Section J Attachments.pdf

Created by dmt – Revised 3/2016

EVALUATION OF CONTRACTOR PERFORMANCE – MEDICAL SERVICES

Great Plains Area Indian Health Service

DATE:

SERVICE UNIT: ___x__ MONTHLY

DEPARTMENT NAME: _____ QUARTERLY

NAME OF EVALUATOR: _____ ANNUAL

CONTRACTOR NAME/ADDRESS: _____ FINAL

CONTRACT NUMBER:

TASK ORDER NUMBER:

MODIFICATION NUMBER:

PERIOD OF PERFORMANCE:

TITLE OF SERVICES BEING PROVIDED:

Y N N/A

CONTRACT REQUIREMENTS:

1. Did the Contractor provide all background and credentialing forms in a timely manner? ____ ____ ____

2. Was seamless coverage provided by the Contractor? ____ ____ ____

3. Were the peer reviews on the contract within acceptable range? (No clinical competency issues identified) ____ ____ ____

4. Was the Contractor compliant with all medical records requirements including documentation completed within required timeframe ____ ____ ____ and according to facility policy?

PROBLEMS:

5. Were any behavior, clinical competency, or conduct issues present with the Contract providers (written/verbal) which were substantiated? ____ ____ ____

6. OVERALL RATING: ____ Exceptional ____ Very Good ____ Satisfactory ____ Marginal ____ Unsatisfactory

7. Marginal/Unsatisfactory Rating - Requesting: _____ Conference call w/contractor _____ CURE Notice _____ Other (comments section)

EVALUATOR COMMENTS:

Evaluator Signature: ________________________________________________________________________ Date: _______________________

(PLEASE COMPLETE AND RETURN)

LICENSURE REQUIREMENT

PERSONAL AND NONPERSONAL SERVICES CONTRACTORS SHALL BE SUBJECT TO THE SAME

QUALITY ASSURANCE, CREDENTIALS, LICENSURE, AND OTHER QUALIFICATION STANDARDS

AS THOSE REQUIRED OF IHS PERSONNEL. IN ADDITION, HEALTH CARE PROVIDERS, OTHER

THAN PROFESSIONALS, MUST BE LICENSED IN A STATE, THE DISTRICT OF COLUMBIA, PUERTO

RICO, OR A TERRITORY OF THE UNITED STATES TO PERFORM THE CONTRACT SERVICES

WITHIN IHS FACILITIES. THE CONTRACTING OFFICER WILL INSERT THE FOLLOWING

CERTIFICATION STATEMENT IN ALL PURCHASE ORDERS AND CONTRACTS FOR

PROFESSIONAL MEDICAL SERVICES:

MY LICENSE TO PRACTICE O HAS O HAS NOT BEEN TERMINATED, SUSPENDED, OR

REVOKED IN ANY STATE, THE DISTRICT OF COLUMBIA, PUERTO RICO, OR A TERRITORY OF

THE U.S ..

I CURRENTLY HOLD AN ACTIVE MEDICAL LICENSE IN THE FOLLOWING STATE(S):

STATE I ,I CENSURE NO. ISSUE DATE

I HA VE AN INACTIVE MEDICAL LICENSE IN THE FOLLOWING STATE{S):

STATE LICENSURE NO. ISSUE DATE

I HEREBY CERTIFY THAT THE PURPOSES OF APPLICATION OF THE FALSE STATEMENTS

PROVISIONS OF THE PROGRAM FRAUD CIVIL REMEDIES ACT OF 1986 (45 CFR 79), THAT TO THE

BEST OF MY KNOWLEDGE, EACH OF THE ABOVE STATEMENTS IS TRUE, ACCURATE, AND

DOES NOT OMIT ANY MATERIAL FACT THAT WOIB.,D RENDER THE STATEMENT FALSE,

FICTITIOUS, FRAUDULENT AS A RESULT OF THE OMISSION.

SIGNATURE OF PRACTITIONER DATE