Attachment_7_-_Tech_ProposSummary_Sheet.pdf

ATTACHMENT 7 – RFPP05081500001

TECHNICAL PROPOSAL SUMMARY SHEETS BY HOSPITAL NETWORK

Comprehensive Medical Services – FCC Forrest City

Each offeror shall complete this two-page attachment for each hospital network proposed, without altering the format or the information sought by the form. The completed attachment supercedes any information described in the technical proposal. In the event of any conflicts between the completed attachment and the technical proposal, the information provided in this attachment shall take precedence.

Offeror:

Hospital provider (name, address):

Type of facility (e.g., acute, tertiary, ambulatory surgery):

Accreditation type/date:

Proximity of hospital to FCC (in miles):

Number/type of beds:

Any exclusions on hospital services offered? Unless indicated herein, all capabilities of the subject hospital provider are understood to be offered. If such exclusions are made, please describe:

Emergency Room trauma level:

Based on proximity and/or capability, is this hospital the primary Emergency Room provider for FCC inmates, as recognized by the local emergency medical service responder?

Summarize enhancements available at this hospital:

Describe how this hospital network would be utilized within the offeror’s overall provider network (e.g., primary provider, secondary provider, etc.):

Physician Specialties in this hospital network

Offered? # of Physicians

Physician Specialties in this hospital network

Offered? # of Physicians

Anesthesiology Other:

Cardiology/Surgery Other:

Dermatology Other:

Emergency Room Other:

ENT/Surgery Other:

Endocrinology Other:

Family Medicine Other:

Gastroenterology Other:

General Surgery Other:

Gynecology (if female) Other:

Hematology Other:

Infectious Disease Other:

Internal Medicine Other:

Nephrology Other:

Neurology Other:

Obstetrics (if female) Other:

Oncology Other:

Ophthalmology Other:

Optometry Other:

Orthopedics/Surgery Other:

Pathology Other:

Psychiatry Other:

Pulmonology Other:

Radiology Other:

Urology Other:

Proximity of physician offices to the FCC: Minimum __________ miles Maximum __________ miles

On-site Clinics at the FPC

Offered?

Privileges at this hospital?

Privileges at another hospital in the offeror’s network?

Will the provider also perform services within an inpatient, outpatient, or office setting? Please indicate.

Cardiologist General Surgeon Orthopedic Surgeon Urologist Optometrist