D.4 HCHV NOTICE OF NEW CONTRACT FORM.pdf
PDF 693 KB Posted
- Solicitation number
- 36C24223R0004
About this file
This document is a notice form used to provide information about new contracts awarded under the Health Care for Homeless Veterans program. The form collects key details about contracted providers including the name, start date and expiration of the contract award, the per diem rate paid, and bed capacity if applicable. It also requests contact information for staff at the provider location and at the Veterans Affairs medical center awarding the contract. Program types covered under the notice include emergency housing, low-demand housing, and safe havens. Once completed, the form is to be submitted to both the HCHV program office and to the Northeast Program Evaluation Center, which will assign a project code to the provider for performance reporting purposes in the HOMES system.
The related federal contract opportunity is a solicitation by the Veterans Health Administration under the Department of Veterans Affairs for low-demand safe haven services to be provided at the Canandaigua VAMC as part of the HCHV program.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C24223R0004 0001.docx | DOCX document | |
| D.6 HCHV CR REQUEST FOR EXTENSION OF PER DIEM.pdf | ||
| D.3 HCHV CONTRACT RESIDENT FACILITY INSPECTION PACKET.pdf | ||
| D.5 HCHV CONTRACT PROGRAM INCIDENT REPORT.pdf | ||
| 36C24223R0004_2.docx | DOCX document | |
| D.2 HEALTH CARE FOR HOMELESS VETERANS CONTRACT RESIDENTIAL SERVICES PROGRAM _ VHA DIRECTIVE 1162.04.docx | DOCX document |
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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 .