Attachment_VI_-_Summary_Sheets_by_Hospital_Network.pdf

RFQP04021500003

ATTACHMENT VI - SUMMARY SHEETS BY HOSPITAL NETWORK

COMPREHENSIVE MEDICAL SERVICES – FPC DULUTH

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 supersedes 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 FPC (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 FCI 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

Dermatology

Emergency Room

ENT/Surgery

Endocrinology

Family Medicine

Gastroenterology

General Surgery

Gynecology (if female)

Hematology

Infectious Disease

Internal Medicine

Nephrology

Neurology

Obstetrics (if female)

Oncology

Ophthalmology

Optometry

Orthopedics/Surgery

Pathology

Psychiatry

Pulmonology

Radiology

Urology

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