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15BCTS23Q00000005 Page 1 of 76
SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS
OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24 & 30
1. REQUISITION NUMBER PAGE 1 OF
5. SOLICITATION NUMBER
15BCTS23Q00000005
2. CONTRACT NO. 3. AWARD/EFFECTIVE
DATE
4. ORDER NUMBER 6. SOLICITATION ISSUE
DATE
08/19/2022
7. FOR SOLICITATION
INFORMATION CALL:
a. NAME
Kia Warner k1warner@bop.gov
b. TELEPHONE NUMBER (No collect calls)
202-616-2464
8. OFFER DUE DATE / LOCAL
TIME
09/19/2022 14:00 ET
CODE 15BCTS
Federal Bureau of Prisons Community Treatment Services Contracting 320 First Street NW Suite 901-5 Washington, DC 20534
9. ISSUED BY UNRESTRICTED OR X SET ASIDE:100.00 % FOR
X SMALL BUSINESS
HUBZONE SMALL
BUSINESS
SERVICE-DISABLED
VETERAN-OWNED
SMALL BUSINESS
WOMEN-OWNED SMALL BUSINESS (WOSB)
ELIGIBLE UNDER THE WOMEN-OWNED
SMALL BUSINESS PROGRAM
EDWOSB
8(A)
NAICS: 621420
SIZE STANDARD: $16,500,000
10. THE ACQUISITION IS
SEE
SCHEDULE
11. DELIVERY FOR FOB DESTINATION
UNLESS BLOCK IS MARKED
12. DISCOUNT TERMS
13a. THIS CONTRACT IS A
RATED ORDER UNDER DPAS
(15 CFR 700)
13b. RATING
X RFQ IFB RFP
14. METHOD OF SOLICITATION
15B100CODE15. DELIVER TO
Federal Bureau of Prisons Mid Atlantic Regional Office 302 Sentinel Drive Suite 200 Annapolis Junction, MD 20701
CODE 15BCTS16. ADMINISTERED BY
Federal Bureau of Prisons Community Treatment Services Contracting 320 First Street NW Suite 901-5 Washington, DC 20534
Kia Warner
(O) 202-616-2464 k1warner@bop.gov
FACILITY
CODE
CODE
TELEPHONE NO.
17a. CONTRACTOR/
OFFEROR
15B100CODE18a. PAYMENT WILL BE MADE BY
Federal Bureau of Prisons Mid Atlantic Regional Office 302 Sentinel Drive Suite 200 Annapolis Junction, MD 20701
BOP-RSD-CRBCTS-BILL-DC@bop.gov
17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN
OFFER SEE ADDENDUM
18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS
CHECKED
19.
ITEM NO.
20.
SCHEDULE OF SUPPLIES/SERVICES
21.
QUANTITY
22.
UNIT
23.
UNIT PRICE
24.
AMOUNT
Substance Use, Mental Health, Sex Offender and Medication Assisted Treatment Services in Greensboro, NC.
Firm Fixed Price
See Continuation Sheet(s) (Use Reverse and/or Attach Additional Sheets as Necessary)
25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)
X 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED
27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED
X 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN 1 COPIES TO
ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER ALL ITEMS SET FORTH
OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEETS SUBJECT TO THE
TERMS AND CONDITIONS SPECIFIED.
29. AWARD OF CONTRACT: REF. _____________________________ OFFER
DATED _________________ . YOUR OFFER ON SOLICITATION (BLOCK 5)
INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH HEREIN,
IS ACCEPTED AS TO ITEMS:
30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)
30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF THE CONTRACTING OFFICER (TYPE OR PRINT)
Kia Warner
31c. DATE SIGNED
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS NOT USABLE
STANDARD FORM 1449 (REV. 2/2012)
Prescribed by GSA - FAR (48 CFR) 53.212
005-23
X
15BCTS23Q00000005 Page 2 of 76
19.
ITEM NO.
20.
SCHEDULE OF SUPPLIES/SERVICES
21.
QUANTITY
22.
UNIT
23.
UNIT PRICE
24.
AMOUNT
32a. QUANTITY IN COLUMN 21 HAS BEEN
RECEIVED INSPECTED ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED: _________________________________
32b. SIGNATURE OF AUTHORIZED GOVERNMENT
REPRESENTATIVE
32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT
REPRESENTATIVE
32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT
REPRESENTATIVE
32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE
PARTIAL FINAL
33. SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED
CORRECT FOR
COMPLETE PARTIAL FINAL
36. PAYMENT 37. CHECK NUMBER
38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID BY
41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 42a. RECEIVED BY (Print)
41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE
42b. RECEIVED AT (Location)
42c. DATE REC'D (YY/MM/DD) 42d. TOTAL CONTAINERS
STANDARD FORM 1449 (REV. 2/2012) BACK
15BCTS23Q00000005 Page 3 of 76
Table of Contents
Section Description Page Number
1 Solicitation/Contract Form 2 Commodity or Services Schedule 3 Contract Clauses
52.242-15 Stop-Work Order (Aug 1989)
52.218-000 CONTINUING CONTRACT PERFORMANCE DURING A PANDEMIC INFLUENZA
OR OTHER NATIONAL EMERGENCY (May 2008) DJAR-PGD-15-03 Security of Department Information and Systems 52.21-603-70 Contracting Officer's Representative (COR) (June 2012) 52.203-3 Gratuities (Apr 1984) 52.232-40 Providing Accelerated Payments to Small Business Subcontractors (Nov 2021) 52.253-1 Computer Generated Forms (Jan 1991) 52.212-4 Contract Terms and Conditions-Commercial Products and Commercial Services (Nov 2021) 52.203-12 Limitation On Payments to Influence Certain Federal Transactions (Jun 2020) 52.242-13 Bankruptcy (July 1995) 52.204-12 Unique Entity Identifier Maintenance (Oct 2016) 52.224-1 Privacy Act Notification (Apr 1984) 52.224-2 Privacy Act (Apr 1984) 52.204-13 System for Award Management Maintenance (Oct 2018) 52.216-19 Order Limitations (Oct 1995) 52.217-8 Option to Extend Services (Nov 1999) 52.232-18 Availability of Funds (Apr 1984) 52.232-19 Availability of Funds for the Next Fiscal Year (Apr 1984) 52.237-7 Indemnification and Medical Liability Insurance (Jan 1997) 52.204-21 Basic Safeguarding of Covered Contractor Information Systems (Nov 2021) 52.217-9 Option to Extend the Term of the Contract (Mar 2000)
BOP 2852.242-71 EVALUATION OF CONTRACTOR PERFORMANCE UTILIZING CPARS (APR
2011) DOJ-03 Personnel Security Requirements For Contractor Employees (Nov 2021); (Alt. I) -- Classified Information -- Cleared Contractors DOJ-01 Whistleblower Information Distribution (Oct 2021) 52.212-5 Contract Terms and Conditions Required To Implement Statutes or Executive Orders- Commercial Products and Commercial Services (May 2022)
52.27-103-72 DOJ CONTRACTOR RESIDENCY REQUIREMENT BUREAU OF PRISONS (JUNE
2004) 52.216-18 Ordering (Aug 2020) 52.216-22 Indefinite Quantity (Oct 1995)
4 List of Attachments 5 Solicitation Provisions
52.203-18 Prohibition on Contracting with Entities that Require Certain Internal Confidentiality Agreements or Statements--Representation (Jan 2017) 52.223-22 Public Disclosure of Greenhouse Gas Emissions and Reduction Goals-Representation (Dec 2016) 52.204-24 Representation Regarding Certain Telecommunications and Video Surveillance Services or Equipment (Nov 2021) 52.209-7 Information Regarding Responsibility Matters (Oct 2018) 52.212-3 Offeror Representations and Certifications-Commercial Products and Commercial Services (Nov 2021) 52.204-26 Covered Telecommunications Equipment or Services-Representation (Oct 2020) 52.216-1 Type of Contract (Apr 1984)
15BCTS23Q00000005 Page 4 of 76
Section 2 - Commodity or Services Schedule
SCHEDULE OF SUPPLIES/SERVICES
CONTINUATION SHEET
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0001 2005 Substance Use Intake Screening
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0002 2010 Individual Counseling
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 160 Estimated Maximum Quantity: 960
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
160 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0003 2011 Substance Use Assessments & Report
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 10 Estimated Maximum Quantity: 40
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0004 2012 Dual Diagnosis Intake Assessment & Report
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
15BCTS23Q00000005 Page 5 of 76
0005 2020 Group Counseling
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 120 Estimated Maximum Quantity: 2880
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
120 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0006 2030 Family Counseling
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0007 4002 MAT Buprenorphine Follow-Up & Report
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0008 4003 MAT Naltrexone Follow-Up & Report
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0009 4020 MAT Administration of Buprenorphine
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 25
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
15BCTS23Q00000005 Page 6 of 76
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0010 4021 MAT Buprenorphine and Administration
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0011 4030 MAT Administration of Buprenorphine Injection
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0012 4040 MAT Administration of Naltrexone
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 50
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0013 4050 MAT Psychiatric Evaluation & Report
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0014 5005 Mental Health Intake
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 8
Use the Guaranteed Minimum Quantity when developing the total amount.
2 EA $________ $_________________
15BCTS23Q00000005 Page 7 of 76
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0015 5011 Mental Health Assessment & Report
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 10 Estimated Maximum Quantity: 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0016 5030 Psychiatric Evaluation & Report
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0017 6000 Crisis Intervention
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 5
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0018 6010 Mental Health Individual Counseling
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 20 Estimated Maximum Quantity: 600
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0019 6031 Mental Health Family Counseling
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 32
Use the Guaranteed Minimum Quantity when developing the total
15BCTS23Q00000005 Page 8 of 76
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0020 6050 Mental Health Case Management Services
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0021 6051 Medication Monitoring and Report
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 120
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0022 5012 Sex offender Specific Intake Assessment & Report
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0023 6005 Sex Offender Intake Screening
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0024 6012 Sex Offender Individual Counseling
Base period: Months 1 through 12
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 640
5 EA $________ $_________________
15BCTS23Q00000005 Page 9 of 76 amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0025 2005 Substance Use Intake Screening
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0026 2010 Individual Counseling
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 160 Estimated Maximum Quantity: 960
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
160 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0027 2011 Substance Use Assessments & Report
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 10 Estimated Maximum Quantity: 40
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0028 2012 Dual Diagnosis Intake Assessment & Report
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0029 2020 Group Counseling
Option Year 1: Months 13 through 24
120 EA $________ $_________________
15BCTS23Q00000005 Page 10 of 76
Guaranteed Minimum Quantity: 120 Estimated Maximum Quantity: 2880
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0030 2030 Family Counseling
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0031 4002 MAT Buprenorphine Follow-Up & Report
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0032 4003 MAT Naltrexone Follow-Up & Report
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0033 4020 MAT Administration of Buprenorphine
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 25
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
0034 4021 MAT Buprenorphine and Administration 1 EA $________ $_________________
15BCTS23Q00000005 Page 11 of 76
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0035 4030 MAT Administration of Buprenorphine Injection
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0036 4040 MAT Administration of Naltrexone
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 50
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0037 4050 MAT Psychiatric Evaluation & Report
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0038 5005 Mental Health Intake
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 8
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
15BCTS23Q00000005 Page 12 of 76
0039 5011 Mental Health Assessment & Report
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 10 Estimated Maximum Quantity: 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0040 5030 Psychiatric Evaluation & Report
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0041 6000 Crisis Intervention
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 5
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0042 6010 Mental Health Individual Counseling
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 20 Estimated Maximum Quantity: 600
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0043 6031 Mental Health Family Counseling
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 32
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000005 Page 13 of 76
QUANTITY
UNIT UNIT PRICE AMOUNT
0044 6050 Mental Health Case Management Services
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0045 6051 Medication Monitoring and Report
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 120
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0046 5012 Sex offender Specific Intake Assessment & Report
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0047 6005 Sex Offender Intake Screening
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0048 6012 Sex Offender Individual Counseling
Option Year 1: Months 13 through 24
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 640
Use the Guaranteed Minimum Quantity when developing the total
5 EA $________ $_________________
15BCTS23Q00000005 Page 14 of 76
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0049 2005 Substance Use Intake Screening
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0050 2010 Individual Counseling
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 160 Estimated Maximum Quantity: 960
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
160 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0051 2011 Substance Use Assessments & Report
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 10 Estimated Maximum Quantity: 40
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0052 2012 Dual Diagnosis Intake Assessment & Report
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0053 2020 Group Counseling
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 120 Estimated Maximum Quantity: 2880
15BCTS23Q00000005 Page 15 of 76
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0054 2030 Family Counseling
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0055 4002 MAT Buprenorphine Follow-Up & Report
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0056 4003 MAT Naltrexone Follow-Up & Report
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0057 4020 MAT Administration of Buprenorphine
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 25
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0058 4021 MAT Buprenorphine and Administration
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10
15BCTS23Q00000005 Page 16 of 76 amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0059 4030 MAT Administration of Buprenorphine Injection
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0060 4040 MAT Administration of Naltrexone
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 50
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0061 4050 MAT Psychiatric Evaluation & Report
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0062 5005 Mental Health Intake
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 8
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0063 5011 Mental Health Assessment & Report
Option Year 2: Months 25 through 36
10 EA $________ $_________________
15BCTS23Q00000005 Page 17 of 76
Guaranteed Minimum Quantity: 10 Estimated Maximum Quantity: 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0064 5030 Psychiatric Evaluation & Report
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0065 6000 Crisis Intervention
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 5
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0066 6010 Mental Health Individual Counseling
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 20 Estimated Maximum Quantity: 600
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0067 6031 Mental Health Family Counseling
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 32
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
0068 6050 Mental Health Case Management Services 1 EA $________ $_________________
15BCTS23Q00000005 Page 18 of 76
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0069 6051 Medication Monitoring and Report
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 120
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0070 5012 Sex offender Specific Intake Assessment & Report
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0071 6005 Sex Offender Intake Screening
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0072 6012 Sex Offender Individual Counseling
Option Year 2: Months 25 through 36
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 640
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
15BCTS23Q00000005 Page 19 of 76
0073 2005 Substance Use Intake Screening
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0074 2010 Individual Counseling
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 160 Estimated Maximum Quantity: 960
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
160 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0075 2011 Substance Use Assessments & Report
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity:10 Estimated Maximum Quantity: 40
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0076 2012 Dual Diagnosis Intake Assessment & Report
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0077 2020 Group Counseling
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 120 Estimated Maximum Quantity: 2880
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000005 Page 20 of 76
QUANTITY
UNIT UNIT PRICE AMOUNT
0078 2030 Family Counseling
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0079 4002 MAT Buprenorphine Follow-Up & Report
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0080 4003 MAT Naltrexone Follow-Up & Report
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0081 4020 MAT Administration of Buprenorphine
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 25
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0082 4021 MAT Buprenorphine and Administration
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total
15BCTS23Q00000005 Page 21 of 76
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0083 4030 MAT Administration of Buprenorphine Injection
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0084 4040 MAT Administration of Naltrexone
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 50
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0085 4050 MAT Psychiatric Evaluation & Report
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0086 5005 Mental Health Intake
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 8
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0087 5011 Mental Health Assessment & Report
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 10 Estimated Maximum Quantity: 60
15BCTS23Q00000005 Page 22 of 76
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0088 5030 Psychiatric Evaluation & Report
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0089 6000 Crisis Intervention
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 5
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0090 6010 Mental Health Individual Counseling
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 20 Estimated Maximum Quantity: 600
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0091 6031 Mental Health Family Counseling
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 32
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0092 6050 Mental Health Case Management Services
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
15BCTS23Q00000005 Page 23 of 76 amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0093 6051 Medication Monitoring and Report
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 120
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0094 5012 Sex offender Specific Intake Assessment & Report
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0095 6005 Sex Offender Intake Screening
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0096 6012 Sex Offender Individual Counseling
Option Year 3: Months 37 through 48
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 640
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0097 2005 Substance Use Intake Screening
Option Year 4: Months 49 through 60
15BCTS23Q00000005 Page 24 of 76
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0098 2010 Individual Counseling
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 160 Estimated Maximum Quantity: 960
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
160 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0099 2011 Substance Use Assessments & Report
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity:10 Estimated Maximum Quantity: 40
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0100 2012 Dual Diagnosis Intake Assessment & Report
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0101 2020 Group Counseling
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 120 Estimated Maximum Quantity: 2880
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
120 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
0102 2030 Family Counseling 2 EA $________ $_________________
15BCTS23Q00000005 Page 25 of 76
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0103 4002 MAT Buprenorphine Follow-Up & Report
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0104 4003 MAT Naltrexone Follow-Up & Report
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0105 4020 MAT Administration of Buprenorphine
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 25
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0106 4021 MAT Buprenorphine and Administration
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
15BCTS23Q00000005 Page 26 of 76
0107 4030 MAT Administration of Buprenorphine Injection
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0108 4040 MAT Administration of Naltrexone
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 50
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0109 4050 MAT Psychiatric Evaluation & Report
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0110 5005 Mental Health Intake
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 8
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0111 5011 Mental Health Assessment & Report
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 10 Estimated Maximum Quantity: 60
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000005 Page 27 of 76
QUANTITY
UNIT UNIT PRICE AMOUNT
0112 5030 Psychiatric Evaluation & Report
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0113 6000 Crisis Intervention
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 5
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0114 6010 Mental Health Individual Counseling
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 20 Estimated Maximum Quantity: 600
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0115 6031 Mental Health Family Counseling
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 32
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0116 6050 Mental Health Case Management Services
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
Use the Guaranteed Minimum Quantity when developing the total
15BCTS23Q00000005 Page 28 of 76
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0117 6051 Medication Monitoring and Report
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 120
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0118 5012 Sex offender Specific Intake Assessment & Report
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0119 6005 Sex Offender Intake Screening
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 15
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0120 6012 Sex Offender Individual Counseling
Option Year 4: Months 49 through 60
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 640
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0121 2005 Substance Use Intake Screening
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 5
15BCTS23Q00000005 Page 29 of 76
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0122 2010 Individual Counseling
Potential Six-Month Extension
Guaranteed Minimum Quantity: 80 Estimated Maximum Quantity: 480
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
80 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0123 2011 Substance Use Assessments & Report
Potential Six-Month Extension
Guaranteed Minimum Quantity:5 Estimated Maximum Quantity: 20
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0124 2012 Dual Diagnosis Intake Assessment & Report
Potential Six-Month Extension
Guaranteed Minimum Quantity: 3 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
3 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0125 2020 Group Counseling
Potential Six-Month Extension
Guaranteed Minimum Quantity: 60 Estimated Maximum Quantity: 1440
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
60 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0126 2030 Family Counseling
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 12
15BCTS23Q00000005 Page 30 of 76 amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0127 4002 MAT Buprenorphine Follow-Up & Report
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0128 4003 MAT Naltrexone Follow-Up & Report
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 6
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0129 4020 MAT Administration of Buprenorphine
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 13
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0130 4021 MAT Buprenorphine and Administration
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 5
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0131 4030 MAT Administration of Buprenorphine Injection
Potential Six-Month Extension
15BCTS23Q00000005 Page 31 of 76
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 6
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0132 4040 MAT Administration of Naltrexone
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 25
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0133 4050 MAT Psychiatric Evaluation & Report
Potential Six-Month Extension
Guaranteed Minimum Quantity: 3 Estimated Maximum Quantity: 8
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
3 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0134 5005 Mental Health Intake
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 4
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0135 5011 Mental Health Assessment & Report
Potential Six-Month Extension
Guaranteed Minimum Quantity: 5 Estimated Maximum Quantity: 30
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
5 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
0136 5030 Psychiatric Evaluation & Report 3 EA $________ $_________________
15BCTS23Q00000005 Page 32 of 76
Potential Six-Month Extension
Guaranteed Minimum Quantity: 3 Estimated Maximum Quantity: 30
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0137 6000 Crisis Intervention
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 3
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0138 6010 Mental Health Individual Counseling
Potential Six-Month Extension
Guaranteed Minimum Quantity: 10 Estimated Maximum Quantity: 300
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0139 6031 Mental Health Family Counseling
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 16
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
QUANTITY
UNIT UNIT PRICE AMOUNT
0140 6050 Mental Health Case Management Services
Potential Six-Month Extension
Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 6
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 EA $________ $_________________
ITEM NO. SUPPLIES/SERVICES EST.
15BCTS23Q00000005 Page 33 of 76
0141 6051 Medication Monitoring and Report
Potential Six-Month…
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