RQ_Submission_Checklist.pdf
PDF 14 KB Posted
- Attached to
- Non-Personal Healthcare Services-Physician & Other Professional Ambulatory Services for PRC Program
- Solicitation number
- 75H70725R00008
About this file
This is a Rate Quotation Agreement Checklist for solicitation #17-242-SOL-00018 for Professional Physician and Other Ambulatory Health Care Services. The checklist outlines the minimum required documentation that must be submitted with rate quotations.
The required documents include: 1) Rate Quotation for Professional Health Care Services (Pages 1-8) with original signature and detailed fee schedule if not using Medicare Fee Schedule pricing, 2) Appendix D-2 Business Associate Agreement, 3) Copies of certifications, licenses, medical malpractice insurance and specialty training for providers, 4) Signed SF-30 Amendment 0003 dated 01/06/2020 with original signature, and 5) Copy of W-9 form to be faxed to 505-256-6848 if not sent by mail. The checklist notes that electronic signatures are acceptable and instructs vendors to retain a copy of the RQ Agreement package for reference.
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Rate Quotation Agreement Checklist
Solicitation#: 17-242-SOL-00018
Professional Physician and Other Ambulatory Health Care Services
The following checklist is to assist you in ensuring that the acceptable minimum documents are submitted with your rate quotation and signed by an official authorized to bind your organization.
Document Requirement Number of Copies
1. Rate Quotation For Professional Health Care Services 1 Copy with Original (Pages 1 -8) Signature o Complete all applicable sections and sign o Please attach a detailed Fee Schedule if pricing will not be based on a percentage of the Medicare Fee Schedule (see bottom of Page 2).
2. Appendix D-2: Business Associate Agreement 1 Copy Complete Fillable items in I and IIA.
3. Copies of Certifications, Licenses, Medical Malpractice Insurance 1 Copy and Specialty Training for each provider (if applicable).
4. Signed SF-30, Amendment of Solicitation, (Amendment 0003) 1 Copy with Original Effective Date 01/06/2020 Signature
5. Copy of W-9, Request for Taxpayer Identification Number and 1 Copy faxed to Certification; please fax if not sending via US Mail. 505-256-6848
Note: Please retain a copy of the RQ Agreement package for your reference.
Note2: Electronic signatures will be accepted,
| Rate Quotation Agreement Checklist |
| Document Requirement Number of Copies |
File details come from the government source that posted it. Updated .