CTR047091_Contract_Amendment_Summary_4.pdf

CONTRACT AMENDMENT

ARIZONA DEPARTMENT

OF HEALTH SERVICES

150 N. 18th Ave., Ste. 530 Phoenix, Arizona 85007

CONTRACT No.:

CTR047091

CONTRACT AMENDMENT No.: 4 ARIZONA PROCUREMENT PORTAL AMENDMENT No.: 3

PROCUREMENT OFFICER

Jacqueline S. Ortega-Avila

REGISTRY STAFFING SERVICES FOR THE ARIZONA STATE HOSPITAL

It is mutually agreed that the Contract referenced in this amendment is amended as follows:

1. Effective November 1st, 2021, pursuant to the Special Terms and Conditions, Provision Three (3), Contract Extensions (5 Year Maximum), the Contract is hereby extended through October 31st, 2022, by this Amendment Four (4).

ALL OTHER PROVISIONS OF THIS CONTRACT SHALL REMAIN IN THEIR ENTIRETY.

Contractor hereby acknowledges receipt and acceptance of above amendment and that a signed copy must be filed with the Procurement Office before the effective date.

The above referenced Contract Amendment is hereby executed this __________ day of____________________, 2021 at Phoenix, Arizona.

(To be filled out by Procurement Office)

Contractor Signature

Contractor Signature Date

Authorized Signatory’s Name and Title

CONCENTRIC HEALTHCARE SOLUTIONS, LLC.

Procurement Officer Signature

Contractor’s Name

October 21st, 2021

Robert Bales

Vice President, Operations

Digitally signed by Robert Bales DN: cn=Robert Bales, o=Concentric Healthcare Staffing, ou=Vice President, Operations, email=rbales@chsaz.com, c=US Date: 2021.10.21 09:25:26 -07'00'

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CONCENTRIC HEALTHCARE SOLUTIONS LLC

DUNS Unique Entity ID

142266860

SAM Unique Entity ID

N94QF8N4VMD9

CAGE / NCAGE

37BB2

Purpose of Registration

All Awards

Registration Status

Active

Expiration Date

Oct 6, 2022

Physical Address

4250 N Drinkwater BLVD STE 100

Scottsdale, Arizona 85251-3982

United States

Mailing Address

4250 N Drinkwater BLVD

STE 100

Scottsdale, Arizona 85251-3985

United States

Business Information

Doing Business as

Concentric Healthcare Solutions

Division Name

(blank)

Division Number

(blank)

Congressional District

Arizona 06

State / Country of Incorporation

Arizona / United States

URL

https://www.concentrichealthcare.com

Registration Dates

Activation Date

Oct 8, 2021

Submission Date

Oct 6, 2021

Initial Registration Date

Mar 10, 2005

Entity Dates

Entity Start Date

Dec 1, 2003

Fiscal Year End Close Date

Dec 31

Immediate Owner

CAGE

(blank)

Legal Business Name

(blank)

Highest Level Owner

CAGE

(blank)

Legal Business Name

(blank)

Executive Compensation

Registrants in the System for Award Management (SAM) respond to the Executive Compensation questions in accordance with Section 6202 of

P.L. 110-252, amending the Federal Funding Accountability and Transparency Act (P.L. 109-282). This information is not displayed in SAM. It is sent to USAspending.gov for display in association with an eligible award. Maintaining an active registration in SAM demonstrates the registrant responded to the questions.

Proceedings Questions

Registrants in the System for Award Management (SAM) respond to proceedings questions in accordance with FAR 52.209-7, FAR 52.209-9, or

2.C.F.R. 200 Appendix XII. Their responses are not displayed in SAM. They are sent to FAPIIS.gov for display as applicable. Maintaining an active registration in SAM demonstrates the registrant responded to the proceedings questions.

SAM Search Authorization

I authorize my entity's non-sensitive information to be displayed in SAM public search results:

Yes

Entity Types

Business Types

Entity Structure

Partnership or Limited Liability Partnership

Entity Type

Business or Organization

Organization Factors

Limited Liability Company

Profit Structure

For Profit Organization

Financial Information

Accepts Credit Card Payments

Yes

Debt Subject To Offset

No

EFT Indicator

CAGE Code

37BB2

Points of Contact

Electronic Business

Robert Bales, Vice President, Operations 4250 N Drinkwater BLVD

Scottsdale, Arizona 85251

United States

Robert Bales, Director 4250 N Drinkwater BLVD

Scottsdale, Arizona 85251

United States

Government Business

Robert Bales, Vice President, Operations 4250 N Drinkwater BLVD

Scottsdale, Arizona 85251

United States

Robert Bales, Director 4250 N Drinkwater BLVD

Scottsdale, Arizona 85251

United States

Past Performance

Robert Bales, Director 4250 N Drinkwater BLVD

Scottsdale, Arizona 85251

United States

Robert Bales, Director 4250 N Drinkwater BLVD

Scottsdale, Arizona 85251

United States

Service Classifications

NAICS Codes

Primary

Yes

NAICS Codes

561311

NAICS Title

Employment Placement Agencies

561320 Temporary Help Services

Product and Service Codes

PSC PSC Name

G004 Social- Social Rehabilitation

Q201 Medical- General Health Care

Q301 Medical- Laboratory Testing

Q401 Medical- Nursing

Q402 Medical- Nursing Home Care Contracts

Q502 Medical- Cardio-Vascular

Q503 Medical- Dentistry

Q504 Medical- Dermatology

Q505 Medical- Gastroenterology

Q506 Medical- Geriatric

Q507 Medical- Gynecology

Q508 Medical- Hematology

Q509 Medical- Internal Medicine

Q510 Medical- Neurology

Q515 Medical- Pathology

Q516 Medical- Pediatric

Q518 Medical- Physical Medicine/Rehabilitation

Q519 Medical- Psychiatry

Q521 Medical- Pulmonary

Q522 Medical- Radiology

Last updated by Robert Bales on Oct 06, 2021 at 01:55 PM CONCENTRIC HEALTHCARE SOLUTIONS LLC https://sam.gov/entity/142266860/coreData?status=Active Page 2 of 3

Q523 Medical- Surgery

Q525 Medical- Urology

Q526 Medical- Medical/Psychiatric Consultation

Q527 Medical- Nuclear Medicine

Q601 Medical Coding And Auditing

Q602 Medical Records

Q603 Medical Transcription

Q701 Specialized Medical Support

Q702 Technical Medical Support

Q802 Clerical Medical Support

Q999 Medical- Other

R401 Support- Professional: Personal Care (Non-Medical)

R431 Support- Professional: Human Resources

R497 Support- Professional: Personal Services Contracts

R499 Support- Professional: Other

Disaster Response

Yes, this entity appears in the disaster response registry.

States

Any

Counties Metropolitan Statistical Areas

Last updated by Robert Bales on Oct 06, 2021 at 01:55 PM CONCENTRIC HEALTHCARE SOLUTIONS LLC https://sam.gov/entity/142266860/coreData?status=Active Page 3 of 3

10/26/21, 11:59 PM Arizona Corporation Commission https://ecorp.azcc.gov/BusinessSearch/BusinessInfo?entityNumber=L11973889 1/3

ENTITY INFORMATION

Search Date and Time: 10/26/2021 11:59:25 PM

Entity Details

Entity Name:

CONCENTRIC HEALTHCARE SOLUTIONS LLC

Entity ID:

L11973889

Entity Type:

Domestic LLC

Entity Status:

Active

Formation Date:

4/27/2005

Reason for Status:

In Good Standing

Approval Date:

4/27/2005

Status Date:

Original Incorporation Date:

4/27/2005

Life Period:

Perpetual

Business Type:

Last Annual Report Filed:

Domicile State:

Arizona

Annual Report Due Date:

Years Due:

Original Publish Date:

6/2/2006

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Page 1 of 1, records 1 to 2 of 2

Title Name Attention Address Date of Taking Office

Last Updated

Member KYLE SILK

6547 E VOLTOIVE AVE,

SCOTTSDALE, AZ, 85254, USA

4/27/2005 5/26/2005

Member

CHRIS

BOLLINGER

6547 E VOLTOIVE AVE,

SCOTTSDALE, AZ, 85254, USA

4/27/2005 5/26/2005

Name:

CHRIS BOLLINGER

Appointed Status:

Active

Attention:

Address:

4250 N DRINKWATER BLVD #165 , SCOTTSDALE, AZ 85251, USA

Agent Last Updated:

6/16/2006

E-mail:

Attention:

Mailing Address:

4250 N DRINKWATER BLVD #165 , SCOTTSDALE, AZ 85251, USA

County:

Principal Information

Address

Attention:

Address:

4250 N DRINKWATER BLVD #165, SCOTTSDALE, AZ, 85251, USA

County:

Maricopa

Last Updated:

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