RFP_Submission_Checklist (2).pdf
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- Non-Personal Healthcare Services-Physician & Other Professional Ambulatory Services for PRC Program
- Solicitation number
- 75H70725R00008
About this file
This is a document submission checklist for a Request for Proposal (RFP) for Professional Physician and Other Ambulatory Health Care Services. The checklist outlines nine required documents that must be submitted with the proposal, each with specified copy requirements.
Key submission requirements include: Standard Form 1449 (Solicitation/Contract/Order for Commercial Items) with original signature and DUNS number; contract purpose details; fee schedule and pricing information including discount/offer/no-show fees; FAR 52.212-3 Offeror Representations and Certifications; Business Associate Agreement; Provider Contract Summary Sheet with original signature; Provider Certification with original signature; and copies of certifications, licenses, medical malpractice insurance, and specialty training documentation for each provider. The RFP is being issued by the Indian Health Service to provide healthcare services for the Purchased/Referred Care (PRC) Program serving American Indian and Alaskan Natives in the Albuquerque Area.
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Document Submission Checklist
Request for Proposal (RFP:)
Professional Physician and Other Ambulatory Health Care Services
The following checklist is to assist you in ensuring that the acceptable minimum documents are submitted with your proposal and signed by an official authorized to bind your organization.
Document Requirement Number of Copies
1. Standard Form 1449, Solicitation/Contract/ 1 Copy with Original Order for Commercial Items Signature (Page 1) (Complete blocks 17a and 30a-30c) *Cite DUNS# in block 17a of the Standard Form 1449*
2. Paragraph B-1.b. (General/Purpose of Contract) 1 Copy Enter in Type of Professional Health Care Service (Page 5)
3. Paragraph B-5.b.1.-5. (Fee Schedule/Pricing) 1 Copy Enter Discount/Offer/No-Show Fee (Page 5)
4. Paragraph C-3 (FAR 52.212-3 Offeror 1 Copy Representation and Certifications – Commercial Items (JAN 2017) Complete Pages 17 and 18, paragraphs (c)1- (c)10 and (d)1- (d)2 (Page 16, only b(2) if Annual Reps & Certs are up to date in SAM.gov)
5. Paragraph C-3 (FAR 52.212-3 Offeror 1 Copy Representation and Certifications – Commercial Items (JAN 2017) Complete Page 22 and 23, paragraphs (l)3- (l)5, (n)2, (q)2 (Page 16, only b(2) if Annual Reps & Certs are up to date in SAM.gov)
6. Appendix D-2: Business Associate Agreement 1 Copy Complete Fillable items in I and IIA.
7. Attachment D-6: Provider Contract Summary Sheet 1 Copy with Original Complete Fillable items and sign. Signature
8. Attachment D-7: Provider Certification 1 Copy with Original Complete Fillable items and sign. Signature
9. Copies of Certifications, Licenses, Medical Malpractice Insurance 1 Copy and Specialty Training for each provider (if applicable).
Note: Please retain a copy of the RFP package for your reference.
File details come from the government source that posted it. Updated .