Exhibit_A.2_-_VC_EMS_Invoice_Template_updated_5-2024.pdf

PDF 1 MB Posted

Attached to
EMS Invoicing Services
Solicitation number
26-B-68TF
Issued by
Volusia County, Florida

About this file

This document is an invoice template exhibit for the County of Volusia Emergency Medical Services Division in Florida, which processes Medicare, Medicaid, and other insurance claims for countywide ambulance and medical services. The template establishes the standardized format for approximately 88,000 invoices annually based on FY 2025 volumes. The Invitation for Bid #26-B-68TF, issued March 3, 2026, solicits comprehensive EMS invoicing services including data processing, printing, and mailing of double-sided invoices on 20-pound paper stock with gradient shading and HIPAA Privacy Notice inserts. The contractor must process and mail invoices within one business day of receiving data files submitted two to three times weekly via Secure File Transfer Protocol and must utilize National Change of Address filtering to reduce returned mail. Sealed proposals are due by March 25, 2026, at 3:01 p.m. through the County's eProcurement Portal, with a question deadline of March 11, 2026, and a non-mandatory solicitation opening scheduled for March 25, 2026, at 3:01 p.m. The initial contract term is three years with options for two subsequent one-year renewals or one two-year renewal, contingent upon mutual written agreement and County Council approval.

Pricing shall be submitted on a per-invoice basis covering all costs associated with data processing, formatting, printing, folding, stuffing, envelopes, and paper, with postage excluded as a direct pass-through cost. Respondents must indicate whether a monthly minimum invoice guarantee is required and may propose prompt payment discounts or Electronic Funds Transfer discounts. The solicitation includes a local preference provision allowing a three percent discount to respondents with documented permanent business locations in Brevard, Lake, Orange, Osceola, Seminole, or Volusia County. Payment terms default to net 45 days from invoice receipt, with interest accrued at up to one percent per month on undisputed invoices unpaid after 30 days. The County will impose a postage deposit based on average monthly mailings and current first-class postage rates. Successful contractors must maintain Professional Liability insurance with minimum coverage of $1,000,000 per claim and $2,000,000 aggregate and Cyber Insurance with minimum coverage of $2,000,000 per claim and $4,000,000 aggregate. All nongovernmental contractors must submit a signed Human Trafficking Attestation form, and the contractor must execute a non-negotiable HIPAA Business Associate Agreement ensuring strict compliance with HIPAA Privacy and Security Rules, the HITECH Act, and the American Recovery and Reinvestment Act.

View the file

Other files

Show all 15

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file

Text version

ADDRESSEE: MAKE CHECKS PAYABLE TO:

PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT

County of Volusia Emergency Medical Services 112 Carswell Ave.

Holly Hill, FL 32117-5010

DATE PAY THIS AMOUNT INVOICE NUMBER

AMOUNT PAID

IF PAYING BY MASTERCARD, VISA, DISCOVER OR AMERICAN EXPRESS, FILL OUT BELOW.

CHECK CARD USING FOR PAYMENT

CARD NUMBER SEC. CODE

SIGNATURE EXP. DATE

MASTERCARD VISA AMERICAN EXPRESSDISCOVER

PATIENT NAME

MEDICARE PATIENTS

covered and medically necessary Medicare Part B claims.

MEDICAID PATIENTS

OTHER INSURANCES

SEND CORRESPONDENCE TO:

County of Volusia Emergency Medical Services 112 Carswell Ave.

Holly Hill, FL 32117-5010

Signature te

YOUR NAME (Last, First, Middle Initial)

ADDRESS

CITY STATE ZIP

TELEPHONE MARITAL STATUS o Separated o Single o Divorced

( ) o Married o Widowed

D.O.B. SOCIAL SECURITY NUMBER

YOUR PRIMARY INSURANCE COMPANY’S NAME EFFECTIVE DATE

PRIMARY INSURANCE CO. CLAIMS MAILING ADDRESS PH. FOR CLAIMS

CITY STATE ZIP

POLICYHOLDER’S ID NUMBER GROUP PLAN NUMBER

SECONDARY INSURANCE COMPANY’S NAME EFFECTIVE DATE

SECONDARY INSURANCE CO. CLAIMS MAILING ADDRESS PH. FOR CLAIMS

CITY STATE ZIP

POLICYHOLDER’S ID NUMBER GROUP PLAN NUMBER

ABOUT YOU: ABOUT YOUR INSURANCE:

IMPORTANT PHONE NUMBERS

Daytona Area (386) 252-4900 Toll-Free 1-800-323-3822

LIFETIME ASSIGNMENT OF CLAIM AND AUTHORIZATION – PROVIDE INSURANCE INFORMATION

or in the future.

PLEASE UPDATE ANY INFORMATION THAT HAS CHANGED SINCE YOUR LAST STATEMENT

File details come from the government source that posted it. Updated .