J-21 Corporate Experience Attestation.docx
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- Attached to
- DME MAC Jurisdiction D
- Solicitation number
- CMS-RFP-2010-0016
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Attachment J-21 Corporate Experience Attestation
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RFP-CMS-2010-0016
(insert company letterhead here)
Attachment J.21 Corporate Experience Attestation (Insert Offeror/Company Name) understands and unconditionally attests that it has experience working on contracts similar in size and scope to the Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) contracts. Specifically, (insert Offeror/Company Name) attests that it has processed health care claims, administered payments for health care services, and performed outreach activities with providers and/or suppliers of health care services.
The contracts listed below, which are consistent with its past performance questionnaire references (see Attachment J-02), represent (Insert Offeror/Company Name)’s experience in performing requirements similar to those listed in the DME MAC statement of work (see Attachment J-01).
1. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
2. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
3. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
4. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
5. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
It is agreed upon and understood that the organization’s Attestations and disclosure documents will become a part of the organization’s proposal.
As an individual with authority to bind the (Insert Offeror/Company Name), I accept responsibility for this written document.
(signature)
(type full name)
Vice President, Medicare Operations
Attachment J-21 Corporate Experience Attestation Source Selection Information – See FAR 2.101 and 3.104 Page | 2
File details come from the government source that posted it. Updated .