D6_PROVIDER CONTRACT SUMMARY SHEET.pdf
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- Attached to
- Non-Personal Healthcare Services-Physicians & Other Professional Ambulatory Services for PRC Program
- Solicitation number
- 75H70726R00002
About this file
This is a Professional Medical Provider's Contract Summary Sheet form required for submission with proposals to the Indian Health Service (IHS) for medical provider contracts.
The form captures essential provider and facility information including facility name, street and billing addresses, telephone and fax numbers, and medical specialty. Providers must supply their Federal Employee or Tax Identification Number (EIN/TIN), DUNS Number, and confirm registration status in SAM.gov. The form requires disclosure of Medicare participation status including provider numbers and carrier information, National Provider Identifier (NPI), and Medicaid acceptance with associated provider numbers. Providers must list all hospitals where they hold admitting and/or staff privileges. For group practices with more than five providers, a spreadsheet must be attached listing each provider's name, EIN/TIN or Social Security Number, specialty, and whether they bill independently or outside the IHS contract.
The form includes a provider certification statement requiring the authorized signatory to attest that they are authorized to respond to the proposal and that all information provided is accurate and subject to verification through the National Practitioner Data Bank, Federation of State Medical Boards, and relevant licensing agencies. A critical note specifies that the EIN/TIN or SSN (with assigned suffix for multiple Medicare numbers or billing sites) will determine pricing claims and payment check addresses, and the appropriate identifier with suffix must appear in Block 26.d of each IHS 843 Purchase-Delivery Order for Health Services.
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Text version
THIS FORM MUST BE COMPLETED AND SUBMITTED WITH PROPOSAL
Professional Medical Provider’s Contract Summary Sheet
TO BE COMPLETED AND SUBMITTED BY THE CONTRACT PROVIDER
Facility Name:
Street Address:
City: State: Zip Code:
Billing Address: (If different from the facility address) Street Address:
City: State: Zip Code:
Telephone: Fax Ph. No:
Medical Specialty Federal Employee or Tax Identification No. (EIN/TIN):
DUNS Number: Registered in SAM.gov? Yes No In Process Medicare Participating Provider: Yes No Medicare Provider Number(s):
Medicare Carrier:
Area: Prevailing Area:
National Provider Identifier (NPI):
Accepts Medicaid Patients: Yes No Medicaid Provider Number:
Admitting/Staff Privileges: Please list the hospitals for which you have admitting and/or staff privileges:
Hospital Name City State
If this is group practice, please list all providers, their EIN/TIN or SSN, Specialty, and if, under any circumstance, they will bill independent of the group practice or outside the IHS Contract. Attach spreadsheet if more than 5 providers.
Name EIN/TIN Specialty Independent Billing: Yes / No
Provider Certification – I certify (for individuals or group affiliations) that I am authorized to respond to the proposal and the above information is true to the best of my knowledge and that IHS may verify the information provided by contacting the National Practitioner Data Bank, Federation of State Medical Boards and/or those agencies responsible for licensing and board certification.
Authorized Signature of Provider:
PLEASE NOTE: The EIN/TIN, or SSN will be used to determine the pricing claims and the address to which each check (payment) is sent. A suffix must be assigned to the EIN/TIN, or SSN to create a unique number for each multiple Medicare Nos.
or multiple billing sites to which a check (payment) should be sent. The appropriate EIN/TIN, or SSN with suffix must appear in Block No. 26, d, of each IHS 843, Purchase-Delivery Order for Health Services.
TO BE COMPLETED AND SUBMITTED BY THE CONTRACT PROVIDER
File details come from the government source that posted it. Updated .