authorized for off-duty employment.

(k) There may be no self-referral from the military setting to their off-duty employment on the part of heath care providers. Refer to 18 U.S.C. §208.

(l) DoD health care providers cannot be authorized TRICARE providers or be reimbursed for providing TRICARE services to DoD beneficiaries per 5 U.S.C. § 5536. TRICARE beneficiaries must be screened and identified as such and the charges reduced to reflect that portion of the services that are provided by the health care provider. This restriction does not apply to dental services provided to TRICARE Dental Program enrollees in the continental United States; however, because Active Duty, Guard, and Reserve Service members are eligible for dental care through the direct care system, dental care services delivered by off-duty employment of Navy dentists to Active Duty, Guard, and Reserve Service members are prohibited by DoD dual compensation and conflict rules.

Title 5 U.S.C. § 5536 does not prohibit DoD health care providers from becoming enrolled Medicare providers with regard to their off-duty employment and billing for Medicare for their services. There are no prohibitions against DoD dentists providing care in their off-duty capacity to family members of active duty or Reserve Component personnel when those family members are enrolled in the TRICARE Dental Program (TDP) because the TDP enrollees are not eligible for because the TDP enrollees are not eligible for care in a military facility. Refer to DoD Health Affairs Policy memo of 23 July 1996 (health care providers) and 15 April 2013 (NOTAL) (dental care providers) refers.

(m) Collateral or subsequent obligations arising out of off-duty employment, such as appearances in court or testimony before a compensation board, which take place during normal working hours, must be accomplished only while on annual leave. Refer to SECNAVINST 5820.8A.

(n) Health care providers are expected to be aware of and comply with all other statutes and regulations pertaining to off-duty employment. Where doubt exists on whether all applicable constraints have been considered, consult with a Navy Medicine attorney or local Naval Legal Service Office.

(o) These guidelines do not apply to the provision of emergency medical assistance in isolated instances.

Also excluded are non-remunerative community services operated by nonprofit organizations for the benefit of all the community and deprived persons, such as a drug abuse program, program volunteer, venereal disease centers, and family planning centers.

l. Medical Department officers are expected to be aware of and comply with all other status and regulations pertaining to off-duty employment. Where doubt exists as to whether all applicable constraints have been considered, consultation should be effected with the local naval legal service office.

3. The local command has primary responsibility of control of off-duty employment by Medical Department officers. Guidelines above serve as a basis for carrying out this responsibility.

4. Medical Department officer requesting permission to engage in off-duty employment shall submit their request to the commanding officer on NAVMED 1610/1, Off-duty Remunerative Professional civilian Employment Request, and shall sign the Statement of Affirmation thereon in the commanding officer’s presence of designee. Approval or disapproval by the commanding officer shall be indicated in the appropriate section of NAVMED 1610/1. Medical Department officers shall advise their off-duty employers that as military members they are required to respond immediately to call for military duty that may arise during schedule off-duty employment. The commanding officer’s approval of an officer’s request for off –duty employment may not be granted without written certification from the off-duty employer that he or she accepts the availability limitations placed on the Medical Department officer.

5. The requester shall inform the commanding officer in writing of any deviation in the stated request prior to the inception of any such changes.

6. Permission shall be withdrawn at any time by the commanding officer when such employment is determined to be inconsistent with the above guidelines. Where permission is withdrawn the officer affected shall be afforded and opportunity to submit to the commanding officer a written statement containing the Medical Department officer’s views or any information pertinent to the discontinuance of the employment.

7. Reports are not required to be submitted to DHA by field activities. However, during Medical and Dental Inspectors General visits or other administrative onsite visits, local command compliance with this article will be reviewed. In addition, adequate records should be maintained to provide summarized information as may be necessary for monitoring and evaluating the functioning of this program by DHA or higher authority.

LETTER OF INTENT ATTACHMENT 2

PROOF OF CITIZENSHIP REQUIREMENTS

For a full copy of the Manual go to http://doni.daps.dla.mil/SECNAV%20Manuals1/5510.30.pdf.

1. All documents submitted as evidence of U. S. citizenship must be original documents or certified copies.

Uncertified copies are not acceptable. The following documents are acceptable proof of citizenship:

a. The original U. S. birth certificate with a raised seal issued at the time of birth from one of the 50 states, or outlying territories or possessions.

b. A hospital birth certification (clinic and commercial birth center certification is not permitted) with an authenticating raised seal or signature provided all vital information is given.

c. A delayed birth certificate provided it shows the birth record was filed within one year after birth; it bears the registrar's seal and signature, and cites secondary evidence such as a baptismal certificate, certificate of circumcision, affidavits of persons having personal knowledge of the facts of the birth or other official records such as early census, school or insurance.

d. U.S. Passport (current or expired) or U.S. passport issued to individual’s parent in which the individual is included.

e. FS-240 Report of Birth Abroad of a Citizen of the United States of America/Consular Report of Birth.

f. FS-545 Certification of Birth issued by a U.S. Consulate or DS-1350 the Department of State Certification.

g. INS N-550/570 U.S. Immigration and Naturalization Service Naturalization Certificate.

h. INS N-560/561 U.S. Immigration and Naturalization Service Certificate of Citizenship. If the individual does not have a Certificate of Citizenship, the original Certificate of Naturalization of the parent(s) may be accepted if the naturalization occurred while the individual was under 18 years of age (or under 16 years of age before 5 October 1978) and residing permanently in the U.S.

i. Certificate of birth issued by the Canal Zone government indicating U.S citizenship is only acceptable if verified by direct government inquiry to: Vital Records Section, Passport Services, 1111 19th Street NW, Suite 510, Washington, D.C. 20522-1705.

j. DD 372, Verification of Birth is acceptable for military members (officer and enlisted) provided the birth data is listed and verified by the Department of Vital Statistics.

k. DD 1966, Application for Enlistment into the Armed Forces of the United States are acceptable provided the documents sighted are listed and attested to by a recruiting official.

5. If none of the above forms of evidence are obtainable, a notice from the registrar issued by the state with the individual’s name, date of birth, which years were searched for a birth record and that there is no birth certificate on file for the applicant should be presented. *The registrar's notice must be accompanied by the best combination of the following secondary evidence:

a. Baptismal certificate

b. Census record

c. Certificate of circumcision http://doni.daps.dla.mil/SECNAV%20Manuals1/5510.30.pdf

d. Early school record

e. Family Bible record

f. Doctor’s record of post-natal care

g. Newspaper files and insurance papers

* NOTE: These documents must be early public records showing the date and place of birth, created within the first five years of life. The individual may also submit an Affidavit of Birth, Form DSP-10A, from an older blood relative, i.e., a parent, aunt, uncle, sibling, who has personal knowledge of the birth. It must be notarized or have the seal and signature of the acceptance agent.

LETTER OF INTENT ATTACHMENT 3

PERSONAL QUALIFICATIONS SHEET

SOLICITATION NUMBER: HT941025R0003

POSITION TITLE: Neonatologist/Neonatal Nurse Practitioner/Pediatric Hospitalist

1. Every item on this Personal Qualifications Sheet must be addressed. Applicant must sign and date where indicated. Any additional information required may be provided on a separate sheet of paper (indicate by number and section the question(s) you are responding to).

2. The information you provide will be used to determine your technical acceptability and acceptability of applicants. In addition to this Personal Qualifications Sheet, please submit two (2) letters of recommendation as described in this form.

3. To be considered for award, each Letter of Intent must include the following documentation to verify applicant qualifications: Professional Education Degree, Release of Information, Personal and Professional Information Sheet for Privileged Providers, all licenses and certifications held since qualifying degree including all voluntary/involuntary lapses of license(s) and expired/inactive licenses, continuing education certificates, and U.S.

citizenship documentation. If false information is submitted, the following actions may occur: If the Quoter submits false information, the Quoter will be deemed ineligible for award and can result in the determination that you are no longer eligible for future Government contracts.. If the potential candidate submits false information, this action may initiate the suspension and debarment process.

4. Health Certification. Individuals providing services under Government contracts are required to undergo a physical exam 60 days prior to beginning work. The exam is not required prior to award but is required prior to the performance of services under this contract. By signing this form, you have acknowledged this requirement.

5. Practice/Medical Information:

Yes No

5.1. Have you ever been the subject of a malpractice claim? * ___ ___

5.2. Have you ever been a defendant in a felony or misdemeanor case? * ___ ___

5.3. Has your license or certification to practice ever been revoked or restricted In any state? * ___ ___

5.4. Do you have any physical handicap or condition that could limit your clinical practice? ___ ___

5.5. Have you been hospitalized for any reason during the past 5 years?* ___ ___

5.6. Are you currently receiving or have you in the past ever received, therapy for any alcohol related program?* ___ ___

5.7 Have you ever been unlawfully involved in the use of controlled substance?* ___ ___

5.8. Are you currently receiving or have you in the past ever received therapy for any drug-related condition?* ___ ___

5.9. a. Are you a U.S. Citizen? ___ ___

b. If yes, do you hold dual citizenship or passport from a ___ ___ foreign country?*

*If any of the above is answered "yes" attach a detailed explanation. Specifically address the disposition of the claim or charges for numbers 5.1 through 5.8 above, and the State of the revocation for number 5.3 above.

LETTER OF INTENT ATTACHMENT 3 CONT’D

PERSONAL QUALIFICATIONS SHEET

SOLICITATION NUMBER: HT941025R0003

POSITION TITLE: Neonatologist/Neonatal Nurse Practitioner/Pediatric Hospiatlist I. General Information:

Name: _______________________________________ Last First Middle

Date of Birth: _______________

Address: _______________________________________________________________

Phone: ( ) _______________ Email: _________________________

II. Education Requirements:

a. Medical Program:

Name of Accredited School Graduation Date:

Address/Location of Program:

ECFMG Certification: _________________________

III. Professional Licensure and Board Certification:

a. Possess and maintain a current unrestricted license to practice as a medicine in any one of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands. The HCW is responsible for complying with all applicable state licensing regulations.

Name of State License/Certification State Received Date Received

Name of State License/Certification State Received Date Received

Name of State License/Certification State Received Date Received

b. List applicable Board Certification

Title of Certification Date of Certification (mm/dd/yy)

c. List applicable fellowships

Title of Certification Date of Certification (mm/dd/yy)

IV. Certifications:

a. I am currently certified in Basic Life Support (BLS) or will be certified in Basic Life Support prior to contract start-date.

YES_____________ NO _____________

b. I am currently certified in Pediatric Advance Cardiac Life Support (PALS) or will be certified in PALS prior to contract start-date.

YES_____________ NO _____________

c. I am currently certified in Neonatal Resuscitation Program (NRP) or will be certified in NRP prior to contract start-date.

YES_____________ NO _____________

D. I am currently certified in S.T.A.B.L.E or will be certified in S.T.A.B.L.E. prior to contract start-date.

YES_____________ NO _____________

V. Professional Employment: List your current and preceding employers. Provide dates as month/year. If more space is required, please use a separate sheet of paper. Identify any medical experience obtained in a military setting.

Name and Address of Present Employer From To

(1) _______________________________ _____ _____

Position Title: ______________

Work Performed: _____________________________________________________________________________

Names and Addresses of Preceding Employer From To

(2) _______________________________ _____ _____ Position Title: ______________

Work Performed: _____________________________________________________________________________

Names and Addresses of Preceding Employer From To

(3) _______________________________ _____ _____

Position Title: ______________

Work Performed: _______________________________________________________________________________ Are you are currently employed on a Navy contract? If so, where is your current contract and what is the position?

VI. Letters of Recommendation:

Provide two (2) letters of recommendation written within the last two (2) years attesting to clinical skills. A minimum of one of the letters must be from a supervisor or clinical peer. The other letter must be from either a clinic or hospital administrator, or a practicing physician. Reference letters shall attest to the quality and quantity of experience. The letters may also address patient rapport and the communication skills between practitioner and patient and among peers. Recommendation letters must include name, title, phone number, date of reference, address and signature of the individual providing reference.

VII. Additional Information:

Provide any additional information you feel may enhance your acecptability such as your resume, curriculum vitae, commendations or documentation of any awards you may have received, etc.

PRIVACY ACT STATEMENT

Under 5 U.S.C. 552a and Executive Order 9397, the information provided on this page and the remainder of the Personal Qualifications Sheet is requested for use in consideration of a contract; disclosure of this information is voluntary; failure to provide this information may result in the denial of the opportunity to enter into a contract.

I hereby certify the above information to be true and accurate:

____________________________ ______________ (mm/dd/yy) (Signature) (Date)

Name (Printed)

LETTER OF INTENT ATTACHMENT 4

Contracted Health Care Worker Examination and Immunization Verification Form

Candidate must be in good health, meeting the immunization and screening required above, and free of any medical condition or infectious disease that may prevent his/her ability to perform services as a Health Care Worker.

Provider’s Signature: __________________________________

Provider’s Name: ___________________________

Phone Number: ________________________________ Date: ____________________