S02 _ SOLICITATION ATTACHMENT - D.4 HEALTH CARE FOR HOMELESS VETERANS NOTICE OF NEW CONTRACT FORM.pdf

VA FORM

MAY 2014

10-10116b 1

HEALTH CARE FOR HOMELESS VETERANS (HCHV)

NOTICE OF NEW CONTRACT FORM

VA MEDICAL CENTER INFORMATION

NOTIFICATION OF NEWLY OPERATIONAL HCHV CONTRACT

PROGRAM / PROVIDER INFORMATION

PROVIDER STAFF

HCHV POC PHONE NUMBER

VISN

Provider Name:

Contract Start Date:

Per Diem Rate:

Locally assigned Contract #:Date Facility passed Inspection:

SITE CODE

FAX NUMBER

PROJECT CODE (TO BE ASSIGNED BY NEPEC)

This form must be completed and forwarded to both the HCHV program office and NEPEC prior to any Veterans being placed at this contracted facility. Program activity should not be reported in HOMES until NEPEC assigns a project code and forwards reporting instructions to the identified HCHV program POC.

PROGRAM TYPE (SELECT ONE)

Contracted Emergency Residential Low Demand Safe Haven

Date Contract Expires:

Bed (Max Capacity:

SITE ADDRESS (CITY, STATE, ZIP)

Provider POC:

Fax No.:Phone No.:

Title

EMAIL:

Provider Fiscal Official:

Fax No.:Phone No.:

Title

EMAIL:

ADDITIONAL COMMENTS

T e x t i e d

36C24222R0035: D.4 HEALTH CARE FOR HOMELESS VETERANS NOTICE OF NEW CONTRACT FORM