RFP-75H70622R00005 - Telehealth.pdf

75H70622R00005

SOLICITATION, OFFER AND AWARD

4. TYPE OF SOLICITATION2. CONTRACT NUMBER 3. SOLICITATION NUMBER

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

ORDER UNDER DPAS (15 CFR 700)

6. REQUISITION/PURCHASE NUMBER

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

NEGOTIATED (RFP)

SEALED BID (IFB)

5. DATE ISSUED

1. THIS CONTRACT IS A RATED RATING PAGE OF PAGES

1 1

C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME

10. FOR

INFORMATION

CALL:

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

(Date)(Hour) local timeuntildepository located in copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the

SOLICITATION

9. Sealed offers in original and

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND

LIST OF ATTACHMENTS

CONTRACT CLAUSES

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

I

J

K

L

M SPECIAL CONTRACT REQUIREMENTS

CONTRACT ADMINISTRATION DATA

DELIVERIES OR PERFORMANCE

INSPECTION AND ACCEPTANCE

PACKAGING AND MARKING

DESCRIPTION/SPECS./WORK STATEMENT

SUPPLIES OR SERVICES AND PRICES/COSTS

SOLICITATION/CONTRACT FORM

PART II - CONTRACT CLAUSESPART I - THE SCHEDULE

H

G

F

E

D

C

B

A

SEC. DESCRIPTION PAGE(S) (X) DESCRIPTION SEC. (X)

11. TABLE OF CONTENTS

18. OFFER DATE17. SIGNATURE

SUCH ADDRESS IN SCHEDULE.

IS DIFFERENT FROM ABOVE - ENTER

15C. CHECK IF REMITTANCE ADDRESS

EXT.NUMBERAREA CODE

15B. TELEPHONE NUMBER

(Type or print)AND

ADDRESS

OF

OFFEROR

CODE

FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME

DATEAMENDMENT NO.DATEAMENDMENT NO.

and related documents numbered and dated):

amendments to the SOLICITATION for offerors

(The offeror acknowledges receipt of

14. ACKNOWLEDGEMENT OF AMENDMENTS

CALENDAR DAYS (%)30 CALENDAR DAYS (%)20 CALENDAR DAYS (%)10 CALENDAR DAYS (%)

(See Section I, Clause No. 52.232.8)

13. DISCOUNT FOR PROMPT PAYMENT

designated point(s), within the time specified in the schedule.

by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

28. AWARD DATE

(Signature of Contracting Officer)

27. UNITED STATES OF AMERICA

25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

CODE 24. ADMINISTERED BY (If other than Item 7)

ITEM

(4 copies unless otherwise specified)

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

41 U.S.C. 253 (c) ( 10 U.S.C. 2304 (c) (

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

21. ACCOUNTING AND APPROPRIATION20. AMOUNT19. ACCEPTED AS TO ITEMS NUMBERED

AWARD (To be completed by government)

CODE

04/29/2022 X

Aberdeen Area Indian Health Servic Federal Building 115 Fourth Ave, SE Aberdeen SD 57401

1200 CS 05/23/2022

WENDA L WRIGHT 605

wenda.wright@ihs.gov

226-7724

X

X

X

X

X

X

X

X

X

X

X

PAGE(S)

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

1-65 1-5

1-54

1-3 1-7 1-10

1-57

1-46

1-9

1-2

12. In compliance with the above, the undersigned agrees, if this offer is accepted within _____0_________ calendar days (60 calendar days unless a different period is inserted

A. This is a combined synopsis/solicitation for commercial items prepared in accordance with the format in Federal Acquisition Regulation (FAR) Subpart 12.6, as supplemented with additional information included in this notice, FAR Part 12, Acquisition of Commercial Items (Title VIII of the Federal Acquisition Streamlining Act of 1994) (Public Law 103-355) & FAR 37.4, Non-Personal Health Care Services Contract (10 U.S.C. 2304 and 41 U.S.C 253). This announcement constitutes the only solicitation; proposals are being requested and a written solicitation will not be issued.

B. The Great Plains Area Indian Health Service (IHS) intends to award a Firm Fixed Unit Price, Non-Personal

Healthcare Service, Indefinite Delivery/Indefinite Quantity (ID/IQ) Contract in response to Request for Proposal

(RFP) 75H70622R00005.

C. This solicitation document and incorporated provisions and clauses are those in effect through Federal Acquisition Circular 2022-04/01-30-2022

D. This RFQ is a 100% Unrestricted solicitation and the associated NAICS Code is 622110, which has a small business standard of $41.5

E. This contract does not obligate funds; funds must be obligated prior to starting performance through a delivery/task order. FAR 52.216-18 Ordering, FAR 52.216-19 Ordering Limitations, and FAR 52.216-22 Indefinite Quantity. Orders may be placed against this contract by issuing task orders and may be submitted electronically by e-mail or mailed by hard copy.

F. The quoted unit pricing must be “all inclusive” (to include but not be limited to travel, lodging, per diem, fringe benefits, federal, state and local taxes) plus all other costs pertinent to the performance of this contract. Utilize your most competitive and reasonable rates.

Complete the attached Price Schedule.

1. Base Year: 12 Month Period

Total Estimated Contract Price for the Base Year $_______________.

2. Option Year One (1): 12 Month Period Total Estimated Contract Price for Option Year One (1) $_______________.

3. Option Year Two (2): 12 Month Period Total Estimated Contract Price for Option Year Two (2) $_______________.

4. Option Year Three (3): 12 Month Period Total Estimated Contract Price for Option Year Three (3) $_______________.

5. Option Year Four (4): 12 Month Period Total Estimated Contract Price for Option Year Four (4) $_______________.

Total Estimated Contract Price for the Base + Four (4) Option Years $_______________.

G. Telehealth Support Services

H. See attached Performance Work Statement(s). Services will be provided for Multiple Locations within the Great

Plains Area Indian Health Service (GPAIHS), Aberdeen, South Dakota. The period of performance will be August 1, 2022 through July 31, 2023 with Four (4) Option Years.

I. FAR 52.212-1 Instructions to Offerors-Commercial Items (November 2021).

Quotes shall be submitted on company letterhead stationery, signed, dated and it shall include:

1. Solicitation number RFP-75H70622R00005;

2. Closing Date: May 23, 2022 at 12:00 pm CST;

3. Name, address and telephone number of company and email address of contact person;

4. Technical description of the item/service being offered in sufficient detail to evaluate compliance with the requirements of the solicitation. This may include product literature, or other documents, if necessary;

5. Price and any discount;

6. “Remit to” address, if different than mailing address;

7. A completed copy of the representations and certifications at FAR 52.212-3 (see FAR 52.212-3(b) for those representations and certifications that the offeror shall complete electronically);

8. Acknowledgment of Solicitation Amendments (if any issued);

9. Past performance information, when included as an evaluation factor, to include recent and relevant contracts for the same or similar items and other references (including contract numbers, points of contact with telephone numbers and other relevant information);

10. A statement specifying the extent of agreement with all terms, conditions, and provisions included in the solicitation. Offerors that fail to furnish required representations or information, or reject the terms and conditions of the solicitation may be excluded from consideration.

In addition, Contractors shall provide the following:

• Name and phone number of three (3) current professional references.

• Complete and sign Child Care Position/Personnel Security Office form.

• Complete and sign the Declaration for Federal Employment – Optional Form 306.

• Complete and sign Addendum to Declaration for Federal Employment (OF306).

• Complete and sign Licensure Requirement Form.

• Copy of malpractice insurance coverage.

• Shall meet the Qualifications and Knowledge Requirements in the Performance Work Statement and provide copies of the required documents (if needed).

• Copy of current Board Certification

• Copy of active, current, full and unrestricted license to practice.

• Copy of a recent Health Examination.

• Copy of Diplomas/Specialty Certifications.

• Copies of Continuing Education.

• Current CV/resume.

J. FAR 52.212-2 Evaluation – Commercial Items (November 2021) – See attachment for full text.

K. FAR 52.212-3 Offer Representations and Certifications-Commercial Items (November 2021). See attachment for full text. The Offeror shall complete only paragraph (b) of this provision if the Offeror has completed the annual representations and certification electronically via the System for Award Management (SAM) website accessed through http://www.acquisition.gov. If the Offeror has not completed the annual representations and certifications electronically, the Offeror shall complete only paragraphs (c) through (p) of this provision.

L. FAR 52.212-4 Contract Terms and Conditions-Commercial Items (November 2021). Applied to this acquisition and it’s incorporated by reference.

M. FAR 52.212-5 Contract Terms and Conditions Required to Implement Statutes or Executive Orders-

Commercial Items (January 2022). See attachment for full text.

N. Attached are the Federal Acquisition Regulations (FAR) & Health & Human Services Acquisition Regulation (HHSAR) clauses that are applicable including below.

O. Submit quote to:

Great Plains Area Indian Health Service Attn: Wenda Wright, Contract Specialist http://www.acquisition.gov/

115 4th Ave. SE, Room 309 Aberdeen, SD 57401 email wenda.wright@ihs.gov

Questions in regards to this solicitation shall be submitted in writing by email no later than May 10, 2022, 12:00pm

CST.

SECURITY CLEARANCE

A security pre-clearance must be performed for any employees referred to IHS through this contract.

Fingerprints must be completed and adjudicated prior to services being performed under this contract.

No contract award shall be made to any vendor or provider listed on the OIG Exclusion List http://exclusions.oig.hhs.gov throughout the duration of the contract. It shall be the responsibility of the contractor to notify the acquisition official if there is a change in provider.

Performance of this contract will require routine access by employees of the Contractor or its subcontractors to facilities or systems controlled by the Indian Health Service (I.H.S.). Before starting work requiring routine access to I.H.S.

facilities or systems each person must complete a FBI National Criminal History Check (Fingerprint Check) adjudicated by an I.H.S. employee using the Office of Personnel Management Personnel Investigations Processing System.

Contractors shall allow five business days for I.H.S. processing of fingerprints taken electronically at an I.H.S. site and thirty business days for non-electronic processing of fingerprints using FBI Form FD-258. A list of I.H.S. sites with electronic fingerprint capability is available from the Contracting Officer.

In addition, no Contractor or subcontractor employee shall be permitted to perform work under this contract if listed on the HHS Office of Inspector General List of Excluded Individuals/Entities (LEIE), http://exclusions.oig.hhs.gov. As soon as practicable prior to the start of work, the performance of the work the Contractor shall provide to the Contracting Officer the names of all individuals to be used in performance of work for screening against the LEIE. During the performance, the Contractor shall provide the Contracting Officer the names of any additional or substitute employees for screening before they begin work.

The Contractor is responsible for conducting security preclearance investigations in sufficient depth to ensure that each Contractor or subcontractor employee referred to I.H.S. is not on the LEIE and can obtain a favorable fingerprint clearance. Each security preclearance shall be conducted sufficiently in advance of the start of performance to avoid delays caused by denial of access. If this is a Time and Materials, Labor-Hour or Cost Reimbursement contract, the contractor shall not charge for or be reimbursed for labor hours or other costs incurred for employees who are unable to perform due to denial or access or the excess time required to resolve and clear unfavorable security clearance findings. If this is a Fixed Price contract, denial of access due to security clearance findings shall not be a basis for excusable delay or an increase to the contract amount.

Government will pay for the cost to process the contractors suitability clearances. However, multiple investigations for the same position may, at the Contracting Officers discretion, lead to reduction(s) in the contract price of no more than the cost of the extra investigation(s).

Employees that DO NOT have access to LMS, contractors, volunteers, or IHS employees with IPA’s or MOA’s to tribal organizations please, click here IHS Sexual Abuse Prevention website. When the contractors have completed and passed the training, please have them send a copy of the last page of the training with Name, Date, and Time to their Supervisor, COR, and Kimmen LeBeau, e-mail: Kimmen.LeBeau@ihs.gov

ACCEPTANCE PERIOD: Your proposal must stipulate that it is predicated upon all the terms and conditions of this RFP.

In addition, it must contain a statement to the effect that it is firm for a period of at least 90 days from the date of receipt by the Government.

mailto:wenda.wright@ihs.gov http://exclusions.oig.hhs.gov/ https://www.ihs.gov/sexualabuseprevention/training/ mailto:Kimmen.LeBeau@ihs.gov

No contract award shall be made to any vendor listed on the OIG Exclusions List at http://exclusions.org.hhs.gov throughout the duration of the contract.

Contractor must be registered with the System for Award Management (SAM) at www.sam.gov

“Contractor Personnel will arrive on a Business Day ONLY to complete all Orientation and Background procedures, as necessary. The Clinical Director or Designee will ensure all Orientation and Background procedures have been completed and an email will be sent to the Contracting department to state as such. The Contractor Personnel will NOT see patients until Background/Fingerprints have been cleared.”

“The standards of medical practice and duties of the Contractor through its Contracting Personnel shall be determined pursuant to the bylaws of the Service Unit. The regulations of the hospital, applicable provisions of law, other rules and regulations of any and all governmental authorities relating to licensure and regulation of physicians and hospitals must be followed. Also the standards and recommendations of Centers for Medicare and Medicaid Services (CMS) or the Accreditation Organization must be adhered to. The Contract Contracting Personnel shall be required to participate in a quality improvement program, which is consistent with current requirements for ongoing monitoring and evaluation of the quality and appropriateness of care.”

Invoice Processing Platform (IPP)

The Indian Health Service (IHS) is in the process of implementing an electronic invoicing system.

In compliance with the Office of Management and Budget (OMB) M-15-19 memorandum “Improving Government Efficiency and Saving Taxpayer Dollars Through Electronic Invoicing” directing Federal agencies to adopt electronic invoicing as the primary means to disburse payment to vendors. Invoices submitted under any award resulting from this solicitation will be required to utilize the Invoice Processing Platform (IPP) in accordance with HHSAR 352.232-71, Electronic Submission and Processing of Payment Requests”

IPP is a secure, web-based electronic invoicing system provided by the U.S. Department of the Treasury’s Bureau of the Fiscal Service, in partnership with the Federal Reserve Bank of St. Louis (FRSTL). Respondents to this solicitation are encouraged to register an account with IPP if they have not already done so. If your organization is already registered to use IPP, you will not be required to re-register- however, we encourage you make sure your organization and designated IPP user accounts are valid and up to date.

The IPP website address is: https://www.ipp.gov

If you require assistance registering or IPP account access, please contact the IPP Helpdesk at (866) 973-3131 (M-F 8AM to 6PM ET), or IPPCustomerSupport@fiscal.treasury.gov

“Should the contractor feel that use of the IPP would be unduly burdensome, their response to this solicitation should include an explanation of this position for a determination by the contracting officer”.

http://exclusions.org.hhs.gov/ http://www.sam.gov/ https://obamawhitehouse.archives.gov/sites/default/files/omb/memoranda/2015/m-15-19.pdf https://www.ipp.gov/ mailto:IPPCustomerSupport@fiscal.treasury.gov

Price Schedule Base Year: 12 Months Period

CLINs RFP Labor Category Unit Estimated

Visits Unit Price Total Price

(Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits 1000 $ $

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

TOTAL CEILING AMOUNT $ $

Option Year I: 12 Months Period

CLINs RFP Labor Category Unit Estimated

Visits Unit Price Total Price

(Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits 1000 $ $

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

TOTAL CEILING AMOUNT $ $

Option Year II: 12 Months Period

CLINs RFP Labor Category Unit Estimated

Visits Unit Price Total Price

(Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits 1000 $ $

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

TOTAL CEILING AMOUNT $ $

Option Year III: 12 Months Period

CLINs RFP Labor Category Unit Estimated

Visits Unit Price Total Price

(Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits 1000 $ $

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

Option Year IV: 12 Months Period

RFP Labor Category Unit Estimated

Visits Unit Price Total Price

(Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits 1000 $ $

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

TOTAL CEILING AMOUNT $ $

TOTAL AMOUNT BASE + FOUR (4) OPTION

YEARS

1./7#

.... "f� (

Indian Health Service Office of Human Resources

Memorandum

To:

From:

Subject:

Date:

Supervisor of child care covered position incumbent Human Resources/Personnel Security Office Child Care Position Provisional Authorization

This is notice you will supervise a position that is covered by Public Laws (P.L.) 101-630, Indian Child Protection and Family Violence Prevention Act and 101-647, Crime Control Act. The Indian Health Service is required to compile a list of all authorized positions with duties and responsibilities that Involve regular contact with or control over Indian children and investigate the character of each individual who is employed or is being considered for employment in such a position. The requirement is that the individual is to be under the supervision and in sight (chaperoned) of a previously investigated staff person (favorably adjudicated).

The position and individual identified below has been designated as a covered position and has been granted provisional authorization:

Name:

Position title:

The following criteria must be met for the above mentioned individual:

► Pre-employment suitability has been favorably adjudicated prior to entrance on duty.

► Continue with processing of background investigation - Tier 1 with child care (minimum).

► Provide requested documentation/information as requested from the Personnel Security/HR

Office.

Employee/Contractor/Affiliate must be 100¾ chaperoned at all times by a staff person and/or alternates who have at a minimum a favorably adjudicated Tier 1 with child care (Tier 1 C) or CNACI investigation.

The following individuals listed below agree and accept responsibility of the chaperone role.

Chaperone name: ___________ Case type favorably adjudicated Chaperone name: ___________ Case type favorably adjudicated Chaperone name: ___________ Case type favorably adjudicated

I have verified a favorable investigation is on file for identified chaperones:

Personnel Security/HR Office designee Date

Your signature indicates you are accepting responsibility, will comply with the above criteria, and will assure the above named individual will be chaperoned at times while on site.

Department Supervisor/Designee Date

This provisional authorization is in effect until the favorably adjudicated certification of investigation is in place. I am aware that failure to comply with the above criteria could result in removal and termination of the granted provisional authorization.

Employee/Contractor/Affiliate Date

Declaration for Federal Employment"'

('Thia form may also be used to eases& fltneu ror federal contract employment) form Al)prove<l:

0MB No 3206-01$2

Instructions-------------------------------

The Information collected on lhls form Is used to determine your acceptablllty for Federal and Federal contract employment end your enrollment status In lhe Government's Life Insurance program. You may be asked to complete this form et any lime during the hiring process. Follow Instructions lhel the agency provides. If you ere selected, before you are appointed you wlll be asked to Update your responses on this form end on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this dec laratlon or attached fom,s or sheets may be grounds for not hiring you, or for flrlng you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, tltle 18, section 1001).

Either type your responses on this form or print clearly In dark Ink. If you need addition el space, attach letter-size sheets (B.6" X 11"), Include your name, Social Security Number, and Item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement

The Office of Personnel Management Is authOrlzed to request this Information under sections 1302, 3301, 3304, 3328, and 8716 or title 6, U.S. Code. Sectlon 1104 of tllle 5 allows the Office ot Personnel Management 10 delegate personnel management functions to other Federal agencies. If necessary, and usually In conjunction with another form or forms, this form may be used In conducting an Investigation to determine your sultablllty or your ability to hold a security clearance, and II may be disclosed to authorized offlclels making similar, subsequent determinations.

Your Social Security Number (SSN) Is needed to keep our records accurate, because other people may have the same name and birth dale. Public Law 104-134 (Apr/I 26, 1996) asks Federal agencies to use this number to help Identify Individuals In agency records. Giving us your SSN or any other Information Is voluntary. However, If you do not give us your SSN or any other Information requested, we cannot process your appllcellon. Incomplete addresses end ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure or this record or Information In this record Is In accordance with routine uses found In System Netice OPM/GOVT-1, General Personnel Record�. This system allows disclosure of Information to: training faollllles; organizations deciding claims for retirement. Insurance. unemployment, or health benefits; officials In lillgatlon or administrative proceedings where the Government Is a party; law enforcement agencies concerning e vlolntlon or law or regulallon; Federal agencies for stallslical reports and studies: oHicials of labor organizations recognized by law In connection with representation of employees; Federal agencies or olher sources requesting Information for Federal agencies In connecllon with t'llrlng or ratalnlng, security clearance.

securlly or sullablilty lnvostiga!ions, classifying Jobs, contructing, or Issuing licenses. grants, or olher banellls; public and private organizations, Including news media, which grant or publicize employee recognitions and awards; the Maril Systems Protection Ooard, the Office of Special Counsel, the Equal EfTlployment Opportunity Commission. the Federal Labor Rolellons Authority, Iha National Archives and Records Adtninlstretlon, end Congressional offices In connection with their officla.l functions; prospective non-Federal employers concerning tenure of employment, clvU service status, length of service, end lhe date ond noture of action for separation as shown on the sr- 50 (or authorized exception) of a specifically Identified Individual: requesting organizations or Individuals concerning the home address and other relevant information on those w110 mlgM have contracted en Illness or been exposed to a health hazord; authorized Federal and non-Federi:il agencies for use In computer matching: spouses or dependent children asking whether the employee has changed from a sell-and•famlly to a sell-only hea!th benents enrollment; lndlvldueh;

working on a contract, service, grant, cooperative agreemenl. or job for the Federal government; non-agency members of en agency's performance or other panel; and agency-appointed representaHves or employees concerning Information Issued to the en1ployees about fitness-for-duty or agency-flied dlsablllty rellroment procedures.

Publlc Burden Statement ----------------------------•

Public burden reporting for this collecllon of Information Is estimated lo vary rrom 5 to 30 minutes with an average of 15 minutes per response, Including time for reviewing 1nstn1c1lons, searching existing data sources. gathering the data needed, and complellng and reviewing the collectlon of information. Send comments regarding the burden esllmete or any olher aspect of the collection of Information, Including suggestions for reducing lhls burden, to lhe U.S. Office of Personnel Management, Reports and Forms Manager (3206-0102), Washington, DC 20415-7900. The 0MB nurnber, 3206-0102, Is valid. OPM may (101 coltec;t this Information, and you are not required lo respond, unless this number Is displayed, U.S. Office of Personnel Management 6 U 9 C 1302, 3301, 3�, 3328 & 8718

�form"°6 R•vl>ed Ociober 2011

Provk>u■ edllk>n1 0010/ole and unuub/o

Declaration for Federal Employment* ("This form may also be used to 11&eeu mne88 for federal contraot employment)

GENERAL INFORMATION

fom, /.pproved:

0MB No. �206--0182

1. FULL NAME (Provide your full name. If you h11ve only Initials in your name, provide them and Indicate "Initial only". If you do not have I middle name Indicate "No Middle Name", If you ara a "Jr.," "Sr.," etc. enter this under Suffi>1, First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3b, ARE YOU A U.S. CITIZEN?

3a. PLACE OF BIRTH (Include city and state or country)

J YES I. NO (lf"NO", provide country of citizenship) ♦

4, DATE OF BIRTH (MM/0D/YYYY)

6, OTHER NAMES EYER USEC (For example, maiden name, nickname, elo) 6, PHONE NUMBERS (Include area codes)

Selective Service Registration

Doy ♦

Night ♦

If you are a male born after December 31, 1959, and are at least 1 B years or age, civil service employment law (5 U,S,C, 3326) requires that you must register with the Selective Service System, unless you meet certain exemptions, 7a. Are you a male born after December 31, 1959? ,:; YES r/ NO (If "NO", proceed to 8.)

7b. Have you registered With the Selective Service System? 1: YES (lf"YES", proceed to 8.) r: NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) In Item 16.

MIiitary Service 6, Have you ever served In the United States military? L,, YES (If "YES", provide tnronmetlon below) 1· NO

If you answorod "YES,• I/st the branch, dates, and type of dlschafTJfl for all active duty.

If )'our oll/)1 active duty was trlllnlng In the Reserves or Notional Guard, answer "NO,"

Branch From (MM/D0/YYYY) To IMM/00/YVYY) Type of Discharge

Background Information

For ell quoetlone, provide all additional requeetod Information under ltom 16 or on attachod eheots. The clrcumsIonce.s of eoch event you list wlll be considered. However, In most cases you can sllll be considered for Federal jobs.

for questions 9, 10, and 11, your answers should Include corwte1lons resultlng from a plea of nolo contondere (no contest}, but omll (1) lrllfOu fines of $300 or less, (2) any vlolallon of law commlllod befote your 16th birthday, (3) aoy violation of law committed before your 10th blnhdey Jr nnalty decided In fuvonlle court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or slmilar slate law, and (6) any convicllon for which the record was expunged under Federal or state law •

o. During the lest 7 years, have you been convicted, been Imprisoned, boon on probation, or been on parole? r· YES /! NO (Includes felonies, nreorrns or explosives vlolotlons, mlsdomoenors, and an other offenses.} If "YES,• use ffem 16 to provi<ltJ tho <Joto, exp/anal/or, of tllo vlo/11/ion, ploco of occurronca. anct Illa nomo and addross of tho police department or court Involved.

1 o. Have you been convicted by a mlllta,y cou,1-martlal In the pest 7 years? (If no m/11/ary service, answer "NO.") If "YES,• usu //1:1111 1 (J 10 pro Ide /he data, 01<plonatlon of I/lo violo//on. p/11c nf nccurronoo, end Iha name and address of tho mllitary authority or courl lnvo/Vod,

11. Aro you currently undor charges for any vlototlon or 1ow? If "YES," 11so /tom 16 to provide tho date, oxplonof/on of fho v/olol/on, ploco of occe1rroni;e, end the name and uddross of the po/loo doparlmont or court /11volvod.

12. During the lost 6 years, heve you been fired from any fob for an>' reason, did you quit alter being told that you would be fired, did you leevti any job by mutual agr-eement because of specific problems, or were you debarred (rom federal employment by tho Office of Personnel Menegomenl or any other Federal agency? If "YES,'' use I/om 16 to provide tho da/o, an oxplonallon of the prob/om, reason for /uovlng, end f/Ju employers name and oddmss.

13. Are you delinquent on eny Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of bonents, end other debts to the U.S. Government, plus dofavlts of Federally guaranteed or Insured loans such os student end homo mortgage loans.) If "YES," use !tam f6 to provfdo tho typo, lonr,th, and amount ofthe t10ll111wo11cy or dRfou/1, and stops /hat you ora taking lo correct 1/IO error or ropoy /ho dobt.

r n

Yl;S I. NO

YES ,1 NO

YES ,, NO

YES I NO

U.S. Office of Personnel Management 6 U 6 C 1302, 3301, 3»!, 3328 a. 8715

Op10,01f FCl<ffl X,O ROYllod QclObtl 2011 f'1ovtov1 edMon.t «,1olet1 ind Ur'IJHbla

Declaration for Federal Employment* ('Thia lorm mey also be ueed to aHeU fitness for re de rel contract employment, Additional Questions fom, /.jlptOYod:

0MB No, 320e-0l82

14. Do any of your relalivas work for the agency or government organization 10 which you are submitting th/a form?

r(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, . YES I NO father-In-law.mother-In-law, son-In-law, daughter-In-law, brother-In-law, sister-In-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, and hall sister.) If "YES,• use flam 16 to provide the re/a/Ive"s name, relationship, and the department, agency, or branch of the Armed Forces for which your ro/atlve worns.

15, Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay baaed on mllltary, 1 YES r NO Federal civilian, or District of Columbia Government service?

Continuation Space/ Agency Optional Questions ------------------- 1e, Provide details requested In Items 7 through 15 and 18c In the space below or on attached sheets. Be sure to Identify attached sheets with your name, Social Security Number, and item number, and to Include ZIP Codes In all addresses, If eny questions are printed below, please answer as Instructed (these questions are speo/fio to your position and your agency Is authorized to ask them).

Certifications I Additional Questions

APPLICANT: If you are apply Ing for a position and have not yet been ■elected, carefully review your answers on this form and any attached sheets, When !his form and all attached materials are accurate, read Item 17, and complete 17a.

APPOINTEE: If you are being oppolntod, carefully review your answers on this form and any attached sheels, Including any other appllcatlon materlols that your agency has attached to this form. If any information requires correction to be occurate as of the date you are signing, make changes on this form or lhe ahachmenls andfor provide updated Information on addlUonal sheets, lnltlrillng and dating ell changes and additions.

When this form and all attached materials ere accurate, read Item 17, C-Ompleta 17b, read 1 B, end answer 18a, 18b, and 10c as appropriate.

17. I certify that. 10 lho best or my knowledge end belier, all of the lnrormetlon on and elteched to this Declaratlon for Federal Employment, Including any aUached applicaHon materials, la true, correct, complete, and made In good faith. I undel"ltand that a falao or fraudulenl answer to any question or item on any part of this declaration or Its attachmonts may bo grounds for not hiring mo, or for firing me after I bogln work, and may be punishable by fine or lmprleonment. I understand thal any Information I give may be investloated for purposes of determining ellglbl\lly for Federal employment as allowed by law or Presldenlle\ ardor. I consent to the release of Information about rny ability and lilness for Federal employment by employers, schools, law enforcement agencies, and other lndlvlduels and oroanlzalione 10 lnvestlga10,s, personnel sµeclalist&, end other authorized employees or representallves of the Federal Govemmenl. I understand that for financial or lending \nstilutions, medlcal Institutions, hospitals, health care professtonals, and some other sourcos of Information, a separate spec!t1c release may be needed, and I mey be contacted for such e release al a late, date.

Appointing Offic11r:

17a. Applicant's Signature: .,,,.,.-----------------

(Sign In Ink) Date ______ _ En111 0'1• or ,lj>polnl/nonl 01 Corwt11lon

17b, Appointee's Signature:�---,�,-,--------------- (Sign In Ink)

Date _____ _

MMIDDIYYYY

18. Appolntoe (Only respond It you have boon employed by the Federal Government before); Your eleellons of life Insurance during previous Federal employment may effecl your ollg\blllly for life Insurance during your new appointment. These questions are asked to help your personnel office.make a correct determination.

18a. \!Vhan did you leave your last Federal Job?

MM/00/YYYY

DATE:

16b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life Insurance?

I, YES

1 Be, If you answered "YES" to Item 18b, did you later cancel the waiver(s)? If your answer lo Item r: YES 16c Is "NO," use Item 16 to Identify the type(s) of Insurance for which waivers were not ··· canceled.

U.S. Office of Personnel Management 6 U s,c, 1302, 3301, 3»4, 3320 "8710 r NO I DO NOT KNOW

I NO I DONOTKNOW

OpOorelF<>rm30I!

Rovlltd O<M>er 2011

Pr11vlou11dlllon1 ob1olat1 and um11l>l1

0MB Approved Form No. 0917-0028 Expiration Date: 2/28/2022

Addendum to Declaration for Federal Employment (OF 306)

Indian Health Service

Child Care & Indian Child Care Worker Positions

Item 16. Agency Specific Questions

Name: ____________ _ Social Security Number: _______ _ (Please print)

Job Title in Announcement: Announcement Number:

Section 231 of the Crime Control Act of 1990, Public Law (Pub. L.) 101-647, requires employment applications for individuals seeking employment in a position involved with the provision to children under the age of 18 of "child care services," as defined in 42 U.S.C. § 13041 (a)(2), contain a question asking whether the individual has ever been arrested for or charged with a crime involving a child and for the disposition of the arrest or charge.

Under 42 U.S.C. § 13041(a)(2), the term "child care services" means child protective services

(including the investigation of child abuse and neglect reports), social services, health and mental health care, child (day) care, education (whether or not directly involved in teaching), foster care, residential care, recreational or rehabilitative programs, and detention, correctional, or treatment services. Individuals hired for such positions must undergo a criminal history background check.

Section 408 of the Indian Child Protection and Family Violence Prevention Act, Pub. L. 101-630, contains a related requirement for positions in the Department of Health and Human Services that involve regular contact with or control over Indian children. The agency must ensure that persons hired for these positions have not been found guilty of or pleaded nolo contendere or guilty to certain crimes. The law requires the agency conduct an investigation of the character of each individual who is being considered for employment in such a position and prescribe in regulations the "minimum standards of character" that must be met in order for an individual to fill such a position. The regulations specify that "[t]he minimum standards of character shall be considered met only after the individual has been the subject of a satisfactory background investigation," which includes a criminal history background check.

42 C.F.R. § 136.406.

To assure compliance with the above laws, the following questions are added to the Declaration for Federal Employment:

1. Have you ever been arrested for or charged with a crime involving a child?

YES NO

[If "YES", provide the date, explanation of the violation, disposition of the arrest or charge, place of occurrence, and the name and address of the police department or court involved.]

Section B Solicitation No.: RFP-75H70622R00005 GPAIHS, Aberdeen, South Dakota – Tele-Health Services

SECTION B – PRODUCTS OR SERVICES AND PRICES/COSTS

B.1. TYPE OF CONTRACT (FAR 52.216-1 (APR 1984))

The Great Plains Area - Indian Health Service (IHS) is requesting proposals in accordance with the Request for Proposal to provide Tele-Health Services for the Great Plains Area Indian Health Service (GPAIHS), Aberdeen, South Dakota.

The Great Plains Area - IHS anticipates awarding a performance based Non-Personal Healthcare Service, Firm Fixed Unit Price, Indefinite Delivery/Indefinite Quantity (ID/IQ) Contract, from this solicitation. The contract is for one (1) base year from August 1, 2022 through July 31, 2023 with four (4) – one (1) year options in a twelve (12) month period. The Indian Health Service reserves the discretionary authority to exercise any one of the four (4) option years.

B.2. CONSIDERATION AND PAYMENT

The Contractor shall provide the commercial services described in the Description of Services/Contractor Responsibilities/ Performance Work Statement. Except as otherwise specified in the contract, the Contractor shall furnish the necessary personnel, materials, services, facilities, and otherwise provide all tasks necessary for or incident to the performance of the work set forth herein.

The Contractor shall be paid upon submission of an invoice and completion and acceptance (if deliverable) or verification (if service) by the Contracting Officer Representative at the location where the Task Order has been issued on behalf of or where the services have been rendered, of the deliverables and/or services, clause 52.212-4 (i) (2), Prompt Payment, and Section G.2 of this contract.

This is a 100% Unrestricted competitive solicitation and the offer your firm submits will be used by the Indian Health Service to determine, which offer is the “Best Value” to the government. Be advised that the quantities listed within are, “estimates only” and it is not the intent of IHS to be obligated to order the “maximum quantities”.

B.3. CONTRACT PRICE

a. Upon delivery and acceptance of the item(s) specified in the Delivery Article in Section F of this contract, the Government shall pay to the Contractor resulting from the Firm-Fixed Price cost.

b. Upon delivery and acceptance of the services described in the Performance Work Statement of this contract and identified in the schedule of charges below, the Government shall pay to the Contractor the total prices set forth below and will be paid from the following Contract Line Item Numbers (CLINs) accordingly:

Price Schedule Base Year: 12 Months Period

RFP Labor Category Unit

Estimated Visits

Unit Price Total Price (Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits

Section B Solicitation No.: RFP-75H70622R00005

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

TOTAL CEILING AMOUNT $ $

Option Year I: 12 Months Period

CLINs RFP Labor Category Unit Estimated

Visits Unit Price Total Price

(Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits 1000 $ $

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

TOTAL CEILING AMOUNT $ $

Option Year II: 12 Months Period

CLINs RFP Labor Category Unit Estimated

Visits Unit Price Total Price

(Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits 1000 $ $

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

TOTAL CEILING AMOUNT $ $

Option Year III: 12 Months Period

CLINs RFP Labor Category Unit Estimated

Visits Unit Price Total Price

(Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits 1000 $ $

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

Option Year IV: 12 Months Period

CLINs RFP Labor Category Unit Estimated

Visits Unit Price Total Price

(Max Qty)

0001 Tele-Health Specialty Clinic Services

Visits 1000 $ $

0002 Tele-Health Specialty Clinic Services (No show rate)

Visits 500 $ $

0003 Tele-Health Behavioral Health Services

Visits 3500 $ $

0004 Tele-Health Behavioral Health Services (No show rate)

Visits 1000 $ $

0005 Tele-Health Emergency and E-sane Services

Visits 1000 $ $

TOTAL CEILING AMOUNT $ $

TOTAL AMOUNT BASE + FOUR (4) OPTION

YEARS

B.4. OPTION PRICES

a. Unless the Government exercises its option pursuant to the option clause referenced in Contract Clauses section, this contract consists only of the Base Period specified in this contract.

b. Pursuant to FAR Clause 52.217-8, Option to Extend Services and FAR Clause 52.217-9, Option to Extend the Term of the Contract, set forth in Contract Clauses of this contract, the Government may, by unilateral contract modification, require the Contract to perform the Option Period (s) as defined in the Performance Work Statement(s) of this contract.

If the Government exercises this/these option(s), notice must be given before the expiration date of the contract.

c. Upon the delivery and acceptance of the Option Services described in the Performance Work Statement of the contract and identified in the price schedule, the Government shall

Section B Solicitation No.: RFP-75H70622R00005 pay the Contractor the unit price (s) set in the price schedule and will be paid from the Contract Line Item Numbers (CLINs) accordingly.

d. If the Government exercises its option pursuant to the Option Provision of this contract, the Government’s total estimated contract amount is represented by the sum of the price of base plus option periods as set forth in the proposal schedule.

Section C Solicitation No.: RFP-75H70622R00005

Great Plains Area (GPA)

Telehealth Specialty Clinic Services

Section C Solicitation No.: RFP-75H70622R00005

1 Background

This Performance Work Statement (PWS) describes the requirements for non-personal professional telehealth specialty care services to support the mission of Indian Health Service.

2. General Requirements

The primary function of the telehealth provider shall be to provide remote patient care services in the specialty of his or her training. Telehealth visits will be scheduled for conditions or problems in which a virtual visit is most likely to be suitable, for example 1) management of chronic conditions such as diabetes or hypertension; 2) discussion of test results or diagnostic studies; 3) counseling about diagnostic and therapeutic options; 4) dermatology; 5) medication management; 4) nutrition counseling.

2.1 Non-Personal Services

The Government shall neither supervise contractor employees nor control the method by which the contractor performs the required tasks. Under no circumstances shall the Government assign tasks to, or prepare work schedules for, individual contractor employees.

It shall be the responsibility of the contractor to manage its employees and to guard against any actions that are of the nature of personal services, or give the perception of personal services. If the contractor believes that any actions constitute, or are perceived to constitute personal services, it shall be the contractor's responsibility to notify the Contracting Officer (CO) immediately.

2.2 Business Relations

The contractor shall successfully integrate and coordinate all activity needed to execute the requirement. The contractor is required to provide quality assurance services and effective management of subcontractors. The contractor shall seek to ensure customer satisfaction and professional and ethical behavior of all contractor personnel.

2.3 Contract Administration and Management

The following subsections specify requirements for contract, management, and personnel administration.

2.4. Contract Management

The contractor shall establish clear organizational lines of authority and responsibility to ensure effective management of the resources assigned to the requirement. The contractor must maintain and ensure continuity of the tele-health operations between the contractor's corporate offices and the Indian Health Service.

2.5 Contract Administration

Section C Solicitation No.: RFP-75H70622R00005

The contractor shall establish processes and assign appropriate resources to effectively administer the requirement. The contractor shall respond to Government requests for contractual actions in a timely fashion. The contractor shall have a single point of contact between the Government and Contractor personnel assigned to support contracts or task orders. The contractor shall assign work effort and maintain proper and accurate time keeping records of personnel assigned to work on the requirement.

The Contractor will meet with the Contracting Officer Representative (COR) and IHS officials within seven days of the contract award to become acquainted with the IHS staff, review the Performance Work Statement (PWS), discuss timelines and deliverables, and to begin initial planning. The Contractor and COR will hold kick-off meetings at the beginning of each option year of the contract to revisit and make adjustments (if necessary) to the comprehensive action plan, quality assurance plan, communications plan, evaluation plan, and project plan, to discuss ongoing tasks in the PWS, and deliverables for each option year.

2.6 Personnel Administration

The contractor shall maintain the currency of their employees by providing initial and refresher training as required to meet the PWS requirements. The contractor shall make necessary travel arrangements for employees and maintain adequate infrastructure to support contract tasks.

2.7 Subcontract Management

The contractor shall be responsible for any subcontract management necessary to integrate work performed on this requirement and shall be responsible and accountable for subcontractor performance on this requirement. The prime contractor will manage work distribution to ensure there are no Organizational Conflict of Interest (OCI) considerations.

Contractors may add subcontractors to their team after notification to the CO and COR.

2.8 Contractor Personnel, Disciplines, and Specialties

The contractor shall accomplish the assigned work by employing and utilizing qualified personnel with appropriate combinations of education, training, licensure/certification and experience. The contractor will maintain accreditation for telehealth services by a nationally recognized accreditation organization.