J-21 Corporate Experience Attestation.doc
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- Attached to
- DME MAC Jurisdiction A
- Solicitation number
- RFP-CMS-2010-0004
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J-21 Corporate Experience Attestation
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RFP-CMS-2010-0004 DME JA
(insert company letterhead here)
Attachment J.21 Corporate Experience Attestation [Insert Offeror (as Prime)/Company Name] understands and unconditionally attests that it has experience working on contracts similar in size and scope to the Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) contracts either solely through the offeror’s (as prime) experience, or through the collective experience of the offeror (as Prime) and its subcontractor(s). Specifically, [Insert Offeror (as Prime)/Company Name] attests to at least one of the following:
· It has processed at least 10,000,000 (10 million) health care claims annually in every year since 2005,
· It has administered at least $1,000,000,000 ($1 billion) in payments for health care services annually in every year since 2005, or
· It has performed outreach activities with at least 20,000 (20 thousand) providers and/or suppliers of health care services annually in every year since 2005.
(Insert Offeror/Company Name) attests that this experience is demonstrated through (check one):
| ( |
| The experience of the [Insert Offeror (as Prime)/Company Name], which is attested to by its Vice President of Medicare Operations (or equivalent position). |
| ( |
| The collective experience of the [Insert Offeror (as Prime)/Company Name] and its subcontractors, [Insert Subcontractor(s)/Company Name(s)], which is attested to by its Vice President of Medicare Operations (or equivalent position) and the Vice President of Medicare Operations (or equivalent position) of our subcontractor(s). |
This experience is demonstrated through the contracts submitted under Appendix A.
It is agreed upon and understood that the organization’s Attestations and disclosure documents will become a part of the organization’s proposal.
As an individual with authority to bind the (Insert Offeror/Company Name), I accept responsibility for this written document.
(signature)
(type full name)
[Insert Offeror (as Prime)/Company Name]
Vice President, Medicare Operations (or equivalent position)
(signature – if required)
(type full name)
[Insert Subcontractor(s)/Company Name(s)]
Vice President, Medicare Operations (or equivalent position)
Appendix A
The contracts listed below, which are consistent with its past performance questionnaire references (see Attachment J-02), represent [Insert Offeror (as Prime)/Company Name]’s experience in performing requirements similar to those listed in the DME MAC statement of work (see Attachment J-01).
1. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
2. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
3. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
4. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
5. Contract Name and Number
| Contract Identification |
| Agency Identification |
Contract Type:
Name:
Period of Performance:
Description:
Current contract cost:
Technical Point of Contact:
Description of Services Provided:
Contractual Point of Contact:
Person-hours of effort:
Check if applicable:
| ( |
| A completed Appendix A is also submitted under a separately sealed package for our subcontractor(s), [Insert Subcontractor(s)/Company Name(s)]. |
Attachment J-21 Corporate Experience Attestation
Source Selection Information – See FAR 2.101 and 3.104 Page | 1
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