FBO-Amend-0003.pdf

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

(a) By completing items 8 and 15, and returning or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

E. IMPORTANT: Contractor is not is required to sign this document and return copies to the issuing office.

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. CONTRACT ID CODE

2. AMENDMENT/MODIFICATION NUMBER 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQUISITION NUMBER 5. PROJECT NUMBER (If applicable)

7. ADMINISTERED BY (If other than Item 6) CODE

STANDARD FORM 30 (REV. 11/2016)

Prescribed by GSA FAR (48 CFR) 53.243

FACILITY CODE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED (SEE ITEM 11)

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED (SEE ITEM 13)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended. is not extended.

12. ACCOUNTING AND APPROPRIATION DATA (If required) copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NUMBER AS DESCRIBED IN ITEM 14.

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER

NUMBER IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15C. DATE SIGNED

15A. NAME AND TITLE OF SIGNER (Type or print)

16C. DATE SIGNED

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

PAGE OF PAGES

6. ISSUED BY CODE

8. NAME AND ADDRESS OF CONTRACTOR (Number, street, county, State and ZIP Code) (X)

CODE

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

16B. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

Previous edition unusable

BFAO

Teresa Kennon, Contracting Officer - FAO

Amendment 0003 is being established to include the following changes: (1) Section 2-2 Item VII. ONLY the language pertaining to "Infants Born to Inmates" has been removed in its entirety. (2) Attachment 1: Computation of Basic MS-DRG Payment - Table 4A, Wage Index incorrectly listed Terre Haute, Indiana as the location. Terre Haute, Indiana is being removed and replaced with the correct location "Indianapolis-Carmel-Anderson, Indiana." (3) The Schedule of Items has been revised see pages 2 - 4 (Continuation of Amendment #3) and provide your response accordingly.

**PLEASE BE ADVISED THE DATE OF RECEIPT OF THE AFOREMENTIONED RFP HAS BEEN EXTENDED TO

MAY 10, 2017 (2:00 PM CT)**

BTHX

Field Acquisition Office - US Department of Justice Reserve Armed Forces Complex 346 Marine Forces Drive Grand Prairie, TX 75051

FBOP- FCC Terre Haute 4700 Bureau Rd. South Terre Haute, IN 47802

RFPP04181600001

1 4

05/04/2017

03/03/2017

CONTINUATION – AMENDMENT 0003

FCC TERRE HAUTE – RFPP04181600001

REVISED SCHEDULE OF ITEMS

CONTINUATION OF AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

Schedule of Items

BASE YEAR

Effective Date of Award (DOA) through 12 months from DOA

1a. Inpatient Facility Services: -______ Discount or +______ Premium to Medicare Part A

1b. Outpatient Facility Services: -______ Discount or +______ Premium to Medicare Part B

2a. Inpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2b. Outpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2c. Outpatient Institution Services:

2c1. Other Physicians: -______ Discount or +______ Premium to Medicare Part B

2c2. Optometrist: $_________________ per session

2c3. Oral Surgeon $__________________ per session

NOTE: IF OFFERING A VARIANCE FROM THE BENCHMARK MEDICARE RATE, INSERT

APPLICABLE "-/+" PERCENTAGE. IF NO VARIANCE, ENTER "0".

OPTION YEAR 1

13 through 24 months from DOA

1a. Inpatient Facility Services: -______ Discount or +______ Premium to Medicare Part A

1b. Outpatient Facility Services: -______ Discount or +______ Premium to Medicare Part B

2a. Inpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2b. Outpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2c. Outpatient Institution Services:

2c1. Other Physicians: -______ Discount or +______ Premium to Medicare Part B

2c2. Optometrist: $_________________ per session

2c3. Oral Surgeon $__________________ per session

OPTION YEAR 2

25 through 36 months from DOA

1a. Inpatient Facility Services: -______ Discount or +______ Premium to Medicare Part A

1b. Outpatient Facility Services: -______ Discount or +______ Premium to Medicare Part B

2a. Inpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2b. Outpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2c. Outpatient Institution Services:

2c1. Other Physicians: -______ Discount or +______ Premium to Medicare Part B

2c2. Optometrist: $_________________ per session

2c3. Oral Surgeon $__________________ per session

OPTION YEAR 3

37 through 48 months from DOA

1a. Inpatient Facility Services: -______ Discount or +______ Premium to Medicare Part A

1b. Outpatient Facility Services: -______ Discount or +______ Premium to Medicare Part B

2a. Inpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2b. Outpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2c. Outpatient Institution Services:

2c1. Other Physicians: -______ Discount or +______ Premium to Medicare Part B

2c2. Optometrist: $_________________ per session

2c3. Oral Surgeon $__________________ per session

OPTION YEAR 4

49 through 60 months from DOA

1a. Inpatient Facility Services: -______ Discount or +______ Premium to Medicare Part A

1b. Outpatient Facility Services: -______ Discount or +______ Premium to Medicare Part B

2a. Inpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2b. Outpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2c. Outpatient Institution Services:

2c1. Other Physicians: -______ Discount or +______ Premium to Medicare Part B

2c2. Optometrist: $_________________ per session

2c3. Oral Surgeon $__________________ per session

OPTION TO EXTEND SERVICES AS AUTHORIZED BY FAR 52.217-8

Six Month Extension as Authorized by FAR 52.217-8

1a. Inpatient Facility Services: -______ Discount or +______ Premium to Medicare Part A

1b. Outpatient Facility Services: -______ Discount or +______ Premium to Medicare Part B

2a. Inpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2b. Outpatient Physician Services: -______ Discount or +______ Premium to Medicare Part B

2c. Outpatient Institution Services:

2c1. Other Physicians: -______ Discount or +______ Premium to Medicare Part B

2c2. Optometrist: $_________________ per session

2c3. Oral Surgeon $__________________ per session