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.
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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 .