Amedn 1.pdf

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Great Plains Area lndian Health Service 1 15 4h Avenue SE Federal Building, Room 309 Aberdeen, SD 57401

Jlur:re 28,2021

OUR REFERENCE: CRHC/Procurement Amendment No. One (l)

CRLIC2I.47

To whom it may concern:

Enclosed is the executed SF-30 document signed and dated by the Supervisory Contract Specialist in reference to solicitation number CRHC21-47. Please retain for your own records.

Should you have any questions or need information, please contact Paige Kerstiens, Purchasing Agent at (60s) 964-ts6s.

Sincerely, \ ,/-*,wffi/^" Supervisory Contract Specialist Cheyenne River Health Center

Attachments cc: file

REQUEST FOR QUOTATIONS

(THrS rS NOTAN ORDER)

THIS RFQ IS A SMALL BUSINESS SET.ASIDE

PAGE OFPAGES

1of 2

I. REQUESTNO.

ORHC-Z1-47

2. DATE ISSUED

7 t28t2021

3. REQUISITION/PURCHASE REQUEST NO

Amendment No. One (1)

4- CERT.FOR NAT. DEF.

UNDER BDSA REG.2

AND/OR DMS REG. I

RATING

54. ISSUED BY

Eagle Butte lndian Health Service, Cheyenne River Service Unit 24276166th St, PO Box 1012, Easle Butte, SD 57625

6. DELIVER BY (Date)

See schedule

5b. FOR INFORMATION CALL (NO COLLECTCALLS) 7. DELIVERY OTHER n aos DESTINATIoN R Gee schedute)

NAME

Paige Kerstiens oaise.kerstiens(Eihs. sov

TELEPHONE NUMBER 9. DESTINATION

AREACODE

NUMBER

964-1 565

a. NAME OF CONSIGNEE

Chevenne River Service Unit

8. TO: b. STREET ADDRESS

242761661h St. PO Box 1012

a. NAME b, COMPANY c. CITY

Eagle Butte

c. STREET ADDRESS

d. CITY I e. STATE f. ZIP CODE d. STATE I e. ZIPCODE sD I s7625

IO. PLEASE FURNISH QUOTATIONS TO

THE ISSUING OFFICE IN BLOCK

5a ON OR BY l:00 PM MST ON (Date)

July 30, 2021

IMPORTANT: This is a request for information, and quotations fumished are not oftiers. If you axe unablo to quote, please so indicate on this form and retum it to the address in Block 5a. This request does not commit the Govemment to pay any costs incurred in the preparation ofthe submission ofthis quotation or to contract for supplies or services. Supplies are of domestic origin unless otherwise indicated by quoter. Any representations and/or ce(ifications attached to this Request for Ouotations must be comoleted bv the ouoter.

I l. SCHEDULE finclude apolicable Federil, State and locol loxes)

ITEMNO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

UNIT PRICE

(e)

AMOUNT

(fl

Amendment No. One (1), hereby authorizes the following:

l) Change Box 10, Fumish by date, from July 29, 2021 to July 30, 2021.

2) Incorporate the following questions and answers:

Q: What is the average volume of patients seen from 8a-5p. A: 10-15 patients per day.

Probably 15 is the high end

Q: Is there any on-call requirement on the weekends or weekday nights? A: No weekend call.

3) All else remains the same.

There are no other changes by reason ofthis amendment.

12. DISCOUNT FOR PROMPT

PAYMENT

a. l0 CALENDAR DAYS o/n b.20

CALENDAR

DAYS%

c. 30 CALENDAR DAYS Yo

d. CALENDAR DAYS

NUMBER PERCENTAGE

NOTE: Additional orovisions and representations Ll are are not attached.

13. NAME AND ADDRESS OF QUOTER 15- SIGNATURE OF PERSON AUTHORIZED TO

SIGN QUOTATION

I5. DATE OF

QUOTATION

a. NAME OF QUOTER

b. STREET ADDRESS

c. COUNTY 16. SIGNER

a. NAME (Type of print) b.

.ELEPHONE

AREA CODE

d. CITY e. STATE f. ZIP CODE c. TITLE (type or print) NUMBER

IZED FOR LOCAL REPRODUCTION Form Inc. STANDARD PN (REV 6-95) Previous edition not usable Prescribed by GSA-FAR (48 CFR) 53-215-l(a)

ITEM

NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

LINIT PRICE

(e)

AMOUNT

(0

DLrNS & Bradstreet Number:

(The Duns & Bradstreet number is required.

Provided you do not have it, you may call 866-705- 571I and obtain one.) You will need a DUNS & Bradstreet NUMBER to be awarded the purchase order and repistered with the Svstem for Award Management: vou can register at www.samgov

The quoter is hereby notified that they must be registered in the System for Award Management (SAIVI) before the Government will issue an award. You may do this by going to www.sam.gov to register and you are required to update this registration every year prior to the expiration date.

No contract award shall be made to a vendor listed on the OIG Exclusion List (http://exlusions.ois.hhs. eov) throughout the duration of the contract.

Federal Tax ID Number:

Email Address:

Net Terms: