D.4 HCHV NOTICE OF NEW CONTRACT FORM.pdf
PDF 694 KB Posted
- Solicitation number
- 36C24223R0003
About this file
This document is a notice form for new Health Care for Homeless Veterans (HCHV) contract programs. The form provides fields for providers to fill out relevant details about new HCHV contracts, including the provider and staff names, contract start and end dates, per diem rates, bed capacity, facility addresses and points of contact. Upon completion, the form is to be forwarded to both the HCHV program office and the Northeast Program Evaluation Center (NEPEC) prior to veterans being placed at the new contracted facility. NEPEC will then assign a project code and provide reporting instructions to the identified HCHV program point of contact. The related federal contract opportunity is solicitation number 36C24223R0003 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 2 for G004--HCHV Contract Residential Services in VISN 2 Upstate.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24223R0003 0003.docx | DOCX document | |
| 36C24223R0003 0002.docx | DOCX document | |
| 36C24223R0003 0001.docx | DOCX document | |
| 36C24223R0003_1.docx | DOCX document | |
| D.6 HCHV CR REQUEST FOR EXTENSION OF PER DIEM.pdf | ||
| D.5 HCHV CONTRACT PROGRAM INCIDENT REPORT.pdf | ||
| D.2 HEALTH CARE FOR HOMELESS VETERANS CONTRACT RESIDENTIAL SERVICES PROGRAM _ VHA DIRECTIVE 1162.04.docx | DOCX document | |
| D.3 HCHV CONTRACT RESIDENT FACILITY INSPECTION PACKET.pdf |
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Text version
VA FORM
MAY 2014
10-10116b 1
HEALTH CARE FOR HOMELESS VETERANS (HCHV)
NOTICE OF NEW CONTRACT FORM
VA MEDICAL CENTER INFORMATION
NOTIFICATION OF NEWLY OPERATIONAL HCHV CONTRACT
PROGRAM / PROVIDER INFORMATION
PROVIDER STAFF
HCHV POC PHONE NUMBER
VISN
Provider Name:
Contract Start Date:
Per Diem Rate:
Locally assigned Contract #:Date Facility passed Inspection:
SITE CODE
FAX NUMBER
PROJECT CODE (TO BE ASSIGNED BY NEPEC)
This form must be completed and forwarded to both the HCHV program office and NEPEC prior to any Veterans being placed at this contracted facility. Program activity should not be reported in HOMES until NEPEC assigns a project code and forwards reporting instructions to the identified HCHV program POC.
PROGRAM TYPE (SELECT ONE)
Contracted Emergency Residential Low Demand Safe Haven
Date Contract Expires:
Bed (Max Capacity:
SITE ADDRESS (CITY, STATE, ZIP)
Provider POC:
Fax No.:Phone No.:
Title
EMAIL:
Provider Fiscal Official:
Fax No.:Phone No.:
Title
EMAIL:
ADDITIONAL COMMENTS
T e x t i e d
D.4 HCHV NOTICE OF NEW CONTRACT FORM
File details come from the government source that posted it. Updated .