Attachment IV Tech Proposal Summary.pdf
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- Comprehensive Medical Services (FCI Dublin)
- Solicitation number
- RFPDUB-0001
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Attachment IV - Technical Proposal Summary Sheets
RFP DUB-0001
Comprehensive Medical Services - FCI Dublin
Facility Providers - Complete one for each facility provider proposed.
Offeror: _______________________________________________________________
Facility Name: _______________________________________________________________
Facility Address: _______________________________________________________________
Accreditation Type/Date: _______________________________________________________________ (Attach documentation for verification)
Facility Type: Acute Care _____ Tertiary Care _____
Number/Type of Beds: _______________________________________________________________
Specialties Represented: _______________________________________________________________
Proximity to FCI: _______________________________________________________________
Comprehensive Medical Services - FCI Dublin
Physician Providers - Please provide the following information in a table format to detail physician providers utilized at each proposed facility.
Offeror:_______________________________________________________________
Specialty
Represented
Physician Group
Name
If applicable or
Name of Physician
Associated
Facility Provider
Inpatient, Outpatient, and/or
Office Setting
Number of
Physicians
Proposed for
Specialty
Proximity of
Provider
Offices to
FCI
(Minimum
Miles)
Proximity of
Provider
Offices to
FCI
(Maximum
Miles)
In addition, please provide the total number of physicians proposed.
Comprehensive Medical Services - FCI Dublin
Outpatient Institution Service Providers
Offeror: _______________________________________________________________
Please complete for outpatient institution services the offeror proposes to provide, as referenced in Solicitation Section A.1:
Specialty Represented Name of Physician Associated Facility
Provider
If Applicable
Will the Provider Provide
Services Within an
Inpatient, Outpatient, and/or
Office Setting?
Cardiology
Dermatology
Gastroenterology
General Surgeon
Ophthalmology
Oral Surgery
Orthopedic
Otorhinolaryngology (ENT)
Urology
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