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PAGE 1 OF1. REQUISITION NO. 2. CONTRACT NO.3. AWARD/EFFECTIVE DATE4. ORDER NO.5. SOLICITATION NUMBER6. SOLICITATION ISSUE DATEa. NAMEb. TELEPHONE NO. (No Collect Calls)8. OFFER DUE DATE/LOCALTIME9. ISSUED BYCODE10. THIS ACQUISITION IS UNRESTRICTED ORSET ASIDE: % FOR:SMALL BUSINESSHUBZONE SMALLBUSINESSSERVICE-DISABLEDVETERAN-OWNEDSMALL BUSINESSWOMEN-OWNED SMALL BUSINESS(WOSB) ELIGIBLE UNDER THE WOMEN-OWNEDSMALL BUSINESS PROGRAMEDWOSB8(A)NAICS:SIZE STANDARD:11. DELIVERY FOR FOB DESTINA-TION UNLESS BLOCK ISMARKEDSEE SCHEDULE12. DISCOUNT TERMS 13a. THIS CONTRACT IS A RATED ORDER UNDERDPAS (15 CFR 700)13b. RATING14. METHOD OF SOLICITATIONRFQIFBRFP15. DELIVER TO CODE16. ADMINISTERED BYCODE17a. CONTRACTOR/OFFERORCODEFACILITY CODE18a. PAYMENT WILL BE MADE BYCODETELEPHONE NO.DUNS:DUNS+4:PHONE:FAX:17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKEDSEE ADDENDUM19.20.21.22.23.24.ITEM NO.SCHEDULE OF SUPPLIES/SERVICESQUANTITYUNITUNIT PRICEAMOUNT(Use Reverse and/or Attach Additional Sheets as Necessary)25. ACCOUNTING AND APPROPRIATION DATA26. TOTAL AWARD AMOUNT (For Govt. Use Only)27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDAAREARE NOT ATTACHED.27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDAAREARE NOT ATTACHED28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________ 29. AWARD OF CONTRACT: REF. ___________________________________ OFFERCOPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DATED ________________________________. YOUR OFFER ON SOLICITATION DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIEDSET FORTH HEREIN IS ACCEPTED AS TO ITEMS:30a. SIGNATURE OF OFFEROR/CONTRACTOR31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT)30c. DATE SIGNED31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT)31c. DATE SIGNEDAUTHORIZED FOR LOCAL REPRODUCTION(REV. 2/2012)PREVIOUS EDITION IS NOT USABLEPrescribed by GSA - FAR (48 CFR) 53.2127. FOR SOLICITATIONINFORMATION CALL:STANDARD FORM 1449OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS266673-16-2-095-0001VA248-16-R-025904-22-2016Brett Cook813-631-282705-23-201612:00 P.M.EST00248Department of Veterans AffairsNetwork Contracting Office 8 (NCO 8)8875 Hidden River Pkwy Suite 525Tampa FL 33637X621493$15 MillionXN/AN/AX00673Department of Veterans AffairsJames A. Haley Veterans Hospital (90C)13000 Bruce B. Downs BlvdTampa FL 3361200248Department of Veterans AffairsNetwork Contracting Office 8 (NCO 8)8875 Hidden River PkwyTampa FL 33637 Department of Veterans AffairsFinancial Services CenterP.O. Box 149971Austin TX 78714-9971The contractor shall provide Ambulatory Surgery Centerslocated within fifteen (15) miles of the James A. Haley VAHospital (JAHVH), 13000 Bruce B. Downs Blvd, Tampa, FL 33612to provide anesthesia services; qualified operating room(OR) nurses and technicians; operating microscope andinstruments; and usual and customary supplies requiredduring operative procedures.Reference pages 8 thru 159 for the Price/Cost Schedule.XXX1Yamil O. RodriguezContracting OfficerTable of ContentsSECTION A1 TOC \o &quot;1-4&quot; \f \h \z \u \x A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS1SECTION B - CONTINUATION OF SF 1449 BLOCKS5B.1 CONTRACT ADMINISTRATION DATA5B.2 PRICE/COST SCHEDULE8ITEM INFORMATION10B.3 PERFORMANCE WORK STATEMENT160SECTION C - CONTRACT CLAUSES177C.1 52.203-16 PREVENTING PERSONAL CONFLICTS OF INTEREST (DEC 2011)177C.2 52.203-99 PROHIBITION ON CONTRACTING WITH ENTITIES THAT REQUIRE CERTAIN INTERNAL CONFIDENTIALITY AGREEMENTS (DEVIATION) (FEB 2015)180C.3 52.204-4 PRINTED OR COPIED DOUBLE-SIDED ON POSTCONSUMER FIBER CONTENT PAPER (MAY 2011)180C.4 52.204-9 PERSONAL IDENTITY VERIFICATION OF CONTRACTOR PERSONNEL (JAN 2011)181C.5 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL ITEMS (MAY 2015)181C.6 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT STATUTES OR EXECUTIVE ORDERS—COMMERCIAL ITEMS (NOV 2015)187C.7 52.216-18 ORDERING (OCT 1995)193C.8 52.216-19 ORDER LIMITATIONS (OCT 1995)194C.9 52.216-22 INDEFINITE QUANTITY (OCT 1995)194C.10 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)195C.11 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000)195C.12 52.224-1 PRIVACY ACT NOTIFICATION (APR 1984)195C.13 52.224-2 PRIVACY ACT (APR 1984)195C.14 52.227-17 RIGHTS IN DATA – SPECIAL WORKS (DEC 2007)196C.15 52.232-19 AVAILABILITY OF FUNDS FOR THE NEXT FISCAL YEAR (APR 1984)197C.16 52.232-37 MULTIPLE PAYMENT ARRANGEMENTS (MAY 1999)198C.17 52.237-3 CONTINUITY OF SERVICES (JAN 1991)198C.18 52.242-13 BANKRUPTCY (JULY 1995)198C.19 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)199C.20 VAAR 852.203-70 COMMERCIAL ADVERTISING (JAN 2008)199C.21 VAAR 852.203-71 DISPLAY OF DEPARTMENT OF VETERAN AFFAIRS HOTLINE POSTER (DEC 1992)199C.22 VAAR 852.215-70 SERVICE DISABLED VETERAN-OWNED SMALL BUSINESS EVALUATION FACTORS (DEC 2009)200C.23 VAAR 852.215-71 EVALUATION FACTOR COMMITMENTS (DEC 2009)200C.24 VAAR 852.219-9 VA SMALL BUSINESS SUBCONTRACTING PLAN MINIMUM REQUIREMENTS (DEC 2009)200C.25 VAAR 852.219-71 VA MENTOR-PROT?G? PROGRAM (DEC 2009)201C.26 VAAR 852.219-72 EVALUATION FACTOR FOR PARTICIPATION IN THE VA MENTOR-PROT?G? PROGRAM (DEC 2009)202C.27 VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS (NOV 2012)202C.28 VAAR 852.237-7 INDEMNIFICATION AND MEDICAL LIABILITY INSURANCE (JAN 2008)203C.29 VAAR 852.237-70 CONTRACTOR RESPONSIBILITIES (APR 1984)204C.30 MANDATORY WRITTEN DISCLOSURES204SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS205D.1 CONTRACTOR CERTIFICATION206D.2 CONTRACTOR RULES OF BEHAVIOR207D.3 ORGANIZATIONAL CONFLICT OF INTEREST212D.4 SUBCONTRACTING PLAN MODULE214D.5 WAGE DETERMINATION224D.6 SUBCONTRACTING GOALS MEMO234D.7 QUALITY ASSURANCE SURVEILLANCE PLAN (Page 170)235SECTION E - SOLICITATION PROVISIONS240E.1 52.203-98 PROHIBITION ON CONTRACTING WITH ENTITIES THAT REQUIRE CERTAIN INTERNAL CONFIDENTIALITY AGREEMENTS—REPRESENTATION (DEVIATION) (FEB 2015)240E.2 52.209-5 CERTIFICATION REGARDING RESPONSIBILITY MATTERS (OCT 2015)240E.3 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (JUL 2013)242E.4 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL ITEMS (OCT 2015)243E.5 52.212-2 EVALUATION—COMMERCIAL ITEMS (OCT 2014)247E.6 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL ITEMS (NOV 2015)249E.7 52.216-1 TYPE OF CONTRACT (APR 1984)262E.8 52.216-27 SINGLE OR MULTIPLE AWARDS (OCT 1995)262E.9 52.225-25 PROHIBITION ON CONTRACTING WITH ENTITIES ENGAGING IN CERTAIN ACTIVITIES OR TRANSACTIONS RELATING TO IRAN – REPRESENTATION AND CERTIFICATIONS (DEC 2012)262E.10 52.233-2 SERVICE OF PROTEST (SEP 2006)263E.11 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998)264E.12 VAAR 852.209-70 ORGANIZATIONAL CONFLICT OF INTEREST (JAN 2008)264E.13 VAAR 852.215-70 SERVICE-DISABLED VETERAN-OWNED AND VETERAN-OWNED SMALL BUSINESS EVALUATION FACTORS (DEC 2009)265E.14 VAAR 852.233-70 PROTEST CONTENT/ALTERNATIVE DISPUTE RESOLUTION (JAN 2008)265E.15 VAAR 852.233-71 ALTERNATE PROTEST PROCEDURE (JAN 1998)266E.16 VAAR 852.270-1 REPRESENTATIVES OF CONTRACTING OFFICERS (JAN 2008)266E.17 VAAR 852.271-70 NONDISCRIMINATION IN SERVICES PROVIDED TO BENEFICIARIES (JAN 2008)266E.18 VAAR 852.273-70 LATE OFFERS (JAN 2003)266SECTION B - CONTINUATION OF SF 1449 BLOCKSB.1 CONTRACT ADMINISTRATION DATA(continuation from Standard Form 1449, block 18A.) 1. CONTRACT ADMINISTRATION: All contract administration matters will be handled by the following individuals: a. CONTRACTOR: b. GOVERNMENT: Contracting Officer 00248 – Yamil RodriguezAdministrative Contracting Officer 00248 – Brett Cook Department of Veterans AffairsNetwork Contracting Office 8 (NCO 8)8875 Hidden River Pkwy Suite 525Tampa FL 33637 2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:[X]52.232-34, Payment by Electronic Funds Transfer—Other Than System For Award Management, or[]52.232-36, Payment by Third Party 3. INVOICES: Invoices shall be submitted in arrears: a. Quarterly[] b. Semi-Annually[] c. Other[X] Monthly 4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.Department of Veterans AffairsFinancial Services CenterP.O. Box 149971Austin TX 78714-9971 ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:AMENDMENT NODATE 5. ATTENTION TO LARGE BUSINESS: Large Businesses are to submit a Subcontracting Plan, in accordance with FAR 52.219-8 and FAR 52.219-9 with their proposal. Refer to Attachment D.4 - Subcontracting Plan Module and Attachment D.7 - Subcontracting Goals. Goals are recommended and shall express in terms of percentages of total planned dollars. Subcontracting plan is to include a description of the principal types of supplies and services to be subcontracted out and identification of the types planned for subcontracting in the area of Small, Small Disadvantaged, Woman-Owned, Hub-Zone, Service Disabled Veterans and Veteran-Owned Small Business concerns. 6. CAUTION:Offerors must complete and return all information designated in FAR 52.212-1, Instructions to Offerors – Commercial Items, Paragraph b, prior to the time specified in block 8 of SF1449 in order to be considered for award. Late submissions, Modification, and Withdrawals. See Provision 52.212-1. All proposals are subject to all terms and conditions of this solicitation. 7. POST AWARD ORIENTATION: The Contracting Officer will schedule a post award orientation conference for contract orientation purposes. 8. LIMITATIONS ON SUBCONTRACTING-- MONITORING AND COMPLIANCE (JUN 2011) This solicitation includes FAR 52.219-4 Notice of Price Evaluation Preference for HubZone Small Business Concerns. Accordingly, any contract resulting from this solicitation will include this clause. The contractor is advised in performing contract administration functions, the CO may use the services of a support contractor(s) retained by VA to assist in assessing the contractor's compliance with the limitations on subcontracting or percentage of work performance requirements specified in the clause. To that end, the support contractor(s) may require access to contractor's offices where the contractor's business records or other proprietary data are retained and to review such business records regarding the contractor's compliance with this requirement. All support contractors conducting this review on behalf of VA will be required to sign an “Information Protection and Non-Disclosure and Disclosure of Conflicts of Interest Agreement” to ensure the contractor's business records or other proprietary data reviewed or obtained in the course of assisting the CO in assessing the contractor for compliance are protected to ensure information or data is not improperly disclosed or other impropriety occurs. Furthermore, if VA determines any services the support contractor(s) will perform in assessing compliance are advisory and assistance services as defined in FAR 2.101, Definitions, the support contractor(s) must also enter into an agreement with the contractor to protect proprietary information as required by FAR 9.505-4, obtaining access to proprietary information, paragraph (b). The contractor is required to cooperate fully and make available any records as may be required to enable the CO to assess the contractor's compliance with the limitations on subcontracting or percentage of work performance requirement. 9. SUBCONTRACTING COMMITMENTS--MONITORING AND COMPLIANCE (JUN 2011) This solicitation includes VAAR 852.215-70, Service-Disabled Veteran-Owned and Veteran-Owned Small Business Evaluation Factors, and VAAR 852.215-71, Evaluation Factor Commitments. Accordingly, any contract resulting from this solicitation will include these clauses. The contractor is advised in performing contract administration functions, the CO may use the services of a support contractor(s) to assist in assessing contractor compliance with the subcontracting commitments incorporated into the contract. To that end, the support contractor(s) may require access to the contractor's business records or other proprietary data to review such business records regarding contract compliance with this requirement. All support contractors conducting this review on behalf of VA will be required to sign an “Information Protection and Non-Disclosure and Disclosure of Conflicts of Interest Agreement” to ensure the contractor's business records or other proprietary data reviewed or obtained in the course of assisting the CO in assessing the contractor for compliance are protected to ensure information or data is not improperly disclosed or other impropriety occurs. Furthermore, if VA determines any services the support contractor(s) will perform in assessing compliance are advisory and assistance services as defined in FAR 2.101, Definitions, the support contractor(s) must also enter into an agreement with the contractor to protect proprietary information as required by FAR 9.505-4, obtaining access to proprietary information, paragraph (b). The contractor is required to cooperate fully and make available any records as may be required to enable the CO to assess the contractor compliance with the subcontracting commitments. 10. SUBCONTRACTING PLAN--MONITORING AND COMPLIANCE (JUN 2011) This solicitation includes FAR 52.219-9, Small Business Subcontracting Plan, and VAAR 852.219-9, VA Small Business Subcontracting Plan Minimum Requirement. Accordingly, any contract resulting from this solicitation will include these clauses. The contractor is advised in performing contract administration functions, the CO may use the services of a support contractor(s) to assist in assessing the contractor's compliance with the plan, including reviewing the contractor's accomplishments in achieving the subcontracting goals in the plan. To that end, the support contractor(s) may require access to the contractor's business records or other proprietary data to review such business records regarding the contractor's compliance with this requirement. All support contractors conducting this review on behalf of VA will be required to sign an “Information Protection and Non-Disclosure and Disclosure of Conflicts of Interest Agreement” to ensure the contractor's business records or other proprietary data reviewed or obtained in the course of assisting the CO in assessing the contractor for compliance are protected to ensure information or data is not improperly disclosed or other impropriety occurs. Furthermore, if VA determines any services the support contractor(s) will perform in assessing compliance are advisory and assistance services as defined in FAR 2.101, Definitions, the support contractor(s) must also enter into an agreement with the contractor to protect proprietary information as required by FAR 9.505-4, obtaining access to proprietary information, paragraph (b). The contractor is required to cooperate fully and make available any records as may be required to enable the CO to assess the contractor compliance with the subcontracting plan.B.2 PRICE/COST SCHEDULEThe Offeror shall furnish a facility or facilities in which to perform ambulatory surgery including but not limited to anesthesia services; qualified operating room nurses and technicians; operating microscopes and instruments; and usual and customary supplies required during operative procedures to eligible beneficiaries of the, James A. Haley VA Hospital, 13000 Bruce B. Downs Blvd, Tampa, FL 33612. All services shall be performed at the Offeror’s facility. Contract type: Fixed Price, Indefinite Delivery Indefinite Quantity (IDIQ), with an EPA adjustment Place of Performance: Services shall be provided offsite at multiple facilities located within fifteen (15) miles of the James A. Haley Veterans Hospital. Period of Performance: July 22, 2016 thru July 21, 2021Task Order Procedures: Per Title 42 CFR 415.170, should the Government choose to exercise any option years; an individual task order will be issued for each option year at the time of exercising the option. The task order will contain date of order, contract number and order number, contract line item number (CLIN) and description, quantity, unit price, performance schedule, place of performance, accounting and appropriations data, and method of payment.Pricing Instructions: Offerors must fill out the cells in the following columns in the Price Schedule for each CLIN. For pricing and evaluation purposes, the most current Centers for Medicare & Medicaid Services (CMS) rates should be used in completing each CLIN for the base year and option years.Throughout the life of the contract the VA will pay the awarded fixed rate but no more than the Medicare rate effective at the time the service is provided by the Offeror.The Government reserves the right to make one or more awards. This basis of the offeror’s proposed fixed percentage of Medicare rate will be used by the Government for future pricing of additional codes/procedures and for reimbursement under the contract. The basis of estimate used for your fixed price, i.e. the way that your price is calculated, shall remain the same throughout the life of the contract and may be validated by post award audits.The Offeror shall complete the attached price schedule for the performance location proposed. No CLINS or codes should be left blank. If for some reason a code on the schedule has expired or is for any other reason unusable, offerors shall annotate the Price per Code block with “N/A” or otherwise notate the replacement code. The Offeror shall base pricing on the application of Medicare reimbursement rules. All spreadsheets must be submitted in Microsoft Excel and without protected/locked portions or other methods which prevent or do not facilitate expeditious pricing validation. PDF files and similarly constructed files are not acceptable.The guaranteed minimum contract amount, including the base year and all option years exercised is $1,250,000 and the maximum contract amount, including the base year and all option years exercised shall not exceed $18 million.Indicate source for CMS rate proposed (Identify source and Internet link): _____________________________Indicate the offeror’s CMS practice expense (PE) designation for the rate proposed: (facility or non-facility): _____________________________The Government intends to make one (1) or more awards. The estimated quantities in the Price Schedule reflect the total estimated quantity needed. These quantities will be split among the awardees if multiple awards are made.AGENCY PRESCRIBED EPA CLAUSE FOR PER-PROCEDURE BASED ACQUISITIONS USING MEDICARE RATESThe Per-Procedure rates for the base year and any option years, should they be renewed, will correspond to the most current and active published Medicare rates at the time services are rendered under the contract. Corresponding Per-Procedure rate adjustments could result in either a decrease or increase in payment to the Offeror depending on the rates published by Medicare for any given time period.The burden of notifying the VA Contracting Officer of any changes in Medicare rates lies with the Offeror. The Offeror's notification to the VA Contracting Officer should include a list detailing the new Medicare rates and published documentation that substantiates that these rates are currently effective or will be effective at a future date. Within seven (7) calendar days of being properly notified of the change(s) in Medicare rates by the Offeror, the VA Contracting Officer will attempt to verify the change(s) with the CMS. If the change(s) cannot be verified, the VA Contracting Officer will notify the Offeror of this determination, and will work with the Offeror to identify the issue(s) preventing verification. If the change(s) can be verified, the VA Contracting Officer will implement the corresponding adjustments within fourteen (14) calendar days of verification unless the effective date has not yet arrived. In the latter case, the VA Contracting Officer will implement the change(s) on the effective date unless the effective date falls within the fourteen (14) calendar days the VA Contracting Officer is afforded to implement the change(s) after verification.The VA Contracting Officer reserves the right to retain any of the remaining fourteen (14) calendar days between verification and implementation regardless of the effective date of the change(s). The Offeror is not entitled to retroactive payment rate adjustments prior to implementation of the change(s) in Medicare rates by the VA Contracting Officer. "Piecemeal" changes to Medicare rates, such as only seeking per-procedure rate adjustments for select codes or a select group of codes, will not be permitted under any circumstance. The Offeror shall accept all Medicare rate changes for the period in which they are effective.VA reserves the right to adjust the Per-Procedure rates under this contract at any time should Medicare rates change regardless of whether the Offeror notified the VA Contracting Officer of the change(s). The Offeror will be given a notice of such actions at least seven (7) calendar days prior to the effective date of the change(s). Should there be any disagreement with the VA Contracting Officer's proposed change; the Offeror must submit a response outlining those areas in which the Offeror disagrees. This response must be provided to the Contracting Officer within seven (7) calendar days of notification of the anticipated change. The VA Contracting Officer reserves the right to make the final determination with regard to any change. Should the VA Contracting Officer implement any change(s) in Medicare rates under this contract, the Offeror shall accept all corresponding adjustments for the time period in which they are effective. All changes will be made via a modification to the contract and task order.End of ClausePeriod of Performance: BASE: _July 22, 2016 ___ to ___July 21, 2017____Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionEst.Qty.UnitProposed Unit CostCMS Unit costEst.Total CostOrthopedics000120551Inj tendon origin/insertion1EACH$__________$___________$_______________000220610Drain/inject joint/bursa2EACH$__________$___________$_______________000320670Removal of support implant1EACH$__________$___________$_______________000423120Partial removal collar bone5EACH$__________$___________$_______________000523130Remove shoulder bone part1EACH$__________$___________$_______________000623412Repair rotator cuff chronic3EACH$__________$___________$_______________000723430Repair biceps tendon12EACH$__________$___________$_______________000823700Fixation of shoulder1EACH$__________$___________$_______________000924000Exploratory elbow surgery1EACH$__________$___________$_______________001024006Release elbow joint8EACH$__________$___________$_______________001124075Exc arm/elbow les sc < 3 cm1EACH$__________$___________$_______________001224105Removal of elbow bursa1EACH$__________$___________$_______________001324147Partial removal of elbow2EACH$__________$___________$_______________001424341Repair arm tendon/muscle1EACH$__________$___________$_______________001524342Repair of ruptured tendon1EACH$__________$___________$_______________001624358Repair elbow w/deb open1EACH$__________$___________$_______________001724359Repair elbow deb/attch open1EACH$__________$___________$_______________001826115Exc hand les sc < 1.5 cm1EACH$__________$___________$_______________001926123Release palm contracture1EACH$__________$___________$_______________002026340Manipulate finger w/anesth1EACH$__________$___________$_______________002126607Treat metacarpal fracture10EACH$__________$___________$_______________002226765Treat finger fracture each1EACH$__________$___________$_______________002327340Removal of kneecap bursa1EACH$__________$___________$_______________002427347Remove knee cyst1EACH$__________$___________$_______________002527385Repair of thigh muscle1EACH$__________$___________$_______________002627420Fixation of shoulder1EACH$__________$___________$_______________002727422Revision of unstable kneecap1EACH$__________$___________$_______________002827427Reconstruction knee1EACH$__________$___________$_______________002927570Fixation of knee joint3EACH$__________$___________$_______________003027600Decompression of lower leg2EACH$__________$___________$_______________003127618Exc leg/ankle tum < 3cm1EACH$__________$___________$_______________003227634Exc leg/ankle tum dep 5 cm/>1EACH$__________$___________$_______________003327635Remove lower leg bone lesion1EACH$__________$___________$_______________003429805Shoulder arthroscopy dx1EACH$__________$___________$_______________003529806Shoulder arthroscopy surgery1EACH$__________$___________$_______________003629807Shoulder arthroscopy surgery8EACH$__________$___________$_______________003729820Shoulder arthroscopy/surgery1EACH$__________$___________$_______________003829822Shoulder arthroscopy/surgery18EACH$__________$___________$_______________003929823Shoulder arthroscopy/surgery8EACH$__________$___________$_______________004029824Shoulder arthroscopy/surgery8EACH$__________$___________$_______________004129825Shoulder arthroscopy/surgery6EACH$__________$___________$_______________004229827Arthroscop rotator cuff repr40EACH$__________$___________$_______________004329828Arthroscopy biceps tenodesis8EACH$__________$___________$_______________004429870Knee arthroscopy dx4EACH$__________$___________$_______________004529873Knee arthroscopy/surgery2EACH$__________$___________$_______________004629874Knee arthroscopy/surgery2EACH$__________$___________$_______________004729875Knee arthroscopy/surgery4EACH$__________$___________$_______________004829877Knee arthroscopy/surgery9EACH$__________$___________$_______________004929880Knee arthroscopy/surgery5EACH$__________$___________$_______________005029881Knee arthroscopy/surgery46EACH$__________$___________$_______________005129888Knee arthroscopy/surgery9EACH$__________$___________$_______________005264708Revise arm/leg nerve1EACH$__________$___________$_______________005364721Carpal tunnel surgery8EACH$__________$___________$_______________005464722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Podiatry005520670Removal of support implant1EACH$__________$___________$_______________005620680Removal of support implant2EACH$__________$___________$_______________005727618Exc leg/ankle tum < 3 cm2EACH$__________$___________$_______________005827680Release of lower leg tendon2EACH$__________$___________$_______________005927698Repair of ankle ligament2EACH$__________$___________$______________006028008Incision of foot fascia2EACH$__________$___________$_______________006128043Exc foot/toe tum sc < 1.5 cm2EACH$__________$___________$_______________006228045Exc foot/toe tum deep < 1.5 cm1EACH$__________$___________$_______________006328080Repair lower leg tendons1EACH$__________$___________$_______________006428122Partial removal of foot bone1EACH$__________$___________$_______________006528285Repair of hammertoe7EACH$__________$___________$_______________006628288Partial removal of foot bone1EACH$__________$___________$_______________006728289Repair hallux rigidus2EACH$__________$___________$_______________006828293Correction of bunion4EACH$__________$___________$_______________006928296Correction of bunion4EACH$__________$___________$_______________007064722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Urology007110140Drainage of hematoma/fluid1EACH$__________$___________$_______________007253020Incision of uretha1EACH$__________$___________$_______________007354060Excision of penis lesion (s)1EACH$__________$___________$_______________007454111Treat penis lesion graft1EACH$__________$___________$_______________007554112Treat penis lesion graft1EACH$__________$___________$_______________007654161Circum 28 days or older1EACH$__________$___________$_______________007754360Penis plastic surgery5EACH$__________$___________$_______________007854400Insert semi-rigid prosthesis8EACH$__________$___________$_______________007954405Insert multi-comp penis pros35EACH$__________$___________$_______________008054406Revmove multi-comp penis pros1EACH$__________$___________$_______________008154408Repair multi-comp penis pro3EACH$__________$___________$_______________008254410Remove/replace penis prosth4EACH$__________$___________$_______________008354520Removal of testis1EACH$__________$___________$_______________008454700Drainage of scrotum1EACH$__________$___________$_______________008554840Remove epididymus lesion6EACH$__________$___________$_______________008654860Removal of epididymis4EACH$__________$___________$______________008755040Removal of hydroceles16EACH$__________$___________$_______________008855175Revision of scrotum1EACH$__________$___________$_______________008955250Removal of sperm duct(s)1EACH$__________$___________$_______________009055400Removal of sperm duct14EACH$__________$___________$_______________009155530Revise spermatic cord veins2EACH$__________$___________$_______________009264425N block inj ilio-ing/hypogi1EACH$__________$___________$_______________Plastics009311100Biopsy skin lesion1EACH$__________$___________$_______________009411402Exc tr-ext b9+marg 1.1-2 cm7EACH$__________$___________$________________009511422Exc h-f-nk-sp b9+marg 1.1-23EACH$__________$___________$________________009611440Exc face-mm-b9+marg 0.5 < cm5EACH$__________$___________$________________009711441Exc face-mm b9+marg 0.6-1cm1EACH$__________$___________$________________009811626Exc s/n/h/f/g mal+mrg > 4 cm1EACH$__________$___________$________________009911642Exc face-mm malig+marg 1.1-210EACH$__________$___________$_______________010011643Exc f/e/e/n/l mal+mrg 2.1-32EACH$__________$___________$________________010111646Exc face-mm mlg+marg > 4 cm4EACH$__________$___________$________________010211771Removal of pilonidal lesion1EACH$__________$___________$________________010312035Intmd wnd repair s/a/t/ext1EACH$__________$___________$________________010412044Intmd wnd repair n-hf/genit1EACH$__________$___________$________________010512051Intmd wnd repair face/mm1EACH$__________$___________$________________010612052Intmd wnd repair face/mm1EACH$__________$___________$________________010712053Intmd wnd repair face/mm1EACH$__________$___________$________________010813132Repair of wound or lesion1EACH$__________$___________$________________010914040Skin tissue rearrangement1EACH$__________$___________$________________011014060Skin tissue rearrangement1EACH$__________$___________$________________011115260Skin full graft een & lips35EACH$__________$___________$________________011215275Skin sub graft face/nk/hf/g2EACH$__________$___________$________________011315732Muscle-skin graft head/neck1EACH$__________$___________$_______________011415770Derma-fat-fascia graft1EACH$__________$___________$_______________011515839Excise excessive skin tissue2EACH$__________$___________$_______________011615878Suction assisted lipectomy1EACH$__________$___________$_______________011719300Removal of breast tissue1EACH$__________$___________$_______________011819318Reduction of large breast1EACH$__________$___________$_______________011921011Exc face les sc < 2 cm1EACH$__________$___________$_______________012021014Exc face tum deep 2 cm/>1EACH$__________$___________$_______________012125071Exc forearm les sc 3 cm/>1EACH$__________$___________$_______________Otolaryngology012221235Ear cartilage graft1EACH$__________$___________$_______________012330130Excise inferior turbinate4EACH$__________$___________$_______________012430140Resect inferior turbinate7EACH$__________$___________$_______________012530465Repair nasal stenosis3EACH$__________$___________$_______________012630520Repair of nasal septum18EACH$__________$___________$_______________012730930Ther fx nasal inf turbinate4EACH$__________$___________$_______________012831231Nasal endoscopy dx1EACH$__________$___________$_______________012931237Nasal/sinus endoscopy surg1EACH$__________$___________$_______________013031254Revision of ethmoid sinus4EACH$__________$___________$_______________013131255Removal of ethmoid sinus12EACH$__________$___________$_______________013231256Exploration maxillary sinus7EACH$__________$___________$_______________013331267Endoscopy maxillary sinus10EACH$__________$___________$_______________013431276Sinus endoscopy surgical16EACH$__________$___________$_______________013531287Nasal/sinus endoscopy surg5EACH$__________$___________$_______________013631288Nasal/sinus endoscopy surg4EACH$__________$___________$_______________013731295Sinus endo w/balloon dil1EACH$__________$___________$_______________013831296Sinus endo w/balloon dil1EACH$__________$___________$_______________013940818Excise oral mucosa for graft1EACH$__________$___________$_______________014042826Removal of tonsils1EACH$__________$___________$_______________014169436Create eardrum opening1EACH$__________$___________$_______________Ophthalmology014215820Revision of lower eyelid2EACH$__________$___________$_______________014315821Revision of lower eyelid6EACH$__________$___________$_______________014415822Revision of lower eyelid20EACH$__________$___________$_______________014515823Revision of lower eyelid30EACH$__________$___________$_______________014621390Treat eye socket fracture1EACH$__________$___________$_______________014765105Remove eye/attach implant1EACH$__________$___________$_______________014865130Insert ocular implant2EACH$__________$___________$_______________014966183Insert ant drainage device4EACH$__________$___________$_______________015066825Reposition intraocular lens1EACH$__________$__________$_______________015166840Removal of lens material2EACH$__________$__________$_______________015266982Cataract surgery complex52EACH$__________$__________$_______________015366984Cataract surg w/iol 1 stage720EACH$__________$__________$_______________015467412Explore/treat eye socket2EACH$__________$__________$_______________015567808Remove eyelid lesion(s)1EACH$__________$__________$_______________015667810Biopsy of eyelid4EACH$__________$__________$_______________015767825Revise eyelashes1EACH$__________$__________$_______________015867835Revise eyelashes1EACH$__________$__________$_______________015967840Remove eyelid lesion5EACH$__________$__________$_______________016067875Closure of eyelid by suture5EACH$__________$__________$_______________016167900Repair brow defect35EACH$__________$__________$_______________016267901Repair eyelid defect1EACH$__________$__________$_______________016367904Repair eyelid defect98EACH$__________$__________$_______________016467908Repair eyelid defect4EACH$__________$__________$_______________016567914Repair eyelid defect1EACH$__________$__________$_______________016667917Repair eyelid defect60EACH$__________$__________$_______________016767921Repair eyelid defect5EACH$__________$__________$_______________016867923Repair eyelid defect5EACH$__________$__________$_______________016967924Repair eyelid defect8EACH$__________$__________$_______________017067950Revision of eyelid2EACH$__________$__________$_______________017167961Revision of eyelid1EACH$__________$__________$_______________017267971Reconstruction of eyelid1EACH$__________$__________$_______________017368110Remove eyelid lining lesion1EACH$__________$__________$_______________017468320Revise/graft eyelid lining9EACH$__________$__________$_______________017568330Revise eyelid lining6EACH$__________$__________$_______________017668340Separate eyelid adhesions1EACH$__________$__________$_______________017768720Create tear sac drain2EACH$__________$__________$_______________017868770Close tear system fistula1EACH$__________$__________$_______________017968810Probe nasolacrimal duct1EACH$__________$__________$_______________018068815Probe nasolacrimal duct5EACH$__________$__________$_______________General Surgery018138500Lymph node excisions1EACH$__________$__________$_______________018238745Anoscopy and biopsy1EACH$__________$__________$_______________018346606Anoscopy and biopsy1EACH$__________$__________$_______________018449505prp i/hern init reduc >5 yr2EACH$__________$__________$_______________018549950Rpr rem hernia init reduce5EACH$__________$__________$_______________Surgical Pathology018688304Level III Surgical pathology, gross and microscopic2EACH$__________$__________$_______________018788305Level IV surgical pathology, gross and microscopic26EACH$__________$__________$_______________018888331Intraoperative pathology exam with frozen section19EACH$__________$__________$_______________018988332Intraoperative pathology exam with frozen section24EACH$__________$__________$_______________Total Cost for Ambulatory Surgery Procedures Base Year $_________________________Anesthesia Services for Associated Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionAnesthesia CodeEst.Qty.Medicare Expected Anesthesia Per Unit Reimbursement Rate by Specialty% of discountOffered Anesthesia Per Unit Reimbursement Rate by Specialty (Unit Rate)Medicare Anesthesia Base Unit Value per Anesthesia Code (Base Units)National AVG Anesthesia Time Units (15 minute increments) per Anesthesia Code (Time Units)(Base Units + Time Units) x Unit Rate =(Unit Cost)Total Estimated Unit Cost Per YearOrthopedics019020551Inj tendon origin/insertion000001$___________%$________________$________$________019120610Drain/inject joint/bursa016302$___________%$________________$________$________019220670Removal of support implant016201$___________%$________________$________$________019323120Partial removal collar bone004505$___________%$________________$________$________019423130Remove shoulder bone part016301$___________%$________________$________$________019523412Repair rotator cuff chronic016303$___________%$________________$________$________019623430Repair biceps tendon0163012$___________%$________________$________$________019723700Fixation of shoulder016201$___________%$________________$________$________019824000Exploratory elbow surgery017401$___________%$________________$________$________019924006Release elbow joint017408$___________%$________________$________$________020024075Exc arm/elbow les sc < 3 cm004001$___________%$________________$________$________020124105Removal of elbow bursa017101$___________%$________________$________$________020224147Partial removal of elbow017402$___________%$________________$________$________020324341Repair arm tendon/muscle017101$___________%$________________$________$________020424342Repair of ruptured tendon017101$___________%$________________$________$________020524358Repair elbow w/deb open01712-017161$___________%$________________$________$________020624359Repair elbow deb/attch open01712-017161$___________%$________________$________$________020726115Exc hand les sc < 1.5 cm018101$___________%$________________$________$________020826123Release palm contracture018101$___________%$________________$________$________020926340Manipulate finger w/anesth018201$___________%$________________$________$________021026607Treat metacarpal fracture0182010$___________%$________________$________$________021126765Treat finger fracture each018301$___________%$________________$________$________021227340Removal of kneecap bursa013201$___________%$________________$________$________021327347Remove knee cyst014001$___________%$________________$________$________021427385Repair of thigh muscle013201$___________%$________________$________$________021527420Fixation of shoulder013201$___________%$________________$________$________021627422Revision of unstable kneecap013201$___________%$________________$________$________021727427Reconstruction knee013201$___________%$________________$________$_______021827570Fixation of knee joint013803$___________%$________________$________$_______021927600Decompression of lower leg01470-014742$___________%_$________________$________$_______022027618Exc leg/ankle tum < 3cm004001$___________%$________________$________$_______022127634Exc leg/ankle tum dep 5 cm/>004001$___________%$________________$________$_______022227635Remove lower leg bone lesion01480-014861$___________%$________________$________$_______022329805Shoulder arthroscopy dx016221$___________%$________________$________$_______022429806Shoulder arthroscopy surgery016301$___________%$________________$________$_______022529807Shoulder arthroscopy surgery016308$___________%$________________$________$_______022629820Shoulder arthroscopy/surgery016301$___________%$________________$________$_______022729822Shoulder arthroscopy/surgery0163018$___________%$________________$________$_______022829823Shoulder arthroscopy/surgery016308$___________%$________________$________$_______022929824Shoulder arthroscopy/surgery016308$___________%$________________$________$_______023029825Shoulder arthroscopy/surgery016306$___________%$________________$________$_______023129827Arthroscop rotator cuff repr0163040$___________%$________________$________$_______023229828Arthroscopy biceps tenodesis016308$___________%$________________$________$_______023329870Knee arthroscopy dx013824$___________%$________________$________$_______023429873Knee arthroscopy/surgery014002$___________%$________________$________$_______023529874Knee arthroscopy/surgery014002$___________%$________________$________$_______023629875Knee arthroscopy/surgery014004$___________%$________________$________$_______023729877Knee arthroscopy/surgery014009$___________%$________________$________$_______023829880Knee arthroscopy/surgery014005$___________%$________________$________$_______023929881Knee arthroscopy/surgery0140046$___________%$________________$________$_______024029888Knee arthroscopy/surgery014009$___________%$________________$________$_______024164708Revise arm/leg nerve01470-014741$___________%$________________$________$_______024264721Carpal tunnel surgery018108$___________%$________________$________$_______024364722Relieve pressure on nerve(s)01470-014741$___________%$________________$________$_______Podiatry024420670Removal of support implant018201$___________%$________________$________$_______024520680Removal of support implant018302$___________%$________________$________$_______024627618Exc leg/ankle tum < 3 cm004002$___________%$________________$________$_______024727680Release of lower leg tendon01470-014742$___________%$________________$________$_______024827698Repair of ankle ligament01470-014742$___________%$________________$________$_______024928008Incision of foot fascia01470-014742$___________%$________________$________$_______025028043Exc foot/toe tum sc < 1.5 cm01470-014742$___________%$________________$________$_______025128045Exc foot/toe tum deep < 1.5 cm01470-014741$___________%$________________$________$_______025228080Repair lower leg tendons01470-014741$___________%$________________$________$_______025328122Partial removal of foot bone01480-014861$___________%$________________$________$_______025428285Repair of hammertoe014807$___________%$________________$________$_______025528288Partial removal of foot bone014801$___________%$________________$________$_______025628289Repair hallux rigidus01480-014862$___________%$________________$________$_______025728293Correction of bunion01480-014864$___________%$________________$________$_______025828296Correction of bunion01480-014864$___________%$________________$________$_______025964722Relieve pressure on nerve(s)016101$___________%$________________$________$_______Urology026010140Drainage of hematoma/fluid003001$___________%$________________$_______$_______026153020Incision of uretha009201$___________%$________________$_______$_______026254060Excision of penis lesion (s)009201$___________%$________________$_______$_______026354111Treat penis lesion graft009201$___________%$________________$_______$_______026454112Treat penis lesion graft009201$___________%$________________$_______$_______026554161Circum 28 days or older009201$___________%$________________$_______$_______026654360Penis plastic surgery009205$___________%$________________$_______$_______026754400Insert semi-rigid prosthesis009388$___________%$________________$_______$_______026854405Insert multi-comp penis pros0093835$___________%$________________$_______$_______026954406Revmove multi-comp penis pros009201$___________%$________________$_______$_______027054408Repair multi-comp penis pro009203$___________%$________________$_______$_______027154410Remove/replace penis prosth009384$___________%$________________$_______$_______027254520Removal of testis009201$___________%$________________$_______$_______027354700Drainage of scrotum009201$___________%$________________$_______$_______027454840Remove epididymus lesion009206$___________%$________________$_______$_______027554860Removal of epididymis009204$___________%$________________$_______$_______027655040Removal of hydroceles0092016$___________%$________________$_______$_______027755175Revision of scrotum009201$___________%$________________$_______$_______027855250Removal of sperm duct(s)00921-009221$___________%$________________$_______$_______027955400Removal of sperm duct0092014$___________%$________________$_______$_______028055530Revise spermatic cord veins009202$___________%$________________$_______$_______028164425N block inj ilio-ing/hypogi000001$___________%$________________$_______$_______Plastics028211100Biopsy skin lesion003001$___________%$________________$_______$_______028311402Exc tr-ext b9+marg 1.1-2 cm003007$___________%$________________$_______$_______028411422Exc h-f-nk-sp b9+marg 1.1-2003003$___________%$________________$_______$_______028511440Exc face-mm-b9+marg 0.5 < cm003005$___________%$________________$_______$_______028611441Exc face-mm b9+marg 0.6-1cm003001$___________%$________________$_______$_______028711626Exc s/n/h/f/g mal+mrg > 4 cm003001$___________%$________________$_______$_______028811642Exc face-mm malig+marg 1.1-20030010$___________%$________________$_______$_______028911643Exc f/e/e/n/l mal+mrg 2.1-3003002$___________%$________________$_______$_______029011646Exc face-mm mlg+marg > 4 cm003004$___________%$________________$_______$_______029111771Removal of pilonidal lesion003001$___________%$________________$_______$_______029212035Intmd wnd repair s/a/t/ext003001$___________%$________________$_______$_______029312044Intmd wnd repair n-hf/genit003001$___________%$________________$_______$_______029412051Intmd wnd repair face/mm003001$___________%$________________$_______$_______029512052Intmd wnd repair face/mm003001$___________%$________________$_______$_______029612053Intmd wnd repair face/mm003001$___________%$________________$_______$_______029713132Repair of wound or lesion003001$___________%$________________$_______$_______029814040Skin tissue rearrangement003001$___________%$________________$_______$_______029914060Skin tissue rearrangement003001$___________%$________________$_______$_______030015260Skin full graft een & lips0030035$___________%$________________$_______$_______030115275Skin sub graft face/nk/hf/g003002$___________%$________________$_______$_______030215732Muscle-skin graft head/neck003001$___________%$________________$_______$_______030315770Derma-fat-fascia graft003001$___________%$________________$_______$_______030415839Excise excessive skin tissue003002$___________%$________________$_______$_______030515878Suction assisted lipectomy004001$___________%$________________$_______$_______030619300Removal of breast tissue004001$___________%$________________$_______$_______030719318Reduction of large breast004021$___________%$________________$_______$_______030821011Exc face les sc < 2 cm003001$___________%$________________$_______$_______030921014Exc face tum deep 2 cm/>003001$___________%$________________$_______$_______031025071Exc forearm les sc 3 cm/>004001$___________%$________________$_______$_______Otolaryngology031121235Ear cartilage graft00120-001261$___________%$________________$_______$_______031230130Excise inferior turbinate00160-001644$___________%$________________$_______$_______031330140Resect inferior turbinate00160-001647$___________%$________________$_______$_______031430465Repair nasal stenosis00160-001643$___________%$________________$_______$_______031530520Repair of nasal septum00160-0016418$___________%$________________$_______$_______031630930Ther fx nasal inf turbinate00160-001644$___________%$________________$_______$_______031731231Nasal endoscopy dx00160-001641$___________%$________________$_______$_______031831237Nasal/sinus endoscopy surg00160-001641$___________%$________________$_______$_______031931254Revision of ethmoid sinus00160-001644$___________%$________________$_______$_______032031255Removal of ethmoid sinus00160-0016412$___________%$________________$_______$_______032131256Exploration maxillary sinus00160-001647$___________%$________________$_______$_______032231267Endoscopy maxillary sinus00160-0016410$___________%$________________$_______$_______032331276Sinus endoscopy surgical00160-0016416$___________%$________________$_______$_______032431287Nasal/sinus endoscopy surg00160-001645$___________%$________________$_______$_______032531288Nasal/sinus endoscopy surg00160-001644$___________%$________________$_______$_______032631295Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______032731296Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______032840818Excise oral mucosa for graft001701$___________%$________________$_______$_______032942826Removal of tonsils001701$___________%$________________$_______$_______033069436Create eardrum opening00120-001261$___________%$________________$_______$_______Ophthalmology033115820Revision of lower eyelid001032$___________%$________________$_______$_______033215821Revision of lower eyelid001036$___________%$________________$_______$_______033315822Revision of lower eyelid0010320$___________%$________________$_______$_______033415823Revision of lower eyelid0010330$___________%$________________$_______$_______033521390Treat eye socket fracture00190-001921$___________%$________________$_______$_______033665105Remove eye/attach implant00140-001481$___________%$________________$_______$_______033765130Insert ocular implant00140-001482$___________%$________________$_______$_______033866183Insert ant drainage device00140-001484$___________%$________________$_______$_______033966825Reposition intraocular lens00140-001481$___________%$________________$_______$_______034066840Removal of lens material00140-001482$___________%$________________$_______$_______034166982Cataract surgery complex00140-0014852$___________%$________________$_______$_______034266984Cataract surg w/iol 1 stage00140-00148720$___________%$________________$_______$_______034367412Explore/treat eye socket00140-001482$___________%$________________$_______$_______034467808Remove eyelid lesion(s)003001$___________%$________________$_______$_______034567810Biopsy of eyelid003004$___________%$________________$_______$_______034667825Revise eyelashes001031$___________%$________________$_______$_______034767835Revise eyelashes001031$___________%$________________$_______$_______034867840Remove eyelid lesion003005$___________%$________________$_______$_______034967875Closure of eyelid by suture003005$___________%$________________$_______$_______035067900Repair brow defect0030035$___________%$________________$_______$_______035167901Repair eyelid defect003001$___________%$________________$_______$_______035267904Repair eyelid defect0010398$___________%$________________$_______$_______035367908Repair eyelid defect001034$___________%$________________$_______$_______035467914Repair eyelid defect001031$___________%$________________$_______$_______035567917Repair eyelid defect0010360$___________%$________________$_______$_______035667921Repair eyelid defect001035$___________%$________________$_______$_______035767923Repair eyelid defect001035$___________%$________________$_______$_______035867924Repair eyelid defect001038$___________%$________________$_______$_______035967950Revision of eyelid001032$___________%$________________$_______$_______036067961Revision of eyelid001031$___________%$________________$_______$_______036167971Reconstruction of eyelid001031$___________%$________________$_______$_______036268110Remove eyelid lining lesion00140-001481$___________%$________________$_______$_______036368320Revise/graft eyelid lining00140-001489$___________%$________________$_______$_______036468330Revise eyelid lining00140-001486$___________%$________________$_______$_______036568340Separate eyelid adhesions00140-001481$___________%$________________$_______$_______036668720Create tear sac drain00140-001482$___________%$________________$_______$_______036768770Close tear system fistula00140-001481$___________%$________________$_______$_______036868810Probe nasolacrimal duct00140-001481$___________%$________________$_______$_______036968815Probe nasolacrimal duct00140-001485$___________%$________________$_______$_______General Surgery037038500Lymph node excisions003201$___________%$________________$_______$_______037138745Anoscopy and biopsy016101$___________%$________________$_______$_______037246606Anoscopy and biopsy009021$___________%$________________$_______$_______037349505prp i/hern init reduc >5 yr00830-008362$___________%$________________$_______$_______037449950Rpr rem hernia init reduce00830-008365$___________%$________________$_______$_______Surgical Pathology037588304Level III Surgical pathology, gross and microscopicN/A2$___________%$________________$_______$_______037688305Level IV surgical pathology, gross and microscopicN/A26$___________%$________________$_______$_______037788331Intraoperative pathology exam with frozen sectionN/A19$___________%$________________$_______$_______037888332Intraoperative pathology exam with frozen sectionN/A24$___________%$________________$_______$_______Total Cost for Anesthesia Services Base Year $_________________________Total Cost for Ambulatory Surgery Procedures + Anesthesia Services Base Year $______________Period of Performance: Option Year One (1): _July 22, 2017 ___ to ___July 21, 2018____Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionEst.Qty.UnitProposed Unit CostCMS Unit costEst.Total CostOrthopedics100120551Inj tendon origin/insertion1EACH$__________$___________$_______________100220610Drain/inject joint/bursa2EACH$__________$___________$_______________100320670Removal of support implant1EACH$__________$___________$_______________100423120Partial removal collar bone5EACH$__________$___________$_______________100523130Remove shoulder bone part1EACH$__________$___________$_______________100623412Repair rotator cuff chronic3EACH$__________$___________$_______________100723430Repair biceps tendon12EACH$__________$___________$_______________100823700Fixation of shoulder1EACH$__________$___________$_______________100924000Exploratory elbow surgery1EACH$__________$___________$_______________101024006Release elbow joint8EACH$__________$___________$_______________101124075Exc arm/elbow les sc < 3 cm1EACH$__________$___________$_______________101224105Removal of elbow bursa1EACH$__________$___________$_______________101324147Partial removal of elbow2EACH$__________$___________$_______________101424341Repair arm tendon/muscle1EACH$__________$___________$_______________101524342Repair of ruptured tendon1EACH$__________$___________$_______________101624358Repair elbow w/deb open1EACH$__________$___________$_______________101724359Repair elbow deb/attch open1EACH$__________$___________$_______________101826115Exc hand les sc < 1.5 cm1EACH$__________$___________$_______________101926123Release palm contracture1EACH$__________$___________$_______________102026340Manipulate finger w/anesth1EACH$__________$___________$_______________102126607Treat metacarpal fracture10EACH$__________$___________$_______________102226765Treat finger fracture each1EACH$__________$___________$_______________102327340Removal of kneecap bursa1EACH$__________$___________$_______________102427347Remove knee cyst1EACH$__________$___________$_______________102527385Repair of thigh muscle1EACH$__________$___________$_______________102627420Fixation of shoulder1EACH$__________$___________$_______________102727422Revision of unstable kneecap1EACH$__________$___________$_______________102827427Reconstruction knee1EACH$__________$___________$_______________102927570Fixation of knee joint3EACH$__________$___________$_______________103027600Decompression of lower leg2EACH$__________$___________$_______________103127618Exc leg/ankle tum < 3cm1EACH$__________$___________$_______________103227634Exc leg/ankle tum dep 5 cm/>1EACH$__________$___________$_______________103327635Remove lower leg bone lesion1EACH$__________$___________$_______________103429805Shoulder arthroscopy dx1EACH$__________$___________$_______________103529806Shoulder arthroscopy surgery1EACH$__________$___________$_______________103629807Shoulder arthroscopy surgery8EACH$__________$___________$_______________103729820Shoulder arthroscopy/surgery1EACH$__________$___________$_______________103829822Shoulder arthroscopy/surgery18EACH$__________$___________$_______________103929823Shoulder arthroscopy/surgery8EACH$__________$___________$_______________104029824Shoulder arthroscopy/surgery8EACH$__________$___________$_______________104129825Shoulder arthroscopy/surgery3EACH$__________$___________$_______________104229827Arthroscop rotator cuff repr40EACH$__________$___________$_______________104329828Arthroscopy biceps tenodesis8EACH$__________$___________$_______________104429870Knee arthroscopy dx4EACH$__________$___________$_______________104529873Knee arthroscopy/surgery2EACH$__________$___________$_______________104629874Knee arthroscopy/surgery2EACH$__________$___________$_______________104729875Knee arthroscopy/surgery4EACH$__________$___________$_______________104829877Knee arthroscopy/surgery9EACH$__________$___________$_______________104929880Knee arthroscopy/surgery5EACH$__________$___________$_______________105029881Knee arthroscopy/surgery46EACH$__________$___________$_______________105129888Knee arthroscopy/surgery9EACH$__________$___________$_______________105264708Revise arm/leg nerve1EACH$__________$___________$_______________105364721Carpal tunnel surgery8EACH$__________$___________$_______________105464722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Podiatry105520670Removal of support implant1EACH$__________$___________$_______________105620680Removal of support implant2EACH$__________$___________$_______________105727618Exc leg/ankle tum < 3 cm2EACH$__________$___________$_______________105827680Release of lower leg tendon2EACH$__________$___________$_______________105927698Repair of ankle ligament2EACH$__________$___________$______________106028008Incision of foot fascia2EACH$__________$___________$_______________106128043Exc foot/toe tum sc < 1.5 cm2EACH$__________$___________$_______________106228045Exc foot/toe tum deep < 1.5 cm1EACH$__________$___________$_______________106328080Repair lower leg tendons1EACH$__________$___________$_______________106428122Partial removal of foot bone1EACH$__________$___________$_______________106528285Repair of hammertoe7EACH$__________$___________$_______________106628288Partial removal of foot bone1EACH$__________$___________$_______________106728289Repair hallux rigidus2EACH$__________$___________$_______________106828293Correction of bunion4EACH$__________$___________$_______________106928296Correction of bunion4EACH$__________$___________$_______________107064722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Urology107110140Drainage of hematoma/fluid1EACH$__________$___________$_______________107253020Incision of uretha1EACH$__________$___________$_______________107354060Excision of penis lesion (s)1EACH$__________$___________$_______________107454111Treat penis lesion graft1EACH$__________$___________$_______________107554112Treat penis lesion graft1EACH$__________$___________$_______________107654161Circum 28 days or older1EACH$__________$___________$_______________107754360Penis plastic surgery5EACH$__________$___________$_______________107854400Insert semi-rigid prosthesis8EACH$__________$___________$_______________107954405Insert multi-comp penis pros35EACH$__________$___________$_______________108054406Revmove multi-comp penis pros1EACH$__________$___________$_______________108154408Repair multi-comp penis pro3EACH$__________$___________$_______________108254410Remove/replace penis prosth4EACH$__________$___________$_______________108354520Removal of testis1EACH$__________$___________$_______________108454700Drainage of scrotum1EACH$__________$___________$_______________108554840Remove epididymus lesion6EACH$__________$___________$_______________108654860Removal of epididymis4EACH$__________$___________$______________108755040Removal of hydroceles16EACH$__________$___________$_______________108855175Revision of scrotum1EACH$__________$___________$_______________108955250Removal of sperm duct(s)1EACH$__________$___________$_______________109055400Removal of sperm duct14EACH$__________$___________$_______________109155530Revise spermatic cord veins2EACH$__________$___________$_______________109264425N block inj ilio-ing/hypogi1EACH$__________$___________$_______________Plastics109311100Biopsy skin lesion1EACH$__________$___________$_______________109411402Exc tr-ext b9+marg 1.1-2 cm7EACH$__________$___________$________________109511422Exc h-f-nk-sp b9+marg 1.1-23EACH$__________$___________$________________109611440Exc face-mm-b9+marg 0.5 < cm5EACH$__________$___________$________________109711441Exc face-mm b9+marg 0.6-1cm1EACH$__________$___________$________________109811626Exc s/n/h/f/g mal+mrg > 4 cm1EACH$__________$___________$________________109911642Exc face-mm malig+marg 1.1-210EACH$__________$___________$_______________110011643Exc f/e/e/n/l mal+mrg 2.1-32EACH$__________$___________$________________110111646Exc face-mm mlg+marg > 4 cm4EACH$__________$___________$________________110211771Removal of pilonidal lesion1EACH$__________$___________$________________110312035Intmd wnd repair s/a/t/ext1EACH$__________$___________$________________110412044Intmd wnd repair n-hf/genit1EACH$__________$___________$________________110512051Intmd wnd repair face/mm1EACH$__________$___________$________________110612052Intmd wnd repair face/mm1EACH$__________$___________$________________110712053Intmd wnd repair face/mm1EACH$__________$___________$________________110813132Repair of wound or lesion1EACH$__________$___________$________________110914040Skin tissue rearrangement1EACH$__________$___________$________________111014060Skin tissue rearrangement1EACH$__________$___________$________________111115260Skin full graft een & lips35EACH$__________$___________$________________111215275Skin sub graft face/nk/hf/g2EACH$__________$___________$________________111315732Muscle-skin graft head/neck1EACH$__________$___________$_______________111415770Derma-fat-fascia graft1EACH$__________$___________$_______________111515839Excise excessive skin tissue2EACH$__________$___________$_______________111615878Suction assisted lipectomy1EACH$__________$___________$_______________111719300Removal of breast tissue1EACH$__________$___________$_______________111819318Reduction of large breast1EACH$__________$___________$_______________111921011Exc face les sc < 2 cm1EACH$__________$___________$_______________112021014Exc face tum deep 2 cm/>1EACH$__________$___________$_______________112125071Exc forearm les sc 3 cm/>1EACH$__________$___________$_______________Otolaryngology112221235Ear cartilage graft1EACH$__________$___________$_______________112330130Excise inferior turbinate4EACH$__________$___________$_______________112430140Resect inferior turbinate7EACH$__________$___________$_______________112530465Repair nasal stenosis3EACH$__________$___________$_______________112630520Repair of nasal septum18EACH$__________$___________$_______________112730930Ther fx nasal inf turbinate4EACH$__________$___________$_______________112831231Nasal endoscopy dx1EACH$__________$___________$_______________112931237Nasal/sinus endoscopy surg1EACH$__________$___________$_______________113031254Revision of ethmoid sinus4EACH$__________$___________$_______________113131255Removal of ethmoid sinus12EACH$__________$___________$_______________113231256Exploration maxillary sinus7EACH$__________$___________$_______________113331267Endoscopy maxillary sinus10EACH$__________$___________$_______________113431276Sinus endoscopy surgical16EACH$__________$___________$_______________113531287Nasal/sinus endoscopy surg5EACH$__________$___________$_______________113631288Nasal/sinus endoscopy surg4EACH$__________$___________$_______________113731295Sinus endo w/balloon dil1EACH$__________$___________$_______________113831296Sinus endo w/balloon dil1EACH$__________$___________$_______________113940818Excise oral mucosa for graft1EACH$__________$___________$_______________114042826Removal of tonsils1EACH$__________$___________$_______________114169436Create eardrum opening1EACH$__________$___________$_______________Ophthalmology114215820Revision of lower eyelid2EACH$__________$___________$_______________114315821Revision of lower eyelid6EACH$__________$___________$_______________114415822Revision of lower eyelid20EACH$__________$___________$_______________114515823Revision of lower eyelid30EACH$__________$___________$_______________114621390Treat eye socket fracture1EACH$__________$___________$_______________114765105Remove eye/attach implant1EACH$__________$___________$_______________114865130Insert ocular implant2EACH$__________$___________$_______________114966183Insert ant drainage device4EACH$__________$___________$_______________115066825Reposition intraocular lens1EACH$__________$__________$_______________115166840Removal of lens material2EACH$__________$__________$_______________115266982Cataract surgery complex52EACH$__________$__________$_______________115366984Cataract surg w/iol 1 stage720EACH$__________$__________$_______________115467412Explore/treat eye socket2EACH$__________$__________$_______________115567808Remove eyelid lesion(s)1EACH$__________$__________$_______________115667810Biopsy of eyelid4EACH$__________$__________$_______________115767825Revise eyelashes1EACH$__________$__________$_______________115867835Revise eyelashes1EACH$__________$__________$_______________115967840Remove eyelid lesion5EACH$__________$__________$_______________116067875Closure of eyelid by suture5EACH$__________$__________$_______________116167900Repair brow defect35EACH$__________$__________$_______________116267901Repair eyelid defect1EACH$__________$__________$_______________116367904Repair eyelid defect98EACH$__________$__________$_______________116467908Repair eyelid defect4EACH$__________$__________$_______________116567914Repair eyelid defect1EACH$__________$__________$_______________116667917Repair eyelid defect60EACH$__________$__________$_______________116767921Repair eyelid defect5EACH$__________$__________$_______________116867923Repair eyelid defect5EACH$__________$__________$_______________116967924Repair eyelid defect8EACH$__________$__________$_______________117067950Revision of eyelid2EACH$__________$__________$_______________117167961Revision of eyelid1EACH$__________$__________$_______________117267971Reconstruction of eyelid1EACH$__________$__________$_______________117368110Remove eyelid lining lesion1EACH$__________$__________$_______________117468320Revise/graft eyelid lining9EACH$__________$__________$_______________117568330Revise eyelid lining6EACH$__________$__________$_______________117668340Separate eyelid adhesions1EACH$__________$__________$_______________117768720Create tear sac drain2EACH$__________$__________$_______________117868770Close tear system fistula1EACH$__________$__________$_______________117968810Probe nasolacrimal duct1EACH$__________$__________$_______________118068815Probe nasolacrimal duct5EACH$__________$__________$_______________General Surgery118138500Lymph node excisions1EACH$__________$__________$_______________118238745Anoscopy and biopsy1EACH$__________$__________$_______________118346606Anoscopy and biopsy1EACH$__________$__________$_______________118449505prp i/hern init reduc >5 yr2EACH$__________$__________$_______________118549950Rpr rem hernia init reduce5EACH$__________$__________$_______________Surgical Pathology118688304Level III Surgical pathology, gross and microscopic2EACH$__________$__________$_______________118788305Level IV surgical pathology, gross and microscopic26EACH$__________$__________$_______________118888331Intraoperative pathology exam with frozen section19EACH$__________$__________$_______________118988332Intraoperative pathology exam with frozen section24EACH$__________$__________$_______________Total Cost for Ambulatory Surgery Procedures Option Year One (1) $_________________________Anesthesia Services for Associated Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionAnesthesia CodeEst.Qty.Medicare Expected Anesthesia Per Unit Reimbursement Rate by Specialty% of discountOffered Anesthesia Per Unit Reimbursement Rate by Specialty (Unit Rate)Medicare Anesthesia Base Unit Value per Anesthesia Code (Base Units)National AVG Anesthesia Time Units (15 minute increments) per Anesthesia Code (Time Units)(Base Units + Time Units) x Unit Rate =(Unit Cost)Total Estimated Unit Cost Per YearOrthopedics119020551Inj tendon origin/insertion000001$___________%$________________$________$________119120610Drain/inject joint/bursa016302$___________%$________________$________$________119220670Removal of support implant016201$___________%$________________$________$________119323120Partial removal collar bone004505$___________%$________________$________$________119423130Remove shoulder bone part016301$___________%$________________$________$________119523412Repair rotator cuff chronic016303$___________%$________________$________$________119623430Repair biceps tendon0163012$___________%$________________$________$________119723700Fixation of shoulder016201$___________%$________________$________$________119824000Exploratory elbow surgery017401$___________%$________________$________$________119924006Release elbow joint017408$___________%$________________$________$________120024075Exc arm/elbow les sc < 3 cm004001$___________%$________________$________$________120124105Removal of elbow bursa017101$___________%$________________$________$________120224147Partial removal of elbow017402$___________%$________________$________$________120324341Repair arm tendon/muscle017101$___________%$________________$________$________120424342Repair of ruptured tendon017101$___________%$________________$________$________120524358Repair elbow w/deb open01712-017161$___________%$________________$________$________120624359Repair elbow deb/attch open01712-017161$___________%$________________$________$________120726115Exc hand les sc < 1.5 cm018101$___________%$________________$________$________120826123Release palm contracture018101$___________%$________________$________$________120926340Manipulate finger w/anesth018201$___________%$________________$________$________121026607Treat metacarpal fracture0182010$___________%$________________$________$________121126765Treat finger fracture each018301$___________%$________________$________$________121227340Removal of kneecap bursa013201$___________%$________________$________$________121327347Remove knee cyst014001$___________%$________________$________$________121427385Repair of thigh muscle013201$___________%$________________$________$________121527420Fixation of shoulder013201$___________%$________________$________$________121627422Revision of unstable kneecap013201$___________%$________________$________$________121727427Reconstruction knee013201$___________%$________________$________$_______121827570Fixation of knee joint013803$___________%$________________$________$_______121927600Decompression of lower leg01470-014742$___________%_$________________$________$_______122027618Exc leg/ankle tum < 3cm004001$___________%$________________$________$_______122127634Exc leg/ankle tum dep 5 cm/>004001$___________%$________________$________$_______122227635Remove lower leg bone lesion01480-014861$___________%$________________$________$_______122329805Shoulder arthroscopy dx016221$___________%$________________$________$_______122429806Shoulder arthroscopy surgery016301$___________%$________________$________$_______122529807Shoulder arthroscopy surgery016308$___________%$________________$________$_______122629820Shoulder arthroscopy/surgery016301$___________%$________________$________$_______122729822Shoulder arthroscopy/surgery0163018$___________%$________________$________$_______122829823Shoulder arthroscopy/surgery016308$___________%$________________$________$_______122929824Shoulder arthroscopy/surgery016308$___________%$________________$________$_______123029825Shoulder arthroscopy/surgery016306$___________%$________________$________$_______123129827Arthroscop rotator cuff repr0163040$___________%$________________$________$_______123229828Arthroscopy biceps tenodesis016308$___________%$________________$________$_______123329870Knee arthroscopy dx013824$___________%$________________$________$_______123429873Knee arthroscopy/surgery014002$___________%$________________$________$_______123529874Knee arthroscopy/surgery014002$___________%$________________$________$_______123629875Knee arthroscopy/surgery014004$___________%$________________$________$_______123729877Knee arthroscopy/surgery014009$___________%$________________$________$_______123829880Knee arthroscopy/surgery014005$___________%$________________$________$_______123929881Knee arthroscopy/surgery0140046$___________%$________________$________$_______124029888Knee arthroscopy/surgery014009$___________%$________________$________$_______124164708Revise arm/leg nerve01470-014741$___________%$________________$________$_______124264721Carpal tunnel surgery018108$___________%$________________$________$_______124364722Relieve pressure on nerve(s)01470-014741$___________%$________________$________$_______Podiatry124420670Removal of support implant018201$___________%$________________$________$_______124520680Removal of support implant018302$___________%$________________$________$_______124627618Exc leg/ankle tum < 3 cm004002$___________%$________________$________$_______124727680Release of lower leg tendon01470-014742$___________%$________________$________$_______124827698Repair of ankle ligament01470-014742$___________%$________________$________$_______124928008Incision of foot fascia01470-014742$___________%$________________$________$_______125028043Exc foot/toe tum sc < 1.5 cm01470-014742$___________%$________________$________$_______125128045Exc foot/toe tum deep < 1.5 cm01470-014741$___________%$________________$________$_______125228080Repair lower leg tendons01470-014741$___________%$________________$________$_______125328122Partial removal of foot bone01480-014861$___________%$________________$________$_______125428285Repair of hammertoe014807$___________%$________________$________$_______125528288Partial removal of foot bone014801$___________%$________________$________$_______125628289Repair hallux rigidus01480-014862$___________%$________________$________$_______125728293Correction of bunion01480-014864$___________%$________________$________$_______125828296Correction of bunion01480-014864$___________%$________________$________$_______125964722Relieve pressure on nerve(s)016101$___________%$________________$________$_______Urology126010140Drainage of hematoma/fluid003001$___________%$________________$_______$_______126153020Incision of uretha009201$___________%$________________$_______$_______126254060Excision of penis lesion (s)009201$___________%$________________$_______$_______126354111Treat penis lesion graft009201$___________%$________________$_______$_______126454112Treat penis lesion graft009201$___________%$________________$_______$_______126554161Circum 28 days or older009201$___________%$________________$_______$_______126654360Penis plastic surgery009205$___________%$________________$_______$_______126754400Insert semi-rigid prosthesis009388$___________%$________________$_______$_______126854405Insert multi-comp penis pros0093835$___________%$________________$_______$_______126954406Revmove multi-comp penis pros009201$___________%$________________$_______$_______127054408Repair multi-comp penis pro009203$___________%$________________$_______$_______127154410Remove/replace penis prosth009384$___________%$________________$_______$_______127254520Removal of testis009201$___________%$________________$_______$_______127354700Drainage of scrotum009201$___________%$________________$_______$_______127454840Remove epididymus lesion009206$___________%$________________$_______$_______127554860Removal of epididymis009204$___________%$________________$_______$_______127655040Removal of hydroceles0092016$___________%$________________$_______$_______127755175Revision of scrotum009201$___________%$________________$_______$_______127855250Removal of sperm duct(s)00921-009221$___________%$________________$_______$_______127955400Removal of sperm duct0092014$___________%$________________$_______$_______128055530Revise spermatic cord veins009202$___________%$________________$_______$_______128164425N block inj ilio-ing/hypogi000001$___________%$________________$_______$_______Plastics128211100Biopsy skin lesion003001$___________%$________________$_______$_______128311402Exc tr-ext b9+marg 1.1-2 cm003007$___________%$________________$_______$_______128411422Exc h-f-nk-sp b9+marg 1.1-2003003$___________%$________________$_______$_______128511440Exc face-mm-b9+marg 0.5 < cm003005$___________%$________________$_______$_______128611441Exc face-mm b9+marg 0.6-1cm003001$___________%$________________$_______$_______128711626Exc s/n/h/f/g mal+mrg > 4 cm003001$___________%$________________$_______$_______128811642Exc face-mm malig+marg 1.1-20030010$___________%$________________$_______$_______128911643Exc f/e/e/n/l mal+mrg 2.1-3003002$___________%$________________$_______$_______129011646Exc face-mm mlg+marg > 4 cm003004$___________%$________________$_______$_______129111771Removal of pilonidal lesion003001$___________%$________________$_______$_______129212035Intmd wnd repair s/a/t/ext003001$___________%$________________$_______$_______129312044Intmd wnd repair n-hf/genit003001$___________%$________________$_______$_______129412051Intmd wnd repair face/mm003001$___________%$________________$_______$_______129512052Intmd wnd repair face/mm003001$___________%$________________$_______$_______129612053Intmd wnd repair face/mm003001$___________%$________________$_______$_______129713132Repair of wound or lesion003001$___________%$________________$_______$_______129814040Skin tissue rearrangement003001$___________%$________________$_______$_______129914060Skin tissue rearrangement003001$___________%$________________$_______$_______130015260Skin full graft een & lips0030035$___________%$________________$_______$_______130115275Skin sub graft face/nk/hf/g003002$___________%$________________$_______$_______130215732Muscle-skin graft head/neck003001$___________%$________________$_______$_______130315770Derma-fat-fascia graft003001$___________%$________________$_______$_______130415839Excise excessive skin tissue003002$___________%$________________$_______$_______130515878Suction assisted lipectomy004001$___________%$________________$_______$_______130619300Removal of breast tissue004001$___________%$________________$_______$_______130719318Reduction of large breast004021$___________%$________________$_______$_______130821011Exc face les sc < 2 cm003001$___________%$________________$_______$_______130921014Exc face tum deep 2 cm/>003001$___________%$________________$_______$_______131025071Exc forearm les sc 3 cm/>004001$___________%$________________$_______$_______Otolaryngology131121235Ear cartilage graft00120-001261$___________%$________________$_______$_______131230130Excise inferior turbinate00160-001644$___________%$________________$_______$_______131330140Resect inferior turbinate00160-001647$___________%$________________$_______$_______131430465Repair nasal stenosis00160-001643$___________%$________________$_______$_______131530520Repair of nasal septum00160-0016418$___________%$________________$_______$_______131630930Ther fx nasal inf turbinate00160-001644$___________%$________________$_______$_______131731231Nasal endoscopy dx00160-001641$___________%$________________$_______$_______131831237Nasal/sinus endoscopy surg00160-001641$___________%$________________$_______$_______131931254Revision of ethmoid sinus00160-001644$___________%$________________$_______$_______132031255Removal of ethmoid sinus00160-0016412$___________%$________________$_______$_______132131256Exploration maxillary sinus00160-001647$___________%$________________$_______$_______132231267Endoscopy maxillary sinus00160-0016410$___________%$________________$_______$_______132331276Sinus endoscopy surgical00160-0016416$___________%$________________$_______$_______132431287Nasal/sinus endoscopy surg00160-001645$___________%$________________$_______$_______132531288Nasal/sinus endoscopy surg00160-001644$___________%$________________$_______$_______132631295Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______132731296Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______132840818Excise oral mucosa for graft001701$___________%$________________$_______$_______132942826Removal of tonsils001701$___________%$________________$_______$_______133069436Create eardrum opening00120-001261$___________%$________________$_______$_______Ophthalmology133115820Revision of lower eyelid001032$___________%$________________$_______$_______133215821Revision of lower eyelid001036$___________%$________________$_______$_______133315822Revision of lower eyelid0010320$___________%$________________$_______$_______133415823Revision of lower eyelid0010330$___________%$________________$_______$_______133521390Treat eye socket fracture00190-001921$___________%$________________$_______$_______133665105Remove eye/attach implant00140-001481$___________%$________________$_______$_______133765130Insert ocular implant00140-001482$___________%$________________$_______$_______133866183Insert ant drainage device00140-001484$___________%$________________$_______$_______133966825Reposition intraocular lens00140-001481$___________%$________________$_______$_______134066840Removal of lens material00140-001482$___________%$________________$_______$_______134166982Cataract surgery complex00140-0014852$___________%$________________$_______$_______134266984Cataract surg w/iol 1 stage00140-00148720$___________%$________________$_______$_______134367412Explore/treat eye socket00140-001482$___________%$________________$_______$_______134467808Remove eyelid lesion(s)003001$___________%$________________$_______$_______134567810Biopsy of eyelid003004$___________%$________________$_______$_______134667825Revise eyelashes001031$___________%$________________$_______$_______134767835Revise eyelashes001031$___________%$________________$_______$_______134867840Remove eyelid lesion003005$___________%$________________$_______$_______134967875Closure of eyelid by suture003005$___________%$________________$_______$_______135067900Repair brow defect0030035$___________%$________________$_______$_______135167901Repair eyelid defect003001$___________%$________________$_______$_______135267904Repair eyelid defect0010398$___________%$________________$_______$_______135367908Repair eyelid defect001034$___________%$________________$_______$_______135467914Repair eyelid defect001031$___________%$________________$_______$_______135567917Repair eyelid defect0010360$___________%$________________$_______$_______135667921Repair eyelid defect001035$___________%$________________$_______$_______135767923Repair eyelid defect001035$___________%$________________$_______$_______135867924Repair eyelid defect001038$___________%$________________$_______$_______135967950Revision of eyelid001032$___________%$________________$_______$_______136067961Revision of eyelid001031$___________%$________________$_______$_______136167971Reconstruction of eyelid001031$___________%$________________$_______$_______136268110Remove eyelid lining lesion00140-001481$___________%$________________$_______$_______136368320Revise/graft eyelid lining00140-001489$___________%$________________$_______$_______136468330Revise eyelid lining00140-001486$___________%$________________$_______$_______136568340Separate eyelid adhesions00140-001481$___________%$________________$_______$_______136668720Create tear sac drain00140-001482$___________%$________________$_______$_______136768770Close tear system fistula00140-001481$___________%$________________$_______$_______136868810Probe nasolacrimal duct00140-001481$___________%$________________$_______$_______136968815Probe nasolacrimal duct00140-001485$___________%$________________$_______$_______General Surgery137038500Lymph node excisions003201$___________%$________________$_______$_______137138745Anoscopy and biopsy016101$___________%$________________$_______$_______137246606Anoscopy and biopsy009021$___________%$________________$_______$_______137349505prp i/hern init reduc >5 yr00830-008362$___________%$________________$_______$_______137449950Rpr rem hernia init reduce00830-008365$___________%$________________$_______$_______Surgical Pathology137588304Level III Surgical pathology, gross and microscopicN/A2$___________%$________________$_______$_______137688305Level IV surgical pathology, gross and microscopicN/A26$___________%$________________$_______$_______137788331Intraoperative pathology exam with frozen sectionN/A19$___________%$________________$_______$_______137888332Intraoperative pathology exam with frozen sectionN/A24$___________%$________________$_______$_______Total Cost for Anesthesia Services Option Year One (1) $_________________________Total Cost for Ambulatory Surgery Procedures + Anesthesia Services Option Year One (1) $_____Period of Performance: Option Year Two (2): _July 22, 2018 ___ to ___July 21, 2019____Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionEst.Qty.UnitProposed Unit CostCMS Unit costEst.Total CostOrthopedics200120551Inj tendon origin/insertion1EACH$__________$___________$_______________200220610Drain/inject joint/bursa2EACH$__________$___________$_______________200320670Removal of support implant1EACH$__________$___________$_______________200423120Partial removal collar bone5EACH$__________$___________$_______________200523130Remove shoulder bone part1EACH$__________$___________$_______________200623412Repair rotator cuff chronic3EACH$__________$___________$_______________200723430Repair biceps tendon12EACH$__________$___________$_______________200823700Fixation of shoulder1EACH$__________$___________$_______________200924000Exploratory elbow surgery1EACH$__________$___________$_______________201024006Release elbow joint8EACH$__________$___________$_______________201124075Exc arm/elbow les sc < 3 cm1EACH$__________$___________$_______________201224105Removal of elbow bursa1EACH$__________$___________$_______________201324147Partial removal of elbow2EACH$__________$___________$_______________201424341Repair arm tendon/muscle1EACH$__________$___________$_______________201524342Repair of ruptured tendon1EACH$__________$___________$_______________201624358Repair elbow w/deb open1EACH$__________$___________$_______________201724359Repair elbow deb/attch open1EACH$__________$___________$_______________201826115Exc hand les sc < 1.5 cm1EACH$__________$___________$_______________201926123Release palm contracture1EACH$__________$___________$_______________202026340Manipulate finger w/anesth1EACH$__________$___________$_______________202126607Treat metacarpal fracture10EACH$__________$___________$_______________202226765Treat finger fracture each1EACH$__________$___________$_______________202327340Removal of kneecap bursa1EACH$__________$___________$_______________202427347Remove knee cyst1EACH$__________$___________$_______________202527385Repair of thigh muscle1EACH$__________$___________$_______________202627420Fixation of shoulder1EACH$__________$___________$_______________202727422Revision of unstable kneecap1EACH$__________$___________$_______________202827427Reconstruction knee1EACH$__________$___________$_______________202927570Fixation of knee joint3EACH$__________$___________$_______________203027600Decompression of lower leg2EACH$__________$___________$_______________203127618Exc leg/ankle tum < 3cm1EACH$__________$___________$_______________203227634Exc leg/ankle tum dep 5 cm/>1EACH$__________$___________$_______________203327635Remove lower leg bone lesion1EACH$__________$___________$_______________203429805Shoulder arthroscopy dx1EACH$__________$___________$_______________203529806Shoulder arthroscopy surgery1EACH$__________$___________$_______________203629807Shoulder arthroscopy surgery8EACH$__________$___________$_______________203729820Shoulder arthroscopy/surgery1EACH$__________$___________$_______________203829822Shoulder arthroscopy/surgery18EACH$__________$___________$_______________203929823Shoulder arthroscopy/surgery8EACH$__________$___________$_______________204029824Shoulder arthroscopy/surgery8EACH$__________$___________$_______________204129825Shoulder arthroscopy/surgery6EACH$__________$___________$_______________204229827Arthroscop rotator cuff repr40EACH$__________$___________$_______________204329828Arthroscopy biceps tenodesis8EACH$__________$___________$_______________204429870Knee arthroscopy dx4EACH$__________$___________$_______________204529873Knee arthroscopy/surgery2EACH$__________$___________$_______________204629874Knee arthroscopy/surgery2EACH$__________$___________$_______________204729875Knee arthroscopy/surgery4EACH$__________$___________$_______________204829877Knee arthroscopy/surgery9EACH$__________$___________$_______________204929880Knee arthroscopy/surgery5EACH$__________$___________$_______________205029881Knee arthroscopy/surgery46EACH$__________$___________$_______________205129888Knee arthroscopy/surgery9EACH$__________$___________$_______________205264708Revise arm/leg nerve1EACH$__________$___________$_______________205364721Carpal tunnel surgery8EACH$__________$___________$_______________205464722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Podiatry205520670Removal of support implant1EACH$__________$___________$_______________205620680Removal of support implant2EACH$__________$___________$_______________205727618Exc leg/ankle tum < 3 cm2EACH$__________$___________$_______________205827680Release of lower leg tendon2EACH$__________$___________$_______________205927698Repair of ankle ligament2EACH$__________$___________$______________206028008Incision of foot fascia2EACH$__________$___________$_______________206128043Exc foot/toe tum sc < 1.5 cm2EACH$__________$___________$_______________206228045Exc foot/toe tum deep < 1.5 cm1EACH$__________$___________$_______________206328080Repair lower leg tendons1EACH$__________$___________$_______________206428122Partial removal of foot bone1EACH$__________$___________$_______________206528285Repair of hammertoe7EACH$__________$___________$_______________206628288Partial removal of foot bone1EACH$__________$___________$_______________206728289Repair hallux rigidus2EACH$__________$___________$_______________206828293Correction of bunion4EACH$__________$___________$_______________206928296Correction of bunion4EACH$__________$___________$_______________207064722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Urology207110140Drainage of hematoma/fluid1EACH$__________$___________$_______________207253020Incision of uretha1EACH$__________$___________$_______________207354060Excision of penis lesion (s)1EACH$__________$___________$_______________207454111Treat penis lesion graft1EACH$__________$___________$_______________207554112Treat penis lesion graft1EACH$__________$___________$_______________207654161Circum 28 days or older1EACH$__________$___________$_______________207754360Penis plastic surgery5EACH$__________$___________$_______________207854400Insert semi-rigid prosthesis8EACH$__________$___________$_______________207954405Insert multi-comp penis pros35EACH$__________$___________$_______________208054406Revmove multi-comp penis pros1EACH$__________$___________$_______________208154408Repair multi-comp penis pro3EACH$__________$___________$_______________208254410Remove/replace penis prosth4EACH$__________$___________$_______________208354520Removal of testis1EACH$__________$___________$_______________208454700Drainage of scrotum1EACH$__________$___________$_______________208554840Remove epididymus lesion6EACH$__________$___________$_______________208654860Removal of epididymis4EACH$__________$___________$______________208755040Removal of hydroceles16EACH$__________$___________$_______________208855175Revision of scrotum1EACH$__________$___________$_______________208955250Removal of sperm duct(s)1EACH$__________$___________$_______________209055400Removal of sperm duct14EACH$__________$___________$_______________209155530Revise spermatic cord veins2EACH$__________$___________$_______________209264425N block inj ilio-ing/hypogi1EACH$__________$___________$_______________Plastics209311100Biopsy skin lesion1EACH$__________$___________$_______________209411402Exc tr-ext b9+marg 1.1-2 cm7EACH$__________$___________$________________209511422Exc h-f-nk-sp b9+marg 1.1-23EACH$__________$___________$________________209611440Exc face-mm-b9+marg 0.5 < cm5EACH$__________$___________$________________209711441Exc face-mm b9+marg 0.6-1cm1EACH$__________$___________$________________209811626Exc s/n/h/f/g mal+mrg > 4 cm1EACH$__________$___________$________________209911642Exc face-mm malig+marg 1.1-210EACH$__________$___________$_______________210011643Exc f/e/e/n/l mal+mrg 2.1-32EACH$__________$___________$________________210111646Exc face-mm mlg+marg > 4 cm4EACH$__________$___________$________________210211771Removal of pilonidal lesion1EACH$__________$___________$________________210312035Intmd wnd repair s/a/t/ext1EACH$__________$___________$________________210412044Intmd wnd repair n-hf/genit1EACH$__________$___________$________________210512051Intmd wnd repair face/mm1EACH$__________$___________$________________210612052Intmd wnd repair face/mm1EACH$__________$___________$________________210712053Intmd wnd repair face/mm1EACH$__________$___________$________________210813132Repair of wound or lesion1EACH$__________$___________$________________210914040Skin tissue rearrangement1EACH$__________$___________$________________211014060Skin tissue rearrangement1EACH$__________$___________$________________211115260Skin full graft een & lips35EACH$__________$___________$________________211215275Skin sub graft face/nk/hf/g2EACH$__________$___________$________________211315732Muscle-skin graft head/neck1EACH$__________$___________$_______________211415770Derma-fat-fascia graft1EACH$__________$___________$_______________211515839Excise excessive skin tissue2EACH$__________$___________$_______________211615878Suction assisted lipectomy1EACH$__________$___________$_______________211719300Removal of breast tissue1EACH$__________$___________$_______________211819318Reduction of large breast1EACH$__________$___________$_______________211921011Exc face les sc < 2 cm1EACH$__________$___________$_______________212021014Exc face tum deep 2 cm/>1EACH$__________$___________$_______________212125071Exc forearm les sc 3 cm/>1EACH$__________$___________$_______________Otolaryngology212221235Ear cartilage graft1EACH$__________$___________$_______________212330130Excise inferior turbinate4EACH$__________$___________$_______________212430140Resect inferior turbinate7EACH$__________$___________$_______________212530465Repair nasal stenosis3EACH$__________$___________$_______________212630520Repair of nasal septum18EACH$__________$___________$_______________212730930Ther fx nasal inf turbinate4EACH$__________$___________$_______________212831231Nasal endoscopy dx1EACH$__________$___________$_______________212931237Nasal/sinus endoscopy surg1EACH$__________$___________$_______________213031254Revision of ethmoid sinus4EACH$__________$___________$_______________213131255Removal of ethmoid sinus12EACH$__________$___________$_______________213231256Exploration maxillary sinus7EACH$__________$___________$_______________213331267Endoscopy maxillary sinus10EACH$__________$___________$_______________213431276Sinus endoscopy surgical16EACH$__________$___________$_______________213531287Nasal/sinus endoscopy surg5EACH$__________$___________$_______________213631288Nasal/sinus endoscopy surg4EACH$__________$___________$_______________213731295Sinus endo w/balloon dil1EACH$__________$___________$_______________213831296Sinus endo w/balloon dil1EACH$__________$___________$_______________213940818Excise oral mucosa for graft1EACH$__________$___________$_______________214042826Removal of tonsils1EACH$__________$___________$_______________214169436Create eardrum opening1EACH$__________$___________$_______________Ophthalmology214215820Revision of lower eyelid2EACH$__________$___________$_______________214315821Revision of lower eyelid6EACH$__________$___________$_______________214415822Revision of lower eyelid20EACH$__________$___________$_______________214515823Revision of lower eyelid30EACH$__________$___________$_______________214621390Treat eye socket fracture1EACH$__________$___________$_______________214765105Remove eye/attach implant1EACH$__________$___________$_______________214865130Insert ocular implant2EACH$__________$___________$_______________214966183Insert ant drainage device4EACH$__________$___________$_______________215066825Reposition intraocular lens1EACH$__________$__________$_______________215166840Removal of lens material2EACH$__________$__________$_______________215266982Cataract surgery complex52EACH$__________$__________$_______________215366984Cataract surg w/iol 1 stage720EACH$__________$__________$_______________215467412Explore/treat eye socket2EACH$__________$__________$_______________215567808Remove eyelid lesion(s)1EACH$__________$__________$_______________215667810Biopsy of eyelid4EACH$__________$__________$_______________215767825Revise eyelashes1EACH$__________$__________$_______________215867835Revise eyelashes1EACH$__________$__________$_______________215967840Remove eyelid lesion5EACH$__________$__________$_______________216067875Closure of eyelid by suture5EACH$__________$__________$_______________216167900Repair brow defect35EACH$__________$__________$_______________216267901Repair eyelid defect1EACH$__________$__________$_______________216367904Repair eyelid defect98EACH$__________$__________$_______________216467908Repair eyelid defect4EACH$__________$__________$_______________216567914Repair eyelid defect1EACH$__________$__________$_______________216667917Repair eyelid defect60EACH$__________$__________$_______________216767921Repair eyelid defect5EACH$__________$__________$_______________216867923Repair eyelid defect5EACH$__________$__________$_______________216967924Repair eyelid defect8EACH$__________$__________$_______________217067950Revision of eyelid2EACH$__________$__________$_______________217167961Revision of eyelid1EACH$__________$__________$_______________217267971Reconstruction of eyelid1EACH$__________$__________$_______________217368110Remove eyelid lining lesion1EACH$__________$__________$_______________217468320Revise/graft eyelid lining9EACH$__________$__________$_______________217568330Revise eyelid lining6EACH$__________$__________$_______________217668340Separate eyelid adhesions1EACH$__________$__________$_______________217768720Create tear sac drain1EACH$__________$__________$_______________217868770Close tear system fistula1EACH$__________$__________$_______________217968810Probe nasolacrimal duct1EACH$__________$__________$_______________218068815Probe nasolacrimal duct5EACH$__________$__________$_______________General Surgery218138500Lymph node excisions1EACH$__________$__________$_______________218238745Anoscopy and biopsy1EACH$__________$__________$_______________218346606Anoscopy and biopsy1EACH$__________$__________$_______________218449505prp i/hern init reduc >5 yr2EACH$__________$__________$_______________218549950Rpr rem hernia init reduce5EACH$__________$__________$_______________Surgical Pathology218688304Level III Surgical pathology, gross and microscopic2EACH$__________$__________$_______________218788305Level IV surgical pathology, gross and microscopic26EACH$__________$__________$_______________218888331Intraoperative pathology exam with frozen section19EACH$__________$__________$_______________218988332Intraoperative pathology exam with frozen section24EACH$__________$__________$_______________Total Cost for Ambulatory Surgery Procedures Option Year Two (2) $________________________Anesthesia Services for Associated Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionAnesthesia CodeEst.Qty.Medicare Expected Anesthesia Per Unit Reimbursement Rate by Specialty% of discountOffered Anesthesia Per Unit Reimbursement Rate by Specialty (Unit Rate)Medicare Anesthesia Base Unit Value per Anesthesia Code (Base Units)National AVG Anesthesia Time Units (15 minute increments) per Anesthesia Code (Time Units)(Base Units + Time Units) x Unit Rate =(Unit Cost)Total Estimated Unit Cost Per YearOrthopedics219020551Inj tendon origin/insertion000001$___________%$________________$________$________219120610Drain/inject joint/bursa016302$___________%$________________$________$________219220670Removal of support implant016201$___________%$________________$________$________219323120Partial removal collar bone004505$___________%$________________$________$________219423130Remove shoulder bone part016301$___________%$________________$________$________219523412Repair rotator cuff chronic016303$___________%$________________$________$________219623430Repair biceps tendon0163012$___________%$________________$________$________219723700Fixation of shoulder016201$___________%$________________$________$________219824000Exploratory elbow surgery017401$___________%$________________$________$________219924006Release elbow joint017408$___________%$________________$________$________220024075Exc arm/elbow les sc < 3 cm004001$___________%$________________$________$________220124105Removal of elbow bursa017101$___________%$________________$________$________220224147Partial removal of elbow017402$___________%$________________$________$________220324341Repair arm tendon/muscle017101$___________%$________________$________$________220424342Repair of ruptured tendon017101$___________%$________________$________$________220524358Repair elbow w/deb open01712-017161$___________%$________________$________$________220624359Repair elbow deb/attch open01712-017161$___________%$________________$________$________220726115Exc hand les sc < 1.5 cm018101$___________%$________________$________$________220826123Release palm contracture018101$___________%$________________$________$________220926340Manipulate finger w/anesth018201$___________%$________________$________$________221026607Treat metacarpal fracture0182010$___________%$________________$________$________221126765Treat finger fracture each018301$___________%$________________$________$________221227340Removal of kneecap bursa013201$___________%$________________$________$________221327347Remove knee cyst014001$___________%$________________$________$________221427385Repair of thigh muscle013201$___________%$________________$________$________221527420Fixation of shoulder013201$___________%$________________$________$________221627422Revision of unstable kneecap013201$___________%$________________$________$________221727427Reconstruction knee013201$___________%$________________$________$_______221827570Fixation of knee joint013803$___________%$________________$________$_______221927600Decompression of lower leg01470-014742$___________%_$________________$________$_______222027618Exc leg/ankle tum < 3cm004001$___________%$________________$________$_______222127634Exc leg/ankle tum dep 5 cm/>004001$___________%$________________$________$_______222227635Remove lower leg bone lesion01480-014861$___________%$________________$________$_______222329805Shoulder arthroscopy dx016221$___________%$________________$________$_______222429806Shoulder arthroscopy surgery016301$___________%$________________$________$_______222529807Shoulder arthroscopy surgery016308$___________%$________________$________$_______222629820Shoulder arthroscopy/surgery016301$___________%$________________$________$_______222729822Shoulder arthroscopy/surgery0163018$___________%$________________$________$_______222829823Shoulder arthroscopy/surgery016308$___________%$________________$________$_______222929824Shoulder arthroscopy/surgery016308$___________%$________________$________$_______223029825Shoulder arthroscopy/surgery016306$___________%$________________$________$_______223129827Arthroscop rotator cuff repr0163040$___________%$________________$________$_______223229828Arthroscopy biceps tenodesis016308$___________%$________________$________$_______223329870Knee arthroscopy dx013824$___________%$________________$________$_______223429873Knee arthroscopy/surgery014002$___________%$________________$________$_______223529874Knee arthroscopy/surgery014002$___________%$________________$________$_______223629875Knee arthroscopy/surgery014004$___________%$________________$________$_______223729877Knee arthroscopy/surgery014009$___________%$________________$________$_______223829880Knee arthroscopy/surgery014005$___________%$________________$________$_______223929881Knee arthroscopy/surgery0140046$___________%$________________$________$_______224029888Knee arthroscopy/surgery014009$___________%$________________$________$_______224164708Revise arm/leg nerve01470-014741$___________%$________________$________$_______224264721Carpal tunnel surgery018108$___________%$________________$________$_______224364722Relieve pressure on nerve(s)01470-014741$___________%$________________$________$_______Podiatry224420670Removal of support implant018201$___________%$________________$________$_______224520680Removal of support implant018302$___________%$________________$________$_______224627618Exc leg/ankle tum < 3 cm004002$___________%$________________$________$_______224727680Release of lower leg tendon01470-014742$___________%$________________$________$_______224827698Repair of ankle ligament01470-014742$___________%$________________$________$_______224928008Incision of foot fascia01470-014742$___________%$________________$________$_______225028043Exc foot/toe tum sc < 1.5 cm01470-014742$___________%$________________$________$_______225128045Exc foot/toe tum deep < 1.5 cm01470-014741$___________%$________________$________$_______225228080Repair lower leg tendons01470-014741$___________%$________________$________$_______225328122Partial removal of foot bone01480-014861$___________%$________________$________$_______225428285Repair of hammertoe014807$___________%$________________$________$_______225528288Partial removal of foot bone014801$___________%$________________$________$_______225628289Repair hallux rigidus01480-014862$___________%$________________$________$_______225728293Correction of bunion01480-014864$___________%$________________$________$_______225828296Correction of bunion01480-014864$___________%$________________$________$_______225964722Relieve pressure on nerve(s)016101$___________%$________________$________$_______Urology226010140Drainage of hematoma/fluid003001$___________%$________________$_______$_______226153020Incision of uretha009201$___________%$________________$_______$_______226254060Excision of penis lesion (s)009201$___________%$________________$_______$_______226354111Treat penis lesion graft009201$___________%$________________$_______$_______226454112Treat penis lesion graft009201$___________%$________________$_______$_______226554161Circum 28 days or older009201$___________%$________________$_______$_______226654360Penis plastic surgery009205$___________%$________________$_______$_______226754400Insert semi-rigid prosthesis009388$___________%$________________$_______$_______226854405Insert multi-comp penis pros0093835$___________%$________________$_______$_______226954406Revmove multi-comp penis pros009201$___________%$________________$_______$_______227054408Repair multi-comp penis pro009203$___________%$________________$_______$_______227154410Remove/replace penis prosth009384$___________%$________________$_______$_______227254520Removal of testis009201$___________%$________________$_______$_______227354700Drainage of scrotum009201$___________%$________________$_______$_______227454840Remove epididymus lesion009206$___________%$________________$_______$_______227554860Removal of epididymis009204$___________%$________________$_______$_______227655040Removal of hydroceles0092016$___________%$________________$_______$_______227755175Revision of scrotum009201$___________%$________________$_______$_______227855250Removal of sperm duct(s)00921-009221$___________%$________________$_______$_______227955400Removal of sperm duct0092014$___________%$________________$_______$_______228055530Revise spermatic cord veins009202$___________%$________________$_______$_______228164425N block inj ilio-ing/hypogi000001$___________%$________________$_______$_______Plastics228211100Biopsy skin lesion003001$___________%$________________$_______$_______228311402Exc tr-ext b9+marg 1.1-2 cm003007$___________%$________________$_______$_______228411422Exc h-f-nk-sp b9+marg 1.1-2003003$___________%$________________$_______$_______228511440Exc face-mm-b9+marg 0.5 < cm003005$___________%$________________$_______$_______228611441Exc face-mm b9+marg 0.6-1cm003001$___________%$________________$_______$_______228711626Exc s/n/h/f/g mal+mrg > 4 cm003001$___________%$________________$_______$_______228811642Exc face-mm malig+marg 1.1-20030010$___________%$________________$_______$_______228911643Exc f/e/e/n/l mal+mrg 2.1-3003002$___________%$________________$_______$_______229011646Exc face-mm mlg+marg > 4 cm003004$___________%$________________$_______$_______229111771Removal of pilonidal lesion003001$___________%$________________$_______$_______229212035Intmd wnd repair s/a/t/ext003001$___________%$________________$_______$_______229312044Intmd wnd repair n-hf/genit003001$___________%$________________$_______$_______229412051Intmd wnd repair face/mm003001$___________%$________________$_______$_______229512052Intmd wnd repair face/mm003001$___________%$________________$_______$_______229612053Intmd wnd repair face/mm003001$___________%$________________$_______$_______229713132Repair of wound or lesion003001$___________%$________________$_______$_______229814040Skin tissue rearrangement003001$___________%$________________$_______$_______229914060Skin tissue rearrangement003001$___________%$________________$_______$_______230015260Skin full graft een & lips0030035$___________%$________________$_______$_______230115275Skin sub graft face/nk/hf/g003002$___________%$________________$_______$_______230215732Muscle-skin graft head/neck003001$___________%$________________$_______$_______230315770Derma-fat-fascia graft003001$___________%$________________$_______$_______230415839Excise excessive skin tissue003002$___________%$________________$_______$_______230515878Suction assisted lipectomy004001$___________%$________________$_______$_______230619300Removal of breast tissue004001$___________%$________________$_______$_______230719318Reduction of large breast004021$___________%$________________$_______$_______230821011Exc face les sc < 2 cm003001$___________%$________________$_______$_______230921014Exc face tum deep 2 cm/>003001$___________%$________________$_______$_______231025071Exc forearm les sc 3 cm/>004001$___________%$________________$_______$_______Otolaryngology231121235Ear cartilage graft00120-001261$___________%$________________$_______$_______231230130Excise inferior turbinate00160-001644$___________%$________________$_______$_______231330140Resect inferior turbinate00160-001647$___________%$________________$_______$_______231430465Repair nasal stenosis00160-001643$___________%$________________$_______$_______231530520Repair of nasal septum00160-0016418$___________%$________________$_______$_______231630930Ther fx nasal inf turbinate00160-001644$___________%$________________$_______$_______231731231Nasal endoscopy dx00160-001641$___________%$________________$_______$_______231831237Nasal/sinus endoscopy surg00160-001641$___________%$________________$_______$_______231931254Revision of ethmoid sinus00160-001644$___________%$________________$_______$_______232031255Removal of ethmoid sinus00160-0016412$___________%$________________$_______$_______232131256Exploration maxillary sinus00160-001647$___________%$________________$_______$_______232231267Endoscopy maxillary sinus00160-0016410$___________%$________________$_______$_______232331276Sinus endoscopy surgical00160-0016416$___________%$________________$_______$_______232431287Nasal/sinus endoscopy surg00160-001645$___________%$________________$_______$_______232531288Nasal/sinus endoscopy surg00160-001644$___________%$________________$_______$_______232631295Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______232731296Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______232840818Excise oral mucosa for graft001701$___________%$________________$_______$_______232942826Removal of tonsils001701$___________%$________________$_______$_______233069436Create eardrum opening00120-001261$___________%$________________$_______$_______Ophthalmology233115820Revision of lower eyelid001032$___________%$________________$_______$_______233215821Revision of lower eyelid001036$___________%$________________$_______$_______233315822Revision of lower eyelid0010320$___________%$________________$_______$_______233415823Revision of lower eyelid0010330$___________%$________________$_______$_______233521390Treat eye socket fracture00190-001921$___________%$________________$_______$_______233665105Remove eye/attach implant00140-001481$___________%$________________$_______$_______233765130Insert ocular implant00140-001482$___________%$________________$_______$_______233866183Insert ant drainage device00140-001484$___________%$________________$_______$_______233966825Reposition intraocular lens00140-001481$___________%$________________$_______$_______234066840Removal of lens material00140-001482$___________%$________________$_______$_______234166982Cataract surgery complex00140-0014852$___________%$________________$_______$_______234266984Cataract surg w/iol 1 stage00140-00148720$___________%$________________$_______$_______234367412Explore/treat eye socket00140-001482$___________%$________________$_______$_______234467808Remove eyelid lesion(s)003001$___________%$________________$_______$_______234567810Biopsy of eyelid003004$___________%$________________$_______$_______234667825Revise eyelashes001031$___________%$________________$_______$_______234767835Revise eyelashes001031$___________%$________________$_______$_______234867840Remove eyelid lesion003005$___________%$________________$_______$_______234967875Closure of eyelid by suture003005$___________%$________________$_______$_______235067900Repair brow defect0030035$___________%$________________$_______$_______235167901Repair eyelid defect003001$___________%$________________$_______$_______235267904Repair eyelid defect0010398$___________%$________________$_______$_______235367908Repair eyelid defect001034$___________%$________________$_______$_______235467914Repair eyelid defect001031$___________%$________________$_______$_______235567917Repair eyelid defect0010360$___________%$________________$_______$_______235667921Repair eyelid defect001035$___________%$________________$_______$_______235767923Repair eyelid defect001035$___________%$________________$_______$_______235867924Repair eyelid defect001038$___________%$________________$_______$_______235967950Revision of eyelid001032$___________%$________________$_______$_______236067961Revision of eyelid001031$___________%$________________$_______$_______236167971Reconstruction of eyelid001031$___________%$________________$_______$_______236268110Remove eyelid lining lesion00140-001481$___________%$________________$_______$_______236368320Revise/graft eyelid lining00140-001489$___________%$________________$_______$_______236468330Revise eyelid lining00140-001486$___________%$________________$_______$_______236568340Separate eyelid adhesions00140-001481$___________%$________________$_______$_______236668720Create tear sac drain00140-001482$___________%$________________$_______$_______236768770Close tear system fistula00140-001481$___________%$________________$_______$_______236868810Probe nasolacrimal duct00140-001481$___________%$________________$_______$_______236968815Probe nasolacrimal duct00140-001485$___________%$________________$_______$_______General Surgery237038500Lymph node excisions003201$___________%$________________$_______$_______237138745Anoscopy and biopsy016101$___________%$________________$_______$_______237246606Anoscopy and biopsy009021$___________%$________________$_______$_______237349505prp i/hern init reduc >5 yr00830-008362$___________%$________________$_______$_______237449950Rpr rem hernia init reduce00830-008365$___________%$________________$_______$_______Surgical Pathology237588304Level III Surgical pathology, gross and microscopicN/A2$___________%$________________$_______$_______237688305Level IV surgical pathology, gross and microscopicN/A26$___________%$________________$_______$_______237788331Intraoperative pathology exam with frozen sectionN/A19$___________%$________________$_______$_______237888332Intraoperative pathology exam with frozen sectionN/A24$___________%$________________$_______$_______Total Cost for Anesthesia Services Option Year Two (2) $_________________________Total Cost for Ambulatory Surgery Procedures + Anesthesia Services Option Year Two (2) $_____Period of Performance: Option Year Three (3): _July 22, 2019 ___ to ___July 21, 2020____Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionEst.Qty.UnitProposed Unit CostCMS Unit costEst.Total CostOrthopedics300120551Inj tendon origin/insertion1EACH$__________$___________$_______________300220610Drain/inject joint/bursa2EACH$__________$___________$_______________300320670Removal of support implant1EACH$__________$___________$_______________300423120Partial removal collar bone5EACH$__________$___________$_______________300523130Remove shoulder bone part1EACH$__________$___________$_______________300623412Repair rotator cuff chronic3EACH$__________$___________$_______________300723430Repair biceps tendon12EACH$__________$___________$_______________300823700Fixation of shoulder1EACH$__________$___________$_______________300924000Exploratory elbow surgery1EACH$__________$___________$_______________301024006Release elbow joint8EACH$__________$___________$_______________301124075Exc arm/elbow les sc < 3 cm1EACH$__________$___________$_______________301224105Removal of elbow bursa1EACH$__________$___________$_______________301324147Partial removal of elbow2EACH$__________$___________$_______________301424341Repair arm tendon/muscle1EACH$__________$___________$_______________301524342Repair of ruptured tendon1EACH$__________$___________$_______________301624358Repair elbow w/deb open1EACH$__________$___________$_______________301724359Repair elbow deb/attch open1EACH$__________$___________$_______________301826115Exc hand les sc < 1.5 cm1EACH$__________$___________$_______________301926123Release palm contracture1EACH$__________$___________$_______________302026340Manipulate finger w/anesth1EACH$__________$___________$_______________302126607Treat metacarpal fracture10EACH$__________$___________$_______________302226765Treat finger fracture each1EACH$__________$___________$_______________302327340Removal of kneecap bursa1EACH$__________$___________$_______________302427347Remove knee cyst1EACH$__________$___________$_______________302527385Repair of thigh muscle1EACH$__________$___________$_______________302627420Fixation of shoulder1EACH$__________$___________$_______________302727422Revision of unstable kneecap1EACH$__________$___________$_______________302827427Reconstruction knee1EACH$__________$___________$_______________302927570Fixation of knee joint3EACH$__________$___________$_______________303027600Decompression of lower leg2EACH$__________$___________$_______________303127618Exc leg/ankle tum < 3cm1EACH$__________$___________$_______________303227634Exc leg/ankle tum dep 5 cm/>1EACH$__________$___________$_______________303327635Remove lower leg bone lesion1EACH$__________$___________$_______________303429805Shoulder arthroscopy dx1EACH$__________$___________$_______________303529806Shoulder arthroscopy surgery1EACH$__________$___________$_______________303629807Shoulder arthroscopy surgery8EACH$__________$___________$_______________303729820Shoulder arthroscopy/surgery1EACH$__________$___________$_______________303829822Shoulder arthroscopy/surgery18EACH$__________$___________$_______________303929823Shoulder arthroscopy/surgery8EACH$__________$___________$_______________304029824Shoulder arthroscopy/surgery8EACH$__________$___________$_______________304129825Shoulder arthroscopy/surgery6EACH$__________$___________$_______________304229827Arthroscop rotator cuff repr40EACH$__________$___________$_______________304329828Arthroscopy biceps tenodesis8EACH$__________$___________$_______________304429870Knee arthroscopy dx4EACH$__________$___________$_______________304529873Knee arthroscopy/surgery2EACH$__________$___________$_______________304629874Knee arthroscopy/surgery2EACH$__________$___________$_______________304729875Knee arthroscopy/surgery4EACH$__________$___________$_______________304829877Knee arthroscopy/surgery9EACH$__________$___________$_______________304929880Knee arthroscopy/surgery5EACH$__________$___________$_______________305029881Knee arthroscopy/surgery46EACH$__________$___________$_______________305129888Knee arthroscopy/surgery9EACH$__________$___________$_______________305264708Revise arm/leg nerve1EACH$__________$___________$_______________305364721Carpal tunnel surgery8EACH$__________$___________$_______________305464722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Podiatry305520670Removal of support implant1EACH$__________$___________$_______________305620680Removal of support implant2EACH$__________$___________$_______________305727618Exc leg/ankle tum < 3 cm2EACH$__________$___________$_______________305827680Release of lower leg tendon2EACH$__________$___________$_______________305927698Repair of ankle ligament2EACH$__________$___________$______________306028008Incision of foot fascia2EACH$__________$___________$_______________306128043Exc foot/toe tum sc < 1.5 cm2EACH$__________$___________$_______________306228045Exc foot/toe tum deep < 1.5 cm1EACH$__________$___________$_______________306328080Repair lower leg tendons1EACH$__________$___________$_______________306428122Partial removal of foot bone1EACH$__________$___________$_______________306528285Repair of hammertoe7EACH$__________$___________$_______________306628288Partial removal of foot bone1EACH$__________$___________$_______________306728289Repair hallux rigidus2EACH$__________$___________$_______________306828293Correction of bunion4EACH$__________$___________$_______________306928296Correction of bunion4EACH$__________$___________$_______________307064722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Urology307110140Drainage of hematoma/fluid1EACH$__________$___________$_______________307253020Incision of uretha1EACH$__________$___________$_______________307354060Excision of penis lesion (s)1EACH$__________$___________$_______________307454111Treat penis lesion graft1EACH$__________$___________$_______________307554112Treat penis lesion graft1EACH$__________$___________$_______________307654161Circum 28 days or older1EACH$__________$___________$_______________307754360Penis plastic surgery5EACH$__________$___________$_______________307854400Insert semi-rigid prosthesis8EACH$__________$___________$_______________307954405Insert multi-comp penis pros35EACH$__________$___________$_______________308054406Revmove multi-comp penis pros1EACH$__________$___________$_______________308154408Repair multi-comp penis pro3EACH$__________$___________$_______________308254410Remove/replace penis prosth4EACH$__________$___________$_______________308354520Removal of testis1EACH$__________$___________$_______________308454700Drainage of scrotum1EACH$__________$___________$_______________308554840Remove epididymus lesion6EACH$__________$___________$_______________308654860Removal of epididymis4EACH$__________$___________$______________308755040Removal of hydroceles16EACH$__________$___________$_______________308855175Revision of scrotum1EACH$__________$___________$_______________308955250Removal of sperm duct(s)1EACH$__________$___________$_______________309055400Removal of sperm duct14EACH$__________$___________$_______________309155530Revise spermatic cord veins2EACH$__________$___________$_______________309264425N block inj ilio-ing/hypogi1EACH$__________$___________$_______________Plastics309311100Biopsy skin lesion1EACH$__________$___________$_______________309411402Exc tr-ext b9+marg 1.1-2 cm7EACH$__________$___________$________________309511422Exc h-f-nk-sp b9+marg 1.1-23EACH$__________$___________$________________309611440Exc face-mm-b9+marg 0.5 < cm5EACH$__________$___________$________________309711441Exc face-mm b9+marg 0.6-1cm1EACH$__________$___________$________________309811626Exc s/n/h/f/g mal+mrg > 4 cm1EACH$__________$___________$________________309911642Exc face-mm malig+marg 1.1-210EACH$__________$___________$_______________310011643Exc f/e/e/n/l mal+mrg 2.1-32EACH$__________$___________$________________310111646Exc face-mm mlg+marg > 4 cm4EACH$__________$___________$________________310211771Removal of pilonidal lesion1EACH$__________$___________$________________310312035Intmd wnd repair s/a/t/ext1EACH$__________$___________$________________310412044Intmd wnd repair n-hf/genit1EACH$__________$___________$________________310512051Intmd wnd repair face/mm1EACH$__________$___________$________________310612052Intmd wnd repair face/mm1EACH$__________$___________$________________310712053Intmd wnd repair face/mm1EACH$__________$___________$________________310813132Repair of wound or lesion1EACH$__________$___________$________________310914040Skin tissue rearrangement1EACH$__________$___________$________________311014060Skin tissue rearrangement1EACH$__________$___________$________________311115260Skin full graft een & lips35EACH$__________$___________$________________311215275Skin sub graft face/nk/hf/g2EACH$__________$___________$________________311315732Muscle-skin graft head/neck1EACH$__________$___________$_______________311415770Derma-fat-fascia graft1EACH$__________$___________$_______________311515839Excise excessive skin tissue2EACH$__________$___________$_______________311615878Suction assisted lipectomy1EACH$__________$___________$_______________311719300Removal of breast tissue1EACH$__________$___________$_______________311819318Reduction of large breast1EACH$__________$___________$_______________311921011Exc face les sc < 2 cm1EACH$__________$___________$_______________312021014Exc face tum deep 2 cm/>1EACH$__________$___________$_______________312125071Exc forearm les sc 3 cm/>1EACH$__________$___________$_______________Otolaryngology312221235Ear cartilage graft1EACH$__________$___________$_______________312330130Excise inferior turbinate4EACH$__________$___________$_______________312430140Resect inferior turbinate7EACH$__________$___________$_______________312530465Repair nasal stenosis3EACH$__________$___________$_______________312630520Repair of nasal septum18EACH$__________$___________$_______________312730930Ther fx nasal inf turbinate4EACH$__________$___________$_______________312831231Nasal endoscopy dx1EACH$__________$___________$_______________312931237Nasal/sinus endoscopy surg1EACH$__________$___________$_______________313031254Revision of ethmoid sinus4EACH$__________$___________$_______________313131255Removal of ethmoid sinus12EACH$__________$___________$_______________313231256Exploration maxillary sinus7EACH$__________$___________$_______________313331267Endoscopy maxillary sinus10EACH$__________$___________$_______________313431276Sinus endoscopy surgical16EACH$__________$___________$_______________313531287Nasal/sinus endoscopy surg5EACH$__________$___________$_______________313631288Nasal/sinus endoscopy surg4EACH$__________$___________$_______________313731295Sinus endo w/balloon dil1EACH$__________$___________$_______________313831296Sinus endo w/balloon dil1EACH$__________$___________$_______________313940818Excise oral mucosa for graft1EACH$__________$___________$_______________314042826Removal of tonsils1EACH$__________$___________$_______________314169436Create eardrum opening1EACH$__________$___________$_______________Ophthalmology314215820Revision of lower eyelid2EACH$__________$___________$_______________314315821Revision of lower eyelid6EACH$__________$___________$_______________314415822Revision of lower eyelid20EACH$__________$___________$_______________314515823Revision of lower eyelid30EACH$__________$___________$_______________314621390Treat eye socket fracture1EACH$__________$___________$_______________314765105Remove eye/attach implant1EACH$__________$___________$_______________314865130Insert ocular implant2EACH$__________$___________$_______________314966183Insert ant drainage device4EACH$__________$___________$_______________315066825Reposition intraocular lens1EACH$__________$__________$_______________315166840Removal of lens material2EACH$__________$__________$_______________315266982Cataract surgery complex52EACH$__________$__________$_______________315366984Cataract surg w/iol 1 stage720EACH$__________$__________$_______________315467412Explore/treat eye socket2EACH$__________$__________$_______________315567808Remove eyelid lesion(s)1EACH$__________$__________$_______________315667810Biopsy of eyelid4EACH$__________$__________$_______________315767825Revise eyelashes1EACH$__________$__________$_______________315867835Revise eyelashes1EACH$__________$__________$_______________315967840Remove eyelid lesion5EACH$__________$__________$_______________316067875Closure of eyelid by suture5EACH$__________$__________$_______________316167900Repair brow defect35EACH$__________$__________$_______________316267901Repair eyelid defect1EACH$__________$__________$_______________316367904Repair eyelid defect98EACH$__________$__________$_______________316467908Repair eyelid defect4EACH$__________$__________$_______________316567914Repair eyelid defect1EACH$__________$__________$_______________316667917Repair eyelid defect60EACH$__________$__________$_______________316767921Repair eyelid defect5EACH$__________$__________$_______________316867923Repair eyelid defect5EACH$__________$__________$_______________316967924Repair eyelid defect8EACH$__________$__________$_______________317067950Revision of eyelid2EACH$__________$__________$_______________317167961Revision of eyelid1EACH$__________$__________$_______________317267971Reconstruction of eyelid1EACH$__________$__________$_______________317368110Remove eyelid lining lesion1EACH$__________$__________$_______________317468320Revise/graft eyelid lining9EACH$__________$__________$_______________317568330Revise eyelid lining6EACH$__________$__________$_______________317668340Separate eyelid adhesions1EACH$__________$__________$_______________317768720Create tear sac drain2EACH$__________$__________$_______________317868770Close tear system fistula1EACH$__________$__________$_______________317968810Probe nasolacrimal duct1EACH$__________$__________$_______________318068815Probe nasolacrimal duct5EACH$__________$__________$_______________General Surgery318138500Lymph node excisions1EACH$__________$__________$_______________318238745Anoscopy and biopsy1EACH$__________$__________$_______________318346606Anoscopy and biopsy1EACH$__________$__________$_______________318449505prp i/hern init reduc >5 yr2EACH$__________$__________$_______________318549950Rpr rem hernia init reduce5EACH$__________$__________$_______________Surgical Pathology318688304Level III Surgical pathology, gross and microscopic2EACH$__________$__________$_______________318788305Level IV surgical pathology, gross and microscopic26EACH$__________$__________$_______________318888331Intraoperative pathology exam with frozen section19EACH$__________$__________$_______________318988332Intraoperative pathology exam with frozen section24EACH$__________$__________$_______________Total Cost for Ambulatory Surgery Procedures Option Year Three (3) $_______________________Anesthesia Services for Associated Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionAnesthesia CodeEst.Qty.Medicare Expected Anesthesia Per Unit Reimbursement Rate by Specialty% of discountOffered Anesthesia Per Unit Reimbursement Rate by Specialty (Unit Rate)Medicare Anesthesia Base Unit Value per Anesthesia Code (Base Units)National AVG Anesthesia Time Units (15 minute increments) per Anesthesia Code (Time Units)(Base Units + Time Units) x Unit Rate =(Unit Cost)Total Estimated Unit Cost Per YearOrthopedics319020551Inj tendon origin/insertion000001$___________%$________________$________$________319120610Drain/inject joint/bursa016302$___________%$________________$________$________319220670Removal of support implant016201$___________%$________________$________$________319323120Partial removal collar bone004505$___________%$________________$________$________319423130Remove shoulder bone part016301$___________%$________________$________$________319523412Repair rotator cuff chronic016303$___________%$________________$________$________319623430Repair biceps tendon0163012$___________%$________________$________$________319723700Fixation of shoulder016201$___________%$________________$________$________319824000Exploratory elbow surgery017401$___________%$________________$________$________319924006Release elbow joint017408$___________%$________________$________$________320024075Exc arm/elbow les sc < 3 cm004001$___________%$________________$________$________320124105Removal of elbow bursa017101$___________%$________________$________$________320224147Partial removal of elbow017402$___________%$________________$________$________320324341Repair arm tendon/muscle017101$___________%$________________$________$________320424342Repair of ruptured tendon017101$___________%$________________$________$________320524358Repair elbow w/deb open01712-017161$___________%$________________$________$________320624359Repair elbow deb/attch open01712-017161$___________%$________________$________$________320726115Exc hand les sc < 1.5 cm018101$___________%$________________$________$________320826123Release palm contracture018101$___________%$________________$________$________320926340Manipulate finger w/anesth018201$___________%$________________$________$________321026607Treat metacarpal fracture0182010$___________%$________________$________$________321126765Treat finger fracture each018301$___________%$________________$________$________321227340Removal of kneecap bursa013201$___________%$________________$________$________321327347Remove knee cyst014001$___________%$________________$________$________321427385Repair of thigh muscle013201$___________%$________________$________$________321527420Fixation of shoulder013201$___________%$________________$________$________321627422Revision of unstable kneecap013201$___________%$________________$________$________321727427Reconstruction knee013201$___________%$________________$________$_______321827570Fixation of knee joint013803$___________%$________________$________$_______321927600Decompression of lower leg01470-014742$___________%_$________________$________$_______322027618Exc leg/ankle tum < 3cm004001$___________%$________________$________$_______322127634Exc leg/ankle tum dep 5 cm/>004001$___________%$________________$________$_______322227635Remove lower leg bone lesion01480-014861$___________%$________________$________$_______322329805Shoulder arthroscopy dx016221$___________%$________________$________$_______322429806Shoulder arthroscopy surgery016301$___________%$________________$________$_______322529807Shoulder arthroscopy surgery016308$___________%$________________$________$_______322629820Shoulder arthroscopy/surgery016301$___________%$________________$________$_______322729822Shoulder arthroscopy/surgery0163018$___________%$________________$________$_______322829823Shoulder arthroscopy/surgery016308$___________%$________________$________$_______322929824Shoulder arthroscopy/surgery016308$___________%$________________$________$_______323029825Shoulder arthroscopy/surgery016306$___________%$________________$________$_______323129827Arthroscop rotator cuff repr0163040$___________%$________________$________$_______323229828Arthroscopy biceps tenodesis016308$___________%$________________$________$_______323329870Knee arthroscopy dx013824$___________%$________________$________$_______323429873Knee arthroscopy/surgery014002$___________%$________________$________$_______323529874Knee arthroscopy/surgery014002$___________%$________________$________$_______323629875Knee arthroscopy/surgery014004$___________%$________________$________$_______323729877Knee arthroscopy/surgery014009$___________%$________________$________$_______323829880Knee arthroscopy/surgery014005$___________%$________________$________$_______323929881Knee arthroscopy/surgery0140046$___________%$________________$________$_______324029888Knee arthroscopy/surgery014009$___________%$________________$________$_______324164708Revise arm/leg nerve01470-014741$___________%$________________$________$_______324264721Carpal tunnel surgery018108$___________%$________________$________$_______324364722Relieve pressure on nerve(s)01470-014741$___________%$________________$________$_______Podiatry324420670Removal of support implant018201$___________%$________________$________$_______324520680Removal of support implant018302$___________%$________________$________$_______324627618Exc leg/ankle tum < 3 cm004002$___________%$________________$________$_______324727680Release of lower leg tendon01470-014742$___________%$________________$________$_______324827698Repair of ankle ligament01470-014742$___________%$________________$________$_______324928008Incision of foot fascia01470-014742$___________%$________________$________$_______325028043Exc foot/toe tum sc < 1.5 cm01470-014742$___________%$________________$________$_______325128045Exc foot/toe tum deep < 1.5 cm01470-014741$___________%$________________$________$_______325228080Repair lower leg tendons01470-014741$___________%$________________$________$_______325328122Partial removal of foot bone01480-014861$___________%$________________$________$_______325428285Repair of hammertoe014807$___________%$________________$________$_______325528288Partial removal of foot bone014801$___________%$________________$________$_______325628289Repair hallux rigidus01480-014862$___________%$________________$________$_______325728293Correction of bunion01480-014864$___________%$________________$________$_______325828296Correction of bunion01480-014864$___________%$________________$________$_______325964722Relieve pressure on nerve(s)016101$___________%$________________$________$_______Urology326010140Drainage of hematoma/fluid003001$___________%$________________$_______$_______326153020Incision of uretha009201$___________%$________________$_______$_______326254060Excision of penis lesion (s)009201$___________%$________________$_______$_______326354111Treat penis lesion graft009201$___________%$________________$_______$_______326454112Treat penis lesion graft009201$___________%$________________$_______$_______326554161Circum 28 days or older009201$___________%$________________$_______$_______326654360Penis plastic surgery009205$___________%$________________$_______$_______326754400Insert semi-rigid prosthesis009388$___________%$________________$_______$_______326854405Insert multi-comp penis pros0093835$___________%$________________$_______$_______326954406Revmove multi-comp penis pros009201$___________%$________________$_______$_______327054408Repair multi-comp penis pro009203$___________%$________________$_______$_______327154410Remove/replace penis prosth009384$___________%$________________$_______$_______327254520Removal of testis009201$___________%$________________$_______$_______327354700Drainage of scrotum009201$___________%$________________$_______$_______327454840Remove epididymus lesion009206$___________%$________________$_______$_______327554860Removal of epididymis009204$___________%$________________$_______$_______327655040Removal of hydroceles0092016$___________%$________________$_______$_______327755175Revision of scrotum009201$___________%$________________$_______$_______327855250Removal of sperm duct(s)00921-009221$___________%$________________$_______$_______327955400Removal of sperm duct0092014$___________%$________________$_______$_______328055530Revise spermatic cord veins009202$___________%$________________$_______$_______328164425N block inj ilio-ing/hypogi000001$___________%$________________$_______$_______Plastics328211100Biopsy skin lesion003001$___________%$________________$_______$_______328311402Exc tr-ext b9+marg 1.1-2 cm003007$___________%$________________$_______$_______328411422Exc h-f-nk-sp b9+marg 1.1-2003003$___________%$________________$_______$_______328511440Exc face-mm-b9+marg 0.5 < cm003005$___________%$________________$_______$_______328611441Exc face-mm b9+marg 0.6-1cm003001$___________%$________________$_______$_______328711626Exc s/n/h/f/g mal+mrg > 4 cm003001$___________%$________________$_______$_______328811642Exc face-mm malig+marg 1.1-20030010$___________%$________________$_______$_______328911643Exc f/e/e/n/l mal+mrg 2.1-3003002$___________%$________________$_______$_______329011646Exc face-mm mlg+marg > 4 cm003004$___________%$________________$_______$_______329111771Removal of pilonidal lesion003001$___________%$________________$_______$_______329212035Intmd wnd repair s/a/t/ext003001$___________%$________________$_______$_______329312044Intmd wnd repair n-hf/genit003001$___________%$________________$_______$_______329412051Intmd wnd repair face/mm003001$___________%$________________$_______$_______329512052Intmd wnd repair face/mm003001$___________%$________________$_______$_______329612053Intmd wnd repair face/mm003001$___________%$________________$_______$_______329713132Repair of wound or lesion003001$___________%$________________$_______$_______329814040Skin tissue rearrangement003001$___________%$________________$_______$_______329914060Skin tissue rearrangement003001$___________%$________________$_______$_______330015260Skin full graft een & lips0030035$___________%$________________$_______$_______330115275Skin sub graft face/nk/hf/g003002$___________%$________________$_______$_______330215732Muscle-skin graft head/neck003001$___________%$________________$_______$_______330315770Derma-fat-fascia graft003001$___________%$________________$_______$_______330415839Excise excessive skin tissue003002$___________%$________________$_______$_______330515878Suction assisted lipectomy004001$___________%$________________$_______$_______330619300Removal of breast tissue004001$___________%$________________$_______$_______330719318Reduction of large breast004021$___________%$________________$_______$_______330821011Exc face les sc < 2 cm003001$___________%$________________$_______$_______330921014Exc face tum deep 2 cm/>003001$___________%$________________$_______$_______331025071Exc forearm les sc 3 cm/>004001$___________%$________________$_______$_______Otolaryngology331121235Ear cartilage graft00120-001261$___________%$________________$_______$_______331230130Excise inferior turbinate00160-001644$___________%$________________$_______$_______331330140Resect inferior turbinate00160-001647$___________%$________________$_______$_______331430465Repair nasal stenosis00160-001643$___________%$________________$_______$_______331530520Repair of nasal septum00160-0016418$___________%$________________$_______$_______331630930Ther fx nasal inf turbinate00160-001644$___________%$________________$_______$_______331731231Nasal endoscopy dx00160-001641$___________%$________________$_______$_______331831237Nasal/sinus endoscopy surg00160-001641$___________%$________________$_______$_______331931254Revision of ethmoid sinus00160-001644$___________%$________________$_______$_______332031255Removal of ethmoid sinus00160-0016412$___________%$________________$_______$_______332131256Exploration maxillary sinus00160-001647$___________%$________________$_______$_______332231267Endoscopy maxillary sinus00160-0016410$___________%$________________$_______$_______332331276Sinus endoscopy surgical00160-0016416$___________%$________________$_______$_______332431287Nasal/sinus endoscopy surg00160-001645$___________%$________________$_______$_______332531288Nasal/sinus endoscopy surg00160-001644$___________%$________________$_______$_______332631295Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______332731296Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______332840818Excise oral mucosa for graft001701$___________%$________________$_______$_______332942826Removal of tonsils001701$___________%$________________$_______$_______333069436Create eardrum opening00120-001261$___________%$________________$_______$_______Ophthalmology333115820Revision of lower eyelid001032$___________%$________________$_______$_______333215821Revision of lower eyelid001036$___________%$________________$_______$_______333315822Revision of lower eyelid0010320$___________%$________________$_______$_______333415823Revision of lower eyelid0010330$___________%$________________$_______$_______333521390Treat eye socket fracture00190-001921$___________%$________________$_______$_______333665105Remove eye/attach implant00140-001481$___________%$________________$_______$_______333765130Insert ocular implant00140-001482$___________%$________________$_______$_______333866183Insert ant drainage device00140-001484$___________%$________________$_______$_______333966825Reposition intraocular lens00140-001481$___________%$________________$_______$_______334066840Removal of lens material00140-001482$___________%$________________$_______$_______334166982Cataract surgery complex00140-0014852$___________%$________________$_______$_______334266984Cataract surg w/iol 1 stage00140-00148720$___________%$________________$_______$_______334367412Explore/treat eye socket00140-001482$___________%$________________$_______$_______334467808Remove eyelid lesion(s)003001$___________%$________________$_______$_______334567810Biopsy of eyelid003004$___________%$________________$_______$_______334667825Revise eyelashes001031$___________%$________________$_______$_______334767835Revise eyelashes001031$___________%$________________$_______$_______334867840Remove eyelid lesion003005$___________%$________________$_______$_______334967875Closure of eyelid by suture003005$___________%$________________$_______$_______335067900Repair brow defect0030035$___________%$________________$_______$_______335167901Repair eyelid defect003001$___________%$________________$_______$_______335267904Repair eyelid defect0010398$___________%$________________$_______$_______335367908Repair eyelid defect001034$___________%$________________$_______$_______335467914Repair eyelid defect001031$___________%$________________$_______$_______335567917Repair eyelid defect0010360$___________%$________________$_______$_______335667921Repair eyelid defect001035$___________%$________________$_______$_______335767923Repair eyelid defect001033$___________%$________________$_______$_______335867924Repair eyelid defect001038$___________%$________________$_______$_______335967950Revision of eyelid001032$___________%$________________$_______$_______336067961Revision of eyelid001031$___________%$________________$_______$_______336167971Reconstruction of eyelid001031$___________%$________________$_______$_______336268110Remove eyelid lining lesion00140-001481$___________%$________________$_______$_______336368320Revise/graft eyelid lining00140-001489$___________%$________________$_______$_______336468330Revise eyelid lining00140-001486$___________%$________________$_______$_______336568340Separate eyelid adhesions00140-001481$___________%$________________$_______$_______336668720Create tear sac drain00140-001482$___________%$________________$_______$_______336768770Close tear system fistula00140-001481$___________%$________________$_______$_______336868810Probe nasolacrimal duct00140-001481$___________%$________________$_______$_______336968815Probe nasolacrimal duct00140-001485$___________%$________________$_______$_______General Surgery337038500Lymph node excisions003201$___________%$________________$_______$_______337138745Anoscopy and biopsy016101$___________%$________________$_______$_______337246606Anoscopy and biopsy009021$___________%$________________$_______$_______337349505prp i/hern init reduc >5 yr00830-008362$___________%$________________$_______$_______337449950Rpr rem hernia init reduce00830-008365$___________%$________________$_______$_______Surgical Pathology337588304Level III Surgical pathology, gross and microscopicN/A2$___________%$________________$_______$_______337688305Level IV surgical pathology, gross and microscopicN/A26$___________%$________________$_______$_______337788331Intraoperative pathology exam with frozen sectionN/A19$___________%$________________$_______$_______337888332Intraoperative pathology exam with frozen sectionN/A24$___________%$________________$_______$_______Total Cost for Anesthesia Services Option Year Three (3) $_________________________Total Cost for Ambulatory Surgery Procedures + Anesthesia Services Option Year Three (3) $____Period of Performance: Option Year Four (4): _July 22, 2020 ___ to ___July 21, 2021____Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionEst.Qty.UnitProposed Unit CostCMS Unit costEst.Total CostOrthopedics400120551Inj tendon origin/insertion1EACH$__________$___________$_______________400220610Drain/inject joint/bursa2EACH$__________$___________$_______________400320670Removal of support implant1EACH$__________$___________$_______________400423120Partial removal collar bone5EACH$__________$___________$_______________400523130Remove shoulder bone part1EACH$__________$___________$_______________400623412Repair rotator cuff chronic3EACH$__________$___________$_______________400723430Repair biceps tendon12EACH$__________$___________$_______________400823700Fixation of shoulder1EACH$__________$___________$_______________400924000Exploratory elbow surgery1EACH$__________$___________$_______________401024006Release elbow joint8EACH$__________$___________$_______________401124075Exc arm/elbow les sc < 3 cm1EACH$__________$___________$_______________401224105Removal of elbow bursa1EACH$__________$___________$_______________401324147Partial removal of elbow2EACH$__________$___________$_______________401424341Repair arm tendon/muscle1EACH$__________$___________$_______________401524342Repair of ruptured tendon1EACH$__________$___________$_______________401624358Repair elbow w/deb open1EACH$__________$___________$_______________401724359Repair elbow deb/attch open1EACH$__________$___________$_______________401826115Exc hand les sc < 1.5 cm1EACH$__________$___________$_______________401926123Release palm contracture1EACH$__________$___________$_______________402026340Manipulate finger w/anesth1EACH$__________$___________$_______________402126607Treat metacarpal fracture10EACH$__________$___________$_______________402226765Treat finger fracture each1EACH$__________$___________$_______________402327340Removal of kneecap bursa1EACH$__________$___________$_______________402427347Remove knee cyst1EACH$__________$___________$_______________402527385Repair of thigh muscle1EACH$__________$___________$_______________402627420Fixation of shoulder1EACH$__________$___________$_______________402727422Revision of unstable kneecap1EACH$__________$___________$_______________402827427Reconstruction knee1EACH$__________$___________$_______________402927570Fixation of knee joint3EACH$__________$___________$_______________403027600Decompression of lower leg2EACH$__________$___________$_______________403127618Exc leg/ankle tum < 3cm1EACH$__________$___________$_______________403227634Exc leg/ankle tum dep 5 cm/>1EACH$__________$___________$_______________403327635Remove lower leg bone lesion1EACH$__________$___________$_______________403429805Shoulder arthroscopy dx1EACH$__________$___________$_______________403529806Shoulder arthroscopy surgery1EACH$__________$___________$_______________403629807Shoulder arthroscopy surgery8EACH$__________$___________$_______________403729820Shoulder arthroscopy/surgery1EACH$__________$___________$_______________403829822Shoulder arthroscopy/surgery18EACH$__________$___________$_______________403929823Shoulder arthroscopy/surgery8EACH$__________$___________$_______________404029824Shoulder arthroscopy/surgery8EACH$__________$___________$_______________404129825Shoulder arthroscopy/surgery6EACH$__________$___________$_______________404229827Arthroscop rotator cuff repr40EACH$__________$___________$_______________404329828Arthroscopy biceps tenodesis8EACH$__________$___________$_______________404429870Knee arthroscopy dx4EACH$__________$___________$_______________404529873Knee arthroscopy/surgery2EACH$__________$___________$_______________404629874Knee arthroscopy/surgery2EACH$__________$___________$_______________404729875Knee arthroscopy/surgery4EACH$__________$___________$_______________404829877Knee arthroscopy/surgery9EACH$__________$___________$_______________404929880Knee arthroscopy/surgery5EACH$__________$___________$_______________405029881Knee arthroscopy/surgery46EACH$__________$___________$_______________405129888Knee arthroscopy/surgery9EACH$__________$___________$_______________405264708Revise arm/leg nerve1EACH$__________$___________$_______________405364721Carpal tunnel surgery8EACH$__________$___________$_______________405464722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Podiatry405520670Removal of support implant1EACH$__________$___________$_______________405620680Removal of support implant2EACH$__________$___________$_______________405727618Exc leg/ankle tum < 3 cm2EACH$__________$___________$_______________405827680Release of lower leg tendon2EACH$__________$___________$_______________405927698Repair of ankle ligament2EACH$__________$___________$______________406028008Incision of foot fascia2EACH$__________$___________$_______________406128043Exc foot/toe tum sc < 1.5 cm2EACH$__________$___________$_______________406228045Exc foot/toe tum deep < 1.5 cm1EACH$__________$___________$_______________406328080Repair lower leg tendons1EACH$__________$___________$_______________406428122Partial removal of foot bone1EACH$__________$___________$_______________406528285Repair of hammertoe7EACH$__________$___________$_______________406628288Partial removal of foot bone1EACH$__________$___________$_______________406728289Repair hallux rigidus2EACH$__________$___________$_______________406828293Correction of bunion4EACH$__________$___________$_______________406928296Correction of bunion4EACH$__________$___________$_______________407064722Relieve pressure on nerve(s)1EACH$__________$___________$_______________Urology407110140Drainage of hematoma/fluid1EACH$__________$___________$_______________407253020Incision of uretha1EACH$__________$___________$_______________407354060Excision of penis lesion (s)1EACH$__________$___________$_______________407454111Treat penis lesion graft1EACH$__________$___________$_______________407554112Treat penis lesion graft1EACH$__________$___________$_______________407654161Circum 28 days or older1EACH$__________$___________$_______________407754360Penis plastic surgery5EACH$__________$___________$_______________407854400Insert semi-rigid prosthesis8EACH$__________$___________$_______________407954405Insert multi-comp penis pros35EACH$__________$___________$_______________408054406Revmove multi-comp penis pros1EACH$__________$___________$_______________408154408Repair multi-comp penis pro3EACH$__________$___________$_______________408254410Remove/replace penis prosth4EACH$__________$___________$_______________408354520Removal of testis1EACH$__________$___________$_______________408454700Drainage of scrotum1EACH$__________$___________$_______________408554840Remove epididymus lesion6EACH$__________$___________$_______________408654860Removal of epididymis4EACH$__________$___________$______________408755040Removal of hydroceles16EACH$__________$___________$_______________408855175Revision of scrotum1EACH$__________$___________$_______________408955250Removal of sperm duct(s)1EACH$__________$___________$_______________409055400Removal of sperm duct14EACH$__________$___________$_______________409155530Revise spermatic cord veins2EACH$__________$___________$_______________409264425N block inj ilio-ing/hypogi1EACH$__________$___________$_______________Plastics409311100Biopsy skin lesion1EACH$__________$___________$_______________409411402Exc tr-ext b9+marg 1.1-2 cm7EACH$__________$___________$________________409511422Exc h-f-nk-sp b9+marg 1.1-23EACH$__________$___________$________________409611440Exc face-mm-b9+marg 0.5 < cm5EACH$__________$___________$________________409711441Exc face-mm b9+marg 0.6-1cm1EACH$__________$___________$________________409811626Exc s/n/h/f/g mal+mrg > 4 cm1EACH$__________$___________$________________409911642Exc face-mm malig+marg 1.1-210EACH$__________$___________$_______________410011643Exc f/e/e/n/l mal+mrg 2.1-32EACH$__________$___________$________________410111646Exc face-mm mlg+marg > 4 cm4EACH$__________$___________$________________410211771Removal of pilonidal lesion1EACH$__________$___________$________________410312035Intmd wnd repair s/a/t/ext1EACH$__________$___________$________________410412044Intmd wnd repair n-hf/genit1EACH$__________$___________$________________410512051Intmd wnd repair face/mm1EACH$__________$___________$________________410612052Intmd wnd repair face/mm1EACH$__________$___________$________________410712053Intmd wnd repair face/mm1EACH$__________$___________$________________410813132Repair of wound or lesion1EACH$__________$___________$________________410914040Skin tissue rearrangement1EACH$__________$___________$________________411014060Skin tissue rearrangement1EACH$__________$___________$________________411115260Skin full graft een & lips35EACH$__________$___________$________________411215275Skin sub graft face/nk/hf/g2EACH$__________$___________$________________411315732Muscle-skin graft head/neck1EACH$__________$___________$_______________411415770Derma-fat-fascia graft1EACH$__________$___________$_______________411515839Excise excessive skin tissue2EACH$__________$___________$_______________411615878Suction assisted lipectomy1EACH$__________$___________$_______________411719300Removal of breast tissue1EACH$__________$___________$_______________411819318Reduction of large breast1EACH$__________$___________$_______________411921011Exc face les sc < 2 cm1EACH$__________$___________$_______________412021014Exc face tum deep 2 cm/>1EACH$__________$___________$_______________412125071Exc forearm les sc 3 cm/>1EACH$__________$___________$_______________Otolaryngology412221235Ear cartilage graft1EACH$__________$___________$_______________412330130Excise inferior turbinate4EACH$__________$___________$_______________412430140Resect inferior turbinate7EACH$__________$___________$_______________412530465Repair nasal stenosis3EACH$__________$___________$_______________412630520Repair of nasal septum18EACH$__________$___________$_______________412730930Ther fx nasal inf turbinate4EACH$__________$___________$_______________412831231Nasal endoscopy dx1EACH$__________$___________$_______________412931237Nasal/sinus endoscopy surg1EACH$__________$___________$_______________413031254Revision of ethmoid sinus4EACH$__________$___________$_______________413131255Removal of ethmoid sinus12EACH$__________$___________$_______________413231256Exploration maxillary sinus7EACH$__________$___________$_______________413331267Endoscopy maxillary sinus10EACH$__________$___________$_______________413431276Sinus endoscopy surgical16EACH$__________$___________$_______________413531287Nasal/sinus endoscopy surg5EACH$__________$___________$_______________413631288Nasal/sinus endoscopy surg4EACH$__________$___________$_______________413731295Sinus endo w/balloon dil1EACH$__________$___________$_______________413831296Sinus endo w/balloon dil1EACH$__________$___________$_______________413940818Excise oral mucosa for graft1EACH$__________$___________$_______________414042826Removal of tonsils1EACH$__________$___________$_______________414169436Create eardrum opening1EACH$__________$___________$_______________Ophthalmology414215820Revision of lower eyelid2EACH$__________$___________$_______________414315821Revision of lower eyelid6EACH$__________$___________$_______________414415822Revision of lower eyelid20EACH$__________$___________$_______________414515823Revision of lower eyelid30EACH$__________$___________$_______________414621390Treat eye socket fracture1EACH$__________$___________$_______________414765105Remove eye/attach implant1EACH$__________$___________$_______________414865130Insert ocular implant2EACH$__________$___________$_______________414966183Insert ant drainage device4EACH$__________$___________$_______________415066825Reposition intraocular lens1EACH$__________$__________$_______________415166840Removal of lens material2EACH$__________$__________$_______________415266982Cataract surgery complex52EACH$__________$__________$_______________415366984Cataract surg w/iol 1 stage720EACH$__________$__________$_______________415467412Explore/treat eye socket2EACH$__________$__________$_______________415567808Remove eyelid lesion(s)1EACH$__________$__________$_______________415667810Biopsy of eyelid4EACH$__________$__________$_______________415767825Revise eyelashes1EACH$__________$__________$_______________415867835Revise eyelashes1EACH$__________$__________$_______________415967840Remove eyelid lesion5EACH$__________$__________$_______________416067875Closure of eyelid by suture5EACH$__________$__________$_______________416167900Repair brow defect35EACH$__________$__________$_______________416267901Repair eyelid defect1EACH$__________$__________$_______________416367904Repair eyelid defect98EACH$__________$__________$_______________416467908Repair eyelid defect4EACH$__________$__________$_______________416567914Repair eyelid defect1EACH$__________$__________$_______________416667917Repair eyelid defect60EACH$__________$__________$_______________416767921Repair eyelid defect5EACH$__________$__________$_______________416867923Repair eyelid defect5EACH$__________$__________$_______________416967924Repair eyelid defect8EACH$__________$__________$_______________417067950Revision of eyelid2EACH$__________$__________$_______________417167961Revision of eyelid1EACH$__________$__________$_______________417267971Reconstruction of eyelid1EACH$__________$__________$_______________417368110Remove eyelid lining lesion1EACH$__________$__________$_______________417468320Revise/graft eyelid lining9EACH$__________$__________$_______________417568330Revise eyelid lining6EACH$__________$__________$_______________417668340Separate eyelid adhesions1EACH$__________$__________$_______________417768720Create tear sac drain2EACH$__________$__________$_______________417868770Close tear system fistula1EACH$__________$__________$_______________417968810Probe nasolacrimal duct1EACH$__________$__________$_______________418068815Probe nasolacrimal duct5EACH$__________$__________$_______________General Surgery418138500Lymph node excisions1EACH$__________$__________$_______________418238745Anoscopy and biopsy1EACH$__________$__________$_______________418346606Anoscopy and biopsy1EACH$__________$__________$_______________418449505prp i/hern init reduc >5 yr2EACH$__________$__________$_______________418549950Rpr rem hernia init reduce5EACH$__________$__________$_______________Surgical Pathology418688304Level III Surgical pathology, gross and microscopic2EACH$__________$__________$_______________418788305Level IV surgical pathology, gross and microscopic26EACH$__________$__________$_______________418888331Intraoperative pathology exam with frozen section19EACH$__________$__________$_______________418988332Intraoperative pathology exam with frozen section24EACH$__________$__________$_______________Total Cost for Ambulatory Surgery Procedures Option Year Four (4) $________________________Anesthesia Services for Associated Ambulatory Surgery ProceduresCLIN No.CPTCODEDescriptionAnesthesia CodeEst.Qty.Medicare Expected Anesthesia Per Unit Reimbursement Rate by Specialty% of discountOffered Anesthesia Per Unit Reimbursement Rate by Specialty (Unit Rate)Medicare Anesthesia Base Unit Value per Anesthesia Code (Base Units)National AVG Anesthesia Time Units (15 minute increments) per Anesthesia Code (Time Units)(Base Units + Time Units) x Unit Rate =(Unit Cost)Total Estimated Unit Cost Per YearOrthopedics419020551Inj tendon origin/insertion000001$___________%$________________$________$________419120610Drain/inject joint/bursa016302$___________%$________________$________$________419220670Removal of support implant016201$___________%$________________$________$________419323120Partial removal collar bone004505$___________%$________________$________$________419423130Remove shoulder bone part016301$___________%$________________$________$________419523412Repair rotator cuff chronic016303$___________%$________________$________$________419623430Repair biceps tendon0163012$___________%$________________$________$________419723700Fixation of shoulder016201$___________%$________________$________$________419824000Exploratory elbow surgery017401$___________%$________________$________$________419924006Release elbow joint017408$___________%$________________$________$________420024075Exc arm/elbow les sc < 3 cm004001$___________%$________________$________$________420124105Removal of elbow bursa017101$___________%$________________$________$________420224147Partial removal of elbow017402$___________%$________________$________$________420324341Repair arm tendon/muscle017101$___________%$________________$________$________420424342Repair of ruptured tendon017101$___________%$________________$________$________420524358Repair elbow w/deb open01712-017161$___________%$________________$________$________420624359Repair elbow deb/attch open01712-017161$___________%$________________$________$________420726115Exc hand les sc < 1.5 cm018101$___________%$________________$________$________420826123Release palm contracture018101$___________%$________________$________$________420926340Manipulate finger w/anesth018201$___________%$________________$________$________421026607Treat metacarpal fracture0182010$___________%$________________$________$________421126765Treat finger fracture each018301$___________%$________________$________$________421227340Removal of kneecap bursa013201$___________%$________________$________$________421327347Remove knee cyst014001$___________%$________________$________$________421427385Repair of thigh muscle013201$___________%$________________$________$________421527420Fixation of shoulder013201$___________%$________________$________$________421627422Revision of unstable kneecap013201$___________%$________________$________$________421727427Reconstruction knee013201$___________%$________________$________$_______421827570Fixation of knee joint013803$___________%$________________$________$_______421927600Decompression of lower leg01470-014742$___________%_$________________$________$_______422027618Exc leg/ankle tum < 3cm004001$___________%$________________$________$_______422127634Exc leg/ankle tum dep 5 cm/>004001$___________%$________________$________$_______422227635Remove lower leg bone lesion01480-014861$___________%$________________$________$_______422329805Shoulder arthroscopy dx016221$___________%$________________$________$_______422429806Shoulder arthroscopy surgery016301$___________%$________________$________$_______422529807Shoulder arthroscopy surgery016308$___________%$________________$________$_______422629820Shoulder arthroscopy/surgery016301$___________%$________________$________$_______422729822Shoulder arthroscopy/surgery0163018$___________%$________________$________$_______422829823Shoulder arthroscopy/surgery016308$___________%$________________$________$_______422929824Shoulder arthroscopy/surgery016308$___________%$________________$________$_______423029825Shoulder arthroscopy/surgery016306$___________%$________________$________$_______423129827Arthroscop rotator cuff repr0163040$___________%$________________$________$_______423229828Arthroscopy biceps tenodesis016308$___________%$________________$________$_______423329870Knee arthroscopy dx013824$___________%$________________$________$_______423429873Knee arthroscopy/surgery014002$___________%$________________$________$_______423529874Knee arthroscopy/surgery014002$___________%$________________$________$_______423629875Knee arthroscopy/surgery014004$___________%$________________$________$_______423729877Knee arthroscopy/surgery014009$___________%$________________$________$_______423829880Knee arthroscopy/surgery014005$___________%$________________$________$_______423929881Knee arthroscopy/surgery0140046$___________%$________________$________$_______424029888Knee arthroscopy/surgery014009$___________%$________________$________$_______424164708Revise arm/leg nerve01470-014741$___________%$________________$________$_______424264721Carpal tunnel surgery018108$___________%$________________$________$_______424364722Relieve pressure on nerve(s)01470-014741$___________%$________________$________$_______Podiatry424420670Removal of support implant018201$___________%$________________$________$_______424520680Removal of support implant018302$___________%$________________$________$_______424627618Exc leg/ankle tum < 3 cm004002$___________%$________________$________$_______424727680Release of lower leg tendon01470-014742$___________%$________________$________$_______424827698Repair of ankle ligament01470-014742$___________%$________________$________$_______424928008Incision of foot fascia01470-014742$___________%$________________$________$_______425028043Exc foot/toe tum sc < 1.5 cm01470-014742$___________%$________________$________$_______425128045Exc foot/toe tum deep < 1.5 cm01470-014741$___________%$________________$________$_______425228080Repair lower leg tendons01470-014741$___________%$________________$________$_______425328122Partial removal of foot bone01480-014861$___________%$________________$________$_______425428285Repair of hammertoe014807$___________%$________________$________$_______425528288Partial removal of foot bone014801$___________%$________________$________$_______425628289Repair hallux rigidus01480-014862$___________%$________________$________$_______425728293Correction of bunion01480-014864$___________%$________________$________$_______425828296Correction of bunion01480-014864$___________%$________________$________$_______425964722Relieve pressure on nerve(s)016101$___________%$________________$________$_______Urology426010140Drainage of hematoma/fluid003001$___________%$________________$_______$_______426153020Incision of uretha009201$___________%$________________$_______$_______426254060Excision of penis lesion (s)009201$___________%$________________$_______$_______426354111Treat penis lesion graft009201$___________%$________________$_______$_______426454112Treat penis lesion graft009201$___________%$________________$_______$_______426554161Circum 28 days or older009201$___________%$________________$_______$_______426654360Penis plastic surgery009205$___________%$________________$_______$_______426754400Insert semi-rigid prosthesis009388$___________%$________________$_______$_______426854405Insert multi-comp penis pros0093835$___________%$________________$_______$_______426954406Revmove multi-comp penis pros009201$___________%$________________$_______$_______427054408Repair multi-comp penis pro009203$___________%$________________$_______$_______427154410Remove/replace penis prosth009384$___________%$________________$_______$_______427254520Removal of testis009201$___________%$________________$_______$_______427354700Drainage of scrotum009201$___________%$________________$_______$_______427454840Remove epididymus lesion009206$___________%$________________$_______$_______427554860Removal of epididymis009204$___________%$________________$_______$_______427655040Removal of hydroceles0092016$___________%$________________$_______$_______427755175Revision of scrotum009201$___________%$________________$_______$_______427855250Removal of sperm duct(s)00921-009221$___________%$________________$_______$_______427955400Removal of sperm duct0092014$___________%$________________$_______$_______428055530Revise spermatic cord veins009202$___________%$________________$_______$_______428164425N block inj ilio-ing/hypogi000001$___________%$________________$_______$_______Plastics428211100Biopsy skin lesion003001$___________%$________________$_______$_______428311402Exc tr-ext b9+marg 1.1-2 cm003007$___________%$________________$_______$_______428411422Exc h-f-nk-sp b9+marg 1.1-2003003$___________%$________________$_______$_______428511440Exc face-mm-b9+marg 0.5 < cm003005$___________%$________________$_______$_______428611441Exc face-mm b9+marg 0.6-1cm003001$___________%$________________$_______$_______428711626Exc s/n/h/f/g mal+mrg > 4 cm003001$___________%$________________$_______$_______428811642Exc face-mm malig+marg 1.1-20030010$___________%$________________$_______$_______428911643Exc f/e/e/n/l mal+mrg 2.1-3003002$___________%$________________$_______$_______429011646Exc face-mm mlg+marg > 4 cm003004$___________%$________________$_______$_______429111771Removal of pilonidal lesion003001$___________%$________________$_______$_______429212035Intmd wnd repair s/a/t/ext003001$___________%$________________$_______$_______429312044Intmd wnd repair n-hf/genit003001$___________%$________________$_______$_______429412051Intmd wnd repair face/mm003001$___________%$________________$_______$_______429512052Intmd wnd repair face/mm003001$___________%$________________$_______$_______429612053Intmd wnd repair face/mm003001$___________%$________________$_______$_______429713132Repair of wound or lesion003001$___________%$________________$_______$_______429814040Skin tissue rearrangement003001$___________%$________________$_______$_______429914060Skin tissue rearrangement003001$___________%$________________$_______$_______430015260Skin full graft een & lips0030035$___________%$________________$_______$_______430115275Skin sub graft face/nk/hf/g003002$___________%$________________$_______$_______430215732Muscle-skin graft head/neck003001$___________%$________________$_______$_______430315770Derma-fat-fascia graft003001$___________%$________________$_______$_______430415839Excise excessive skin tissue003002$___________%$________________$_______$_______430515878Suction assisted lipectomy004001$___________%$________________$_______$_______430619300Removal of breast tissue004001$___________%$________________$_______$_______430719318Reduction of large breast004021$___________%$________________$_______$_______430821011Exc face les sc < 2 cm003001$___________%$________________$_______$_______430921014Exc face tum deep 2 cm/>003001$___________%$________________$_______$_______431025071Exc forearm les sc 3 cm/>004001$___________%$________________$_______$_______Otolaryngology431121235Ear cartilage graft00120-001261$___________%$________________$_______$_______431230130Excise inferior turbinate00160-001644$___________%$________________$_______$_______431330140Resect inferior turbinate00160-001647$___________%$________________$_______$_______431430465Repair nasal stenosis00160-001643$___________%$________________$_______$_______431530520Repair of nasal septum00160-0016418$___________%$________________$_______$_______431630930Ther fx nasal inf turbinate00160-001644$___________%$________________$_______$_______431731231Nasal endoscopy dx00160-001641$___________%$________________$_______$_______431831237Nasal/sinus endoscopy surg00160-001641$___________%$________________$_______$_______431931254Revision of ethmoid sinus00160-001644$___________%$________________$_______$_______432031255Removal of ethmoid sinus00160-0016412$___________%$________________$_______$_______432131256Exploration maxillary sinus00160-001647$___________%$________________$_______$_______432231267Endoscopy maxillary sinus00160-0016410$___________%$________________$_______$_______432331276Sinus endoscopy surgical00160-0016416$___________%$________________$_______$_______432431287Nasal/sinus endoscopy surg00160-001645$___________%$________________$_______$_______432531288Nasal/sinus endoscopy surg00160-001644$___________%$________________$_______$_______432631295Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______432731296Sinus endo w/balloon dil00160-001641$___________%$________________$_______$_______432840818Excise oral mucosa for graft001701$___________%$________________$_______$_______432942826Removal of tonsils001701$___________%$________________$_______$_______433069436Create eardrum opening00120-001261$___________%$________________$_______$_______Ophthalmology433115820Revision of lower eyelid001032$___________%$________________$_______$_______433215821Revision of lower eyelid001036$___________%$________________$_______$_______433315822Revision of lower eyelid0010320$___________%$________________$_______$_______433415823Revision of lower eyelid0010330$___________%$________________$_______$_______433521390Treat eye socket fracture00190-001921$___________%$________________$_______$_______433665105Remove eye/attach implant00140-001481$___________%$________________$_______$_______433765130Insert ocular implant00140-001482$___________%$________________$_______$_______433866183Insert ant drainage device00140-001484$___________%$________________$_______$_______433966825Reposition intraocular lens00140-001481$___________%$________________$_______$_______434066840Removal of lens material00140-001482$___________%$________________$_______$_______434166982Cataract surgery complex00140-0014852$___________%$________________$_______$_______434266984Cataract surg w/iol 1 stage00140-00148720$___________%$________________$_______$_______434367412Explore/treat eye socket00140-001482$___________%$________________$_______$_______434467808Remove eyelid lesion(s)003001$___________%$________________$_______$_______434567810Biopsy of eyelid003004$___________%$________________$_______$_______434667825Revise eyelashes001031$___________%$________________$_______$_______434767835Revise eyelashes001031$___________%$________________$_______$_______434867840Remove eyelid lesion003005$___________%$________________$_______$_______434967875Closure of eyelid by suture003005$___________%$________________$_______$_______435067900Repair brow defect0030035$___________%$________________$_______$_______435167901Repair eyelid defect003001$___________%$________________$_______$_______435267904Repair eyelid defect0010398$___________%$________________$_______$_______435367908Repair eyelid defect001034$___________%$________________$_______$_______435467914Repair eyelid defect001031$___________%$________________$_______$_______435567917Repair eyelid defect0010360$___________%$________________$_______$_______435667921Repair eyelid defect001035$___________%$________________$_______$_______435767923Repair eyelid defect001035$___________%$________________$_______$_______435867924Repair eyelid defect001038$___________%$________________$_______$_______435967950Revision of eyelid001032$___________%$________________$_______$_______436067961Revision of eyelid001031$___________%$________________$_______$_______436167971Reconstruction of eyelid001031$___________%$________________$_______$_______436268110Remove eyelid lining lesion00140-001481$___________%$________________$_______$_______436368320Revise/graft eyelid lining00140-001489$___________%$________________$_______$_______436468330Revise eyelid lining00140-001486$___________%$________________$_______$_______436568340Separate eyelid adhesions00140-001481$___________%$________________$_______$_______436668720Create tear sac drain00140-001482$___________%$________________$_______$_______436768770Close tear system fistula00140-001481$___________%$________________$_______$_______436868810Probe nasolacrimal duct00140-001481$___________%$________________$_______$_______436968815Probe nasolacrimal duct00140-001485$___________%$________________$_______$_______General Surgery437038500Lymph node excisions003201$___________%$________________$_______$_______437138745Anoscopy and biopsy016101$___________%$________________$_______$_______437246606Anoscopy and biopsy009021$___________%$________________$_______$_______437349505prp i/hern init reduc >5 yr00830-008362$___________%$________________$_______$_______437449950Rpr rem hernia init reduce00830-008365$___________%$________________$_______$_______Surgical Pathology437588304Level III Surgical pathology, gross and microscopicN/A2$___________%$________________$_______$_______437688305Level IV surgical pathology, gross and microscopicN/A26$___________%$________________$_______$_______437788331Intraoperative pathology exam with frozen sectionN/A19$___________%$________________$_______$_______437888332Intraoperative pathology exam with frozen sectionN/A24$___________%$________________$_______$_______Total Cost for Anesthesia Services Option Year Four (4) $_________________________Total Cost for Ambulatory Surgery Procedures + Anesthesia Services Option Year Four (4) $____Total for base performance period and all option years: $_________________________B.3 PERFORMANCE WORK STATEMENTGENERALSERVICES REQUIRED: The James A. Haley Veterans’ Hospital, a division of the United States Government’s Department of Veterans Affairs (JAHVH), has a need to provide services to veterans within our service area to provide ambulatory surgical procedures performed by JAHVH Physicians at the contractors’ sites. The contractors shall provide the facility in which to perform ambulatory surgery for patients of the JAHVH including, but not limited to, anesthesia services, qualified OR nurses and technicians; operating microscope and instruments; and usual and customary supplies required during operative procedures at the ambulatory surgery center. Operative procedures at the ambulatory surgery center include but are not limited to orthopedics, podiatry, urology, plastic surgery, otolaryngology, ophthalmology, and general surgery. It is the JAHVH intention to solicit a proposal in accordance with all terms, conditions, provision, specifications, and schedules of this solicitation and award a contract to two (2) facilities on a competitive basis under the authority of FAR Part 12, FAR Part 15, and Title 38 U.S.C. 8153. Place of Performance: The ambulatory surgery facilities must be freestanding, and shall be located within a 15 mile driving distance of the James A. Haley VA Hospital, 13000 Bruce B. Downs Blvd, Tampa, FL. to provide accessibility for JAHVH physicians and patients between the two sites.AUTHORITY/POLICY/HANDBOOKS: It is the JAHVH intention to solicit a proposal in accordance with all terms, conditions, provision, specifications, and schedules of this solicitation and award a contract on a competitive basis under the authority of Title 38 U.S.C. 8153, Health Care Resources (HCR) Sharing Authority,.VA Directive 1663: Health Care Resources Contracting - Buying VHA Handbook 1605.1 Privacy and Release of Information Handbook 1907.01 Health Information Management and Health Records: Privacy Act of 1974 (5 U.S.C. 552a) as amended Insurance Portability and Accountability Act of 1996 (HIPAA) Directive 2006-041 “Veterans’ Health Care Service Standards” (expired but still in effect pending revision) VHA Handbook 1100.18 Reporting And Responding To State Licensing Boards Commission HHS OIG Website American Journal for Infection Control - AJIC 1998; 26:289-354 DEFINITIONS/ACRONYMSAAAHC: Accreditation Association of Ambulatory Health Care – CFR: Code of Federal RegulationsCMS: Centers for Medicare & Medicaid ServicesCO: Contracting OfficerCOR: Contracting Officer RepresentativeCOS: Chief of StaffCPARS: Computerized Performance Assessment Reporting SystemCPRS: Computerized Patient Recordkeeping System-electronic health record system used by the VACRNA: Certified Registered Nurse AnesthetistEFT: Electronic Funds TransferFAR: Federal Acquisition RegulationsHIPAA: Health Insurance Portability and Accountability ActISO: Information Security OfficerIT: Information TechnologyJAHVH: James A. Haley Veterans’ Hospital and ClinicsOIG: Office of Inspector GeneralOI&T: Office of Information and TechnologyOPM: Office of Personnel ManagementOR: Operating RoomQASP: Quality Assurance Surveillance PlanPHI: Protected Health InformationPWS: Performance Work StatementRFP: Request for ProposalTIN: Tax ID NumberUSC: United States CodeVAMC: Veterans Affairs Medical CenterVHA: Veterans Health AdministrationVISTA (Veterans Integrated Systems Technology Architecture): A PC based system that will capture and store clinical imagery, scanned documents and other non-textual data files and integrates them into patient’s medical records and with the hospital information system.QUALIFICATIONSCONTRACTOR PERSONNEL:Anesthesiology Personnel: Anesthesiology Physicians & Certified Registered Nurse Anesthesiologists (CRNA)The contractors’ Anesthesiology Services to include physicians and certified registered nurse anesthetists (CRNA) performing under this contract are required to be Board Eligible or Board Certified by the American Board of Anesthesiology or the American Osteopathic Board of Anesthesiology. These Contract Personnel must show evidence of specialized training in Anesthesiology. Contract Personnel must have experience commensurate with the required services of the contract.Ambulatory Surgery Personnel: Operating Room (OR) Nurses & Operating Room (OR) TechniciansThe contractors’ Ambulatory Surgery Services to include operating room (OR) nurses performing under this contract are required to have a Bachelor of Science in Nursing degree (BSN), a current Basic Cardiac Life Support Certification (BCLS), and a Certification in Operating Room Nursing (CNOR). The Ambulatory Surgery Services will also include Operating Room (OR) Technicians who are required to be certified as a Certified Surgery Technician (CST).Contractor Personnel assigned to perform the services covered by this contract shall be licensed in the State of Florida.The Contractors are responsible for insuring they have a current affiliation agreement with University of South Florida is in place for any fellow, resident or trainee teaching and educational association.The Contractors will comply with hospital and educational program requirements for fellow, resident or trainee supervision. GOVERNMENT PERSONNELThe Contractor(s) is responsible for credentialing and re-credentialing JAHVH staff physicians with the contractor(s) facility. Credentialing must be completed PRIOR to the performance of surgical services.JAHVH staff physicians will complete appropriate application, forms and pertinent documents associated with credentialing.The Contractors shall designate a Contract Point of Contact who shall provide supervision of personnel in its Professional Group that will be performing services under this contract.HOURS OF OPERATION:BUSINESS HOURSWork Hours: hours begin 06:30 a.m. – 5:00 p.m. Monday through Friday for operating rooms Monday, Tuesday, Wednesday, Thursday and Friday with a 60 day notice to increase or decrease number of procedures, except National Holidays, Nonworking hours and Emergency Work hours described below: Federal Holidays: The ten holidays observed by the Federal Government are as follows:New Year’s Day, Martin Luther King Day, President’s Day, Memorial Day, Independence Day, Labor Day, Columbus Day, Veteran’s Day, Thanksgiving and Christmas or any other day specifically declared by the President of the United States to be a National Holiday. Nonworking hours: 5:00 p.m. – 6:30 a.m. Monday through Friday, Saturday, Sunday and National Holidays. Emergency Work hours: 5:00 p.m. – 6:30 a.m. Monday through Friday, Saturday, Sunday and National Holidays.CONTRACTORS RESPONSIBILITIES SERVICES REQUIRED: The Contractors shall pay for usual supplies which are used and needed to perform the operations, excluding implants.The JAHVH will supply and arrange for the vendor to bring to the facility any specialized or high cost implants, screws and instrumentation from the JAHVH or arrange to have it there for a specific operation if required.The Contractors shall provide Operating Room storage for supplies brought to facility for JAHVH physician usage.The Contractors shall provide availability of laparoscopic equipment.The Contractors shall provide information and specifications on laparoscopic equipment to the Contracting Officers Representative (COR) for approval.The Contractors’ will provided a VA dedicated and secure work room, large enough for two (2) to three (3) computer’s and one printer provided by the VA; the contractors will provide one telephone, desks/tables, two to four chairs and one locking floor to ceiling cabinet for additional supplies and items needed for physicians and staff.The Contractors shall provide a secured punch code combination on the door for entry access for JAHVH staff. The VA work room needs to be within close vicinity to the operating rooms for physicians and residents to quickly access for entering the electronic pre and post op notes before and immediately after surgical procedures.The Contractors’ Point of Contact shall be available for advice and assistance to the COR and the appointed JAHVH support staff on the utilization of resources, scheduling and equipment, as well as the overall continuous quality improvement program for functions being performed.The Contractors shall provide access to their electronic scheduling package utilized by the facility to COR and support staff to input patients for surgical procedures.The Contractors will provide access and make available electronic and/or paper documentation from each patient’s medical record the day of surgery for all surgical procedures performed. The contractors shall provide anatomic pathology services in anatomic pathology at the request of JAHVH physicians. Anatomic pathology services shall include gross tissue evaluation, frozen section, permanent histology and intraoperative cytology. A copy of the report needs to be provided to the JAHVH support staff and COR.Standard Operation Procedures for anatomic pathology services will be established post award as mutually agreed upon between contractors and COR.Contractors shall not release any medical record information provided under the terms of this contract.Contractors shall provide JAHVH physicians, COR and support staff access to all areas deemed necessary to perform and complete all tasks required for direct patient care.The Contractors shall provide access to their electronic clinical documents utilized by the facility via secured portal and/or the paper record to COR and support staff to print and/or make copies on a high quality copier and printer the Nursing Intraoperative report, Time Out Records, Anesthesia Record, and Contractors Informed Consent for Operative Procedures signed the day of surgery for the JAHVH surgical procedures and patients.STANDARDS OF PRACTICE:Contractors shall be responsible for meeting or exceeding VA and Joint Commission along with Accreditation Association of Ambulatory Health Care (AAAHC) (or equivalent) standards.RESIDENT SUPERVISION AND TEACHING:The Contractors will comply with hospital and educational program requirements for resident supervision.The Contractors shall complete all medical record documentation as outlined in Medical Staff Bylaws, Rules and Regulations, and Hospital Policy or equivalent accrediting agency. MEDICAL RECORDS:JAHVH physician and/or resident will dictate and/or document the Operative report immediately following the procedure, but no longer than 24 hours after completion of the procedure.JAHVH physician will document in CPRS the pre-operative attending note within 30 minutes of surgical procedure start time.JAHVH physician and/or resident will document in CPRS the immediate post-op note within one (1) hour of operative case completion.The JAHVH physician and/or resident shall enter and sign all CPRS electronic notes (pre-op attending note, operation note, immediate post op note, pathology consult, etc.) as stated in the JAHVH Hospital Policy. JAHVH will provide the Contractors a copy of the completed operative note, post op note, pathology and/or lab results, and notes related to report post-op infections and any documentation of patients transferred to the JAHVH facility emergently from the contracted facility.DIRECT PATIENT CARE: JAHVH patients will be evaluated at the JAHVH and scheduled for the procedure at the ambulatory surgery facility.Necessary preoperative work-up, laboratory testing, cardiac clearance and informed patient consent will be performed at the JAHVH. Laboratory results within 90 days, history and physical, EKG, and cardiac clearance will be provided to the contractors 3-4 days or sooner before scheduled procedure. Contractors Pre-op nurses will contact VA COR and/or support staff of any other relevant preoperative work-up documents needed, the COR and/or support staff will contact VA Mid-level for additional documents as needed.JAHVH will arrange to either provide these from JAHVH support staff from the JAHVH to the contractors or to fax them to a secure location at the contractors’ facility during normal duty hours with a cover sheet containing a confidentiality statement. The schedule/list of procedures will be sent with support staff or faxed (faxing will be to a secure dedicated fax with cover sheet) and/or entered in the contractors’ electronic scheduling package at the ambulatory surgery facility at least one week prior to the date of the procedures. Add on/Urgent cases will be faxed along with a personal call from Clinical Mid-Level at least 3-4 days prior to the date of the procedure. Routine specimens will be picked up by a courier service and delivered to the JAHVH pathology department to be processed and evaluated by JAHVH. Transfer of these specimens to JAHVH will be via courier service supplied by the JAHVH. Courier contact information will be provided to Contractors for setting up the pick-up. Printed pathology consult has to be included with every specimen that will be picked up by Courier. Patient surgical records will be entered by JAHVH physicians, residents, COR and support staff only through a JAHVH computer terminal at the contract facility. The JAHVH will provide computer equipment restricted to use by JAHVH personnel only. Contractors will make available to JAHVH support staff and/or COR their anesthesia records, inter operative nursing record, contractors informed patient consent and anesthesia time out sheet the same day of the procedure. Designated JAHVH support staff and/or COR will copy the documents, enter cases into the Surgery Operative Package in VISTA and will be scanned into the patient record at the JAHVH facility. In emergent situations, operative times will be called for and the documentation will be obtained the following work day and/or faxed (faxing will be to a secure dedicated fax with cover sheet) to a JAHVH authorized and secured fax machine to support staff and/or COR. Requests for medical information shall be referred to the JAHVH Release of Information Unit. Standard Operation Procedures for the processes will be established post award as mutually agreed upon between contractors and COR.PERFORMANCE STANDARDS, QUALITY ASSURANCE AND QUALITY IMPROVEMENT:Methods of Surveillance will be included in the Quality Assurance Surveillance Plan (QASP) provided as an attachment defining: Validation, 100% inspection and random inspection. Performance Measures:Measure: Quality of CarePerformance Requirement: Accreditation of FacilityStandard: Ambulatory Surgery Facility must be accredited by JCAHO or equivalent i.e. Accreditation Association of Ambulatory Health Care (AAAHC)Acceptable Quality Level: 100%Surveillance Method: Documentation of accreditationIncentive: Favorable Contractor Performance Evaluation, and Task Order awardsDisincentive: Unfavorable contractor performance evaluationMeasure: Quality of CarePerformance Requirement: PrivilegesStandard: Anesthesiologist and CRNA providers must be privileged within the scope of their training and experience.Acceptable Quality Level: 100%Surveillance Method: Documentation of accreditationIncentive: Favorable Contractor Performance Evaluation, and Task Order awardsDisincentive: Unfavorable contractor performance evaluationMeasure: Quality of CarePerformance Requirement: Contractor’s ComplianceStandard: Contractors shall be in compliance with Medicare, Medicaid and any other related federal and state statures, regulations, rules and policies.Acceptable Quality Level: 100%Surveillance Method: Documentation of complianceIncentive: Favorable Contractor Performance Evaluation, and Task Order awardsDisincentive: Unfavorable contractor performance evaluationMeasure: Patient SafetyPerformance Requirement: Patient Safety incidents must be reported to the authorizing VA medical center and COR. This should include, but are not limited to: Airway event, Regional/MAC Adverse event, CNS/PNS event, Cardio respiratory event, unplanned admissions, and mortality.Standard: All incidents reported immediately (within 24 hours.)Acceptable Quality Level: 95%Surveillance Method: Observation and random inspection (auditing) or any other method that was proposed in your solution .Incentive: Favorable Contractor Performance Evaluation, and Task Order awardsDisincentive: Unfavorable contractor performance evaluationMeasure: Equipment, Supplies, StaffingPerformance Requirement: The contractors will provide all necessary equipment and supplies needed to perform the operation and qualified OR nurses and technicians.Standard: Equipment will be in proper working conditions, supplies readily available and have licensed and/or certified staff.Acceptable Quality Level: 95%Surveillance Method: Observation and review of staff documentation along with physician feedback and surveys.Incentive: Favorable Contractor Performance Evaluation, and Task Order awardsDisincentive: Unfavorable contractor performance evaluationMeasure: Patient CarePerformance Requirement: Patients will not require hospital admission or EmergencyDepartment visit related to surgery and/or anesthesia after their outpatient ambulatory procedure.Standard: All unplanned admissions or Emergency Department visits - with none to be from adverse event from surgery and/or anesthesia will be monitored on a quarterly base for review.Acceptable Quality Level: 95%Surveillance Method: Quarterly Reports will be submitted and reviewed from the Contract Facility to the COR.Incentive: Favorable Contractor Performance Evaluation, and Task Order awardsDisincentive: Unfavorable contractor performance evaluationMeasure: Surgical ComplicationsPerformance Requirement: Patients will not experience post-operative infections or other surgical complications after their outpatient ambulatory procedure.Standard: All surgical infections and complications per patient will be monitored on the quarterly report and followed for patient satisfaction and case by case peer reviews.Acceptable Quality Level: 95%Surveillance Method: Quarterly Reports will be submitted and reviewed from the Contract Facility to the COR.Incentive: Favorable Contractor Performance Evaluation, and Task Order awardsDisincentive: Unfavorable contractor performance evaluationMeasure: DocumentationPerformance Requirement: Anesthesia recordStandard: All anesthesia post-operative notes will be documented and be readily available after the surgical procedure.Acceptable Quality Level: 95%Surveillance Method: Review of Operative NotesIncentive: Favorable Contractor Performance Evaluation, and Task Order awardsDisincentive: Unfavorable contractor performance evaluationMeasure: Provider QualityPerformance Requirement: Anesthesia serviceStandard: Anesthesia services are accrued through the provision of adequate space, equipment, supplies, medications, and appropriately trained personnel.Acceptable Quality Level: 95%Surveillance Method: Direct observation and review of documentationIncentive: Favorable Contractor Performance Evaluation, and Task Order awardsDisincentive: Unfavorable contractor performance evaluationGOVERNMENT RESPONSIBILITIESGOVERNMENT SERVICES:All services rendered by JAHVH physicians and residents shall be performed at the contracted facilities. The Government shall provide the computers and printer, set up with VA Network Access for electronic documentation, located in the dedicated, secure workroom to be used by JAHVH physicians, resident, support staff, and COR. JAHVH will schedule a minimum of 50 cases a month up 120 maximum. The number of maximum monthly cases is negotiable once 120 volumes met. INHERENTLY GOVERNMENTAL FUNCTIONS:Contractor and contract staff shall not perform inherently governmental functions. This includes, but is not limited to, determination of agency policy, determination of Federal program priorities for budget requests, direction and control of government employees, selection or non-selection of individuals for Federal Government employment including the interviewing of individuals for employment, approval of position descriptions and performance standards for Federal employees, approving any contractual documents, approval of Federal licensing actions and inspections, and/or determination of budget policy, guidance, and strategy.Non-personal Services: The parties agree that The Contractor, contract staff, agents and sub-Contractors shall not be considered VA employees for any purpose.Special Contract RequirementsINVOICES AND PAYMENTSPayment for surgical procedures, anesthesia services and anatomic pathology services provided under this contract will be in accordance with title 42 CFR.415.178. Payments will be based on current Florida Medicare Ambulatory Surgery Center rates and will be all inclusive.The contractors will be paid in arrears upon receipt of invoice. The invoice will include the contractors’ name, purchase order number, the name of the patient, social security number, CPT code, diagnosis, physician name, total dollar amount of invoice, and date of service. The Contractors must include the VA Contract Number on every invoice i.e., 673C-XXXXX. The invoices shall be sent electronically to the Department of Veterans Affairs Financial Services Center (VA FSC). VA FSC offer the following alternatives for electronic invoices:Electronic Data Interchange (EDI) – ANSI X-12 v4010 (minimum required) or v5010 (optional). Further information regarding EDI solution can be obtained by visiting the Department of Veterans Affairs ECD specific site at or email the ECD team directly at FSCEDIFinancialTeam@ or sarah.snyder2@OB10 – A third party provider contracted by Veterans Affairs (VA) to assist with electronic invoicing. Further information regarding OB10 solution can be obtained by visiting the Department of Veterans Affairs OB10 specific site at – A Veterans Affairs Web based portal for low volume vendors using the Internet. Go to and click on the link that says “Not already a user? Click here to create a new account.”Invoices for services shall be submitted by the contractor no more than one (1) year from date the services were performed.CONTRACTORS Security Requirements:Any liability of the VA for any claims, losses, damages, suits, complaints or actions in any forum whatsoever, related to its services under this contract shall be pursuant to the terms of the Federal Tort Claims Act, 28 U.S.C. Section 1346(b), 2671-80, and related regulations and policies. The contractors shall hold harmless and indemnify the VA from any and all claims, losses, damages, liabilities, costs, expenses or obligations arising out of or resulting from the wrongful or negligent conduct of the contractors, its employees, agents or volunteers in performance of this contract.The contractors shall be accredited by The Joint Commission, Accreditation Association of Ambulatory Health Care or equivalent accrediting agency.The contractors shall follow all Joint Commission accreditation standards in determining the appropriate qualifications, credentials of personnel, including maintaining competency skills checklists and onsite inspections conducted by JAHVH Environment of Care Round Team quarterly and if deficiencies are found, facility will be fix within 10 days and update COR and/or support staff of what was done and completion date.The contractors’ expectation is to follow Governmental Body of Requirement Regulatory Guidelines to uphold the standard of care as defined by the JAHVH. The contractors agree to make available the qualifications of personnel performing services under this contract.The Contractors shall bear the expense of obtaining background investigations. If the investigation is conducted by the Office of Personnel Management (OPM), the contractors shall reimburse VA within 30 days.The Contractors shall prescreen all personnel requiring access to the computer systems to ensure they maintain a U.S. citizenship and are able to read, write, speak and understand the English language.Failure to comply with the contractor’s personnel security requirements may result in termination of the contract for default.SECURE FAX: VA Handbook 6500 requires the following statement on all fax cover sheets to be included: “This fax is intended only for the use of the person or office to which it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that the receipt of this fax does not waive any applicable privilege or exemption for disclosure and that any dissemination, distribution, or copying of this communication is prohibited. If you have received this fax in error, please notify this office immediately at the telephone number listed above.”ANNUAL OFFICE OF INSPECTOR GENERAL (OIG) STATEMENT: In accordance with HIPAA and the Balanced Budget Act (BBA) of 1977, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) has established a list of parties and entities excluded from Federal health care programs. Specifically, the listed parties and entities may not receive Federal Health Care program payments due to fraud and/or abuse of the Medicare and Medicaid programs. Therefore, Contractor shall review the HHS OIG List of Excluded Individuals/Entities on the HHS OIG web site referenced above to ensure that the proposed contract physician (s) are not listed. Contractor should note that any excluded individual or entity that submits a claim for reimbursement to a Federal health care program, or causes such a claim to be submitted, may be subject to a Civil Monetary Penalty (CMP) for each item or service furnished during a period that the person was excluded and may also be subject to treble damages for the amount claimed for each item or service. CMP’s may also be imposed against the Contractor that employ or enter into contracts with excluded individuals to provide items or services to Federal program beneficiaries. By submitting their proposal, the Contractor certifies that the HHS OIG List of Excluded Individuals/Entities has been reviewed and that the Contractors are and/or firm is not listed as of the date the offer/bid was signed.SERVICES CHARGED TO VA BENEFICIARIES: VA beneficiaries shall not under any circumstances be charged nor their insurance companies charged for services rendered by the contractor even if VA does not pay for those services. This provision shall survive the termination or ending of the contract.STANDARD OF CARE: Standard of Care should be equal or greater to that provided by the VAMC.REGISTRATION WITH CONTRACT PERFORMANCE ASSESSMENT SYSTEM (CPARS). (a) As prescribed in Federal Acquisition Regulation (FAR) 42.15, the Department of Veterans Affairs (VA) evaluates contractor past performance on all contracts that exceed $150,000, and shares those evaluations with other Federal Government contract specialists and procurement officials. The FAR requires that the contractor be provided an opportunity to comment on past performance evaluations prior to each reporting closing. To fulfill this requirement VA uses an online database, CPARS, which is maintained by the Naval Seal Logistics Center in Portsmouth, Virginia. CPARS has connectivity with the Past Performance Information Retrieval System (PPIRS) database, which is available to all Federal agencies. PPIRS is the system used to collect and retrieve performance assessment reports used in source selection determination and completed CPARS report cards transferred to PPIRS. CPARS also includes access to the federal awardee performance and integrity information system (FAPIIS). FAPIIS is a web-enabled application accessed via CPARS for contractor responsibility determination information. (b) Each contractor whose contract award is estimated to exceed $150,000 is required to register with CPARS database at the following web address: cpars.csd.disa.mil. Help in registering can be obtained by contacting Customer Support Desk @ DSN: 684-1690 or COMM: 207-438-1690. Registration should occur no later than thirty days after contract award, and must be kept current should there be any change to the contractor’s registered representative.(c) For contracts with a period of one year or less, the contracting officer will perform a single evaluation when the contract is complete. For contracts exceeding one year, the contracting officer will evaluate the contractor’s performance annually. Interim reports will be filed each year until the last year of the contract, when the final report will be completed. The report shall be assigned in CPARS to the contractor’s designated representative for comment. The contractor representative will have thirty days to submit any comments and re-assign the report to the VA contracting officer. (d) Failure to have a current registration in the CPARS database, or to re-assign the report to the VA contracting officer within those thirty days, will result in the Government’s evaluation being placed on file in the database with a statement that the contractor failed to respond.SAM REGISTRATION: Offeror must be registered in the System for Award Management (SAM). (SAM includes the functionality of the previous Central Contractor Registration [CCR] and Online Representations and Certifications Application [ORCA]). No contract will be entered into with an unregistered contractor. Internet access allows registration by completing an electronic on-line registration application at AWARD ORIENTATION: The Contracting Officer will schedule a post award orientation conference for contract orientation purposes as required by IL 003A3-12-04.CREDENTIALING AND PRIVLIDGING: The contract must state that credentialing and privileging is to be done in accordance with VA Directive 1663 and in accordance with the provisions of VHA Handbook 1100.19 (October 15, 2012).INSURANCE LIABILITY: Contractor shall not under any circumstances charge VA beneficiaries or their insurance companies for services rendered by the contractor even if VA does not pay for those services. This provision shall survive the termination or ending of the contract.With No Sensitive Data but Requires TrainingVA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGEVA INFORMATION CUSTODIAL LANGUAGE:a. Contractors, contractor’s personnel, subcontractors, and subcontractor’s personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.b. If VA determines that the contractors has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractors or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12. c. A contractors/subcontractors shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order. d. All contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures. SECURITY INCIDENT INVESTIGATION:a. The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractors/subcontractors shall immediately notify the COR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractors/subcontractors has access.b. To the extent known by the contractors/subcontractors, the contractors/subcontractors’ notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractors/subcontractors considers relevant. c. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement. d. In instances of theft or break-in or other criminal activity, the contractors/subcontractors must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractors, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractors/subcontractors shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident. LIQUIDATED DAMAGES FOR DATA BREACH:a. Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractors is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractors/subcontractors processes or maintains under this contract. b. The contractors/subcontractors shall provide notice to VA of a “security incident” as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractors shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination. SECURITY CONTROLS COMPLIANCE TESTING:On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all of the security controls and privacy practices implemented by the contractors under the clauses contained within the contract. With 10 working-days’ notice, at the request of the government, the contractors must fully cooperate and assist in a government-sponsored security controls assessment at each location wherein VA information is processed or stored, or information systems are developed, operated, maintained, or used on behalf of VA, including those initiated by the Office of Inspector General. The government may conduct a security control assessment on shorter notice (to include unannounced assessments) as determined by VA in the event of a security incident or at any other time. TRAINING:a. All contractors’ employees and subcontractors’ employees requiring access to VA information and VA information systems shall complete VA Privacy and Information Security Awareness and Rules of Behavior Training before being granted access to VA information and its systems.(1) Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Rules of Behavior before being granted access to VA information and its systems.b. The contractors shall provide to the contracting officer and/or the COR a copy of the training certificates and certification of signing the Rules of Behavior for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required. c. Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete. The Certification and Accreditation (C&A) requirements do not apply and a Security Accreditation Package is not required for this PWS. Records Management Contract LanguageThe following standard items relate to records generated in executing the contract and should be included in a typical Electronic Information Systems (EIS) procurement contract:1. Citations to pertinent laws, codes and regulations such as 44 U.S.C chapters 21, 29, 31 and 33; Freedom of Information Act (5 U.S.C. 552); Privacy Act (5 U.S.C. 552a); 36 CFR Part 1222 and Part 1228.2. Contractors shall treat all deliverables under the contract as the property of the U.S. Government for which the Government Agency shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. 3. Contractors shall not create or maintain any records that are not specifically tied to or authorized by the contract using Government IT equipment and/or Government records. 4. Contractors shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected by the Freedom of Information Act. 5. Contractors shall not create or maintain any records containing any Government Agency records that are not specifically tied to or authorized by the contract. 6. The Government Agency owns the rights to all data/records produced as part of this contract. 7. The Government Agency owns the rights to all electronic information (electronic data, electronic information systems, electronic databases, etc.) and all supporting documentation created as part of this contract. Contractors must deliver sufficient technical documentation with all data deliverables to permit the agency to use the data. 8. Contractors agree to comply with Federal and Agency records management policies, including those policies associated with the safeguarding of records covered by the Privacy Act of 1974. These policies include the preservation of all records created or received regardless of format [paper, electronic, etc.] or mode of transmission [e-mail, fax, etc.] or state of completion [draft, final, etc.]. 9. No disposition of documents will be allowed without the prior written consent of the Contracting Officer. The Agency and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. Records may not be removed from the legal custody of the Agency or destroyed without regard to the provisions of the agency records schedules. 10. Contractors are required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractors) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, this contract. The Contractors (and any sub-contractors) is required to abide by Government and Agency guidance for protecting sensitive and proprietary information. SECTION C - CONTRACT CLAUSESC.1 52.203-16 PREVENTING PERSONAL CONFLICTS OF INTEREST (DEC 2011)(a) Definitions. As used in this clause— “Acquisition function closely associated with inherently governmental functions” means supporting or providing advice or recommendations with regard to the following activities of a Federal agency:(1) Planning acquisitions.(2) Determining what supplies or services are to be acquired by the Government, including developing statements of work.(3) Developing or approving any contractual documents, to include documents defining requirements, incentive plans, and evaluation criteria.(4) Evaluating contract proposals.(5) Awarding Government contracts.(6) Administering contracts (including ordering changes or giving technical direction in contract performance or contract quantities, evaluating contractor performance, and accepting or rejecting contractor products or services).(7) Terminating contracts.(8) Determining whether contract costs are reasonable, allocable, and allowable.“Covered employee” means an individual who performs an acquisition function closely associated with inherently governmental functions and is—(1) An employee of the contractor; or(2) A subcontractor that is a self-employed individual treated as a covered employee of the contractor because there is no employer to whom such an individual could submit the required disclosures.“Non-public information” means any Government or third-party information that—(1) Is exempt from disclosure under the Freedom of Information Act (5 U.S.C. 552) or otherwise protected from disclosure by statute, Executive order, or regulation; or (2) Has not been disseminated to the general public and the Government has not yet determined whether the information can or will be made available to the public.“Personal conflict of interest” means a situation in which a covered employee has a financial interest, personal activity, or relationship that could impair the employee’s ability to act impartially and in the best interest of the Government when performing under the contract. (A de minimis interest that would not “impair the employee’s ability to act impartially and in the best interest of the Government” is not covered under this definition.) (1) Among the sources of personal conflicts of interest are—(i) Financial interests of the covered employee, of close family members, or of other members of the covered employee’s household;(ii) Other employment or financial relationships (including seeking or negotiating for prospective employment or business); and(iii) Gifts, including travel.(2) For example, financial interests referred to in paragraph (1) of this definition may arise from—(i) Compensation, including wages, salaries, commissions, professional fees, or fees for business referrals;(ii) Consulting relationships (including commercial and professional consulting and service arrangements, scientific and technical advisory board memberships, or serving as an expert witness in litigation);(iii) Services provided in exchange for honorariums or travel expense reimbursements;(iv) Research funding or other forms of research support;(v) Investment in the form of stock or bond ownership or partnership interest (excluding diversified mutual fund investments);(vi) Real estate investments;(vii) Patents, copyrights, and other intellectual property interests; or(viii) Business ownership and investment interests.(b) Requirements. The Contractor shall— (1) Have procedures in place to screen covered employees for potential personal conflicts of interest, by—(i) Obtaining and maintaining from each covered employee, when the employee is initially assigned to the task under the contract, a disclosure of interests that might be affected by the task to which the employee has been assigned, as follows:(A) Financial interests of the covered employee, of close family members, or of other members of the covered employee’s household.(B) Other employment or financial relationships of the covered employee (including seeking or negotiating for prospective employment or business).(C) Gifts, including travel; and(ii) Requiring each covered employee to update the disclosure statement whenever the employee’s personal or financial circumstances change in such a way that a new personal conflict of interest might occur because of the task the covered employee is performing.(2) For each covered employee—(i) Prevent personal conflicts of interest, including not assigning or allowing a covered employee to perform any task under the contract for which the Contractor has identified a personal conflict of interest for the employee that the Contractor or employee cannot satisfactorily prevent or mitigate in consultation with the contracting agency;(ii) Prohibit use of non-public information accessed through performance of a Government contract for personal gain; and(iii) Obtain a signed non-disclosure agreement to prohibit disclosure of non-public information accessed through performance of a Government contract.(3) Inform covered employees of their obligation—(i) To disclose and prevent personal conflicts of interest;(ii) Not to use non-public information accessed through performance of a Government contract for personal gain; and(iii) To avoid even the appearance of personal conflicts of interest;(4) Maintain effective oversight to verify compliance with personal conflict-of-interest safeguards;(5) Take appropriate disciplinary action in the case of covered employees who fail to comply with policies established pursuant to this clause; and(6) Report to the Contracting Officer any personal conflict-of-interest violation by a covered employee as soon as it is identified. This report shall include a description of the violation and the proposed actions to be taken by the Contractor in response to the violation. Provide follow-up reports of corrective actions taken, as necessary. Personal conflict-of-interest violations include—(i) Failure by a covered employee to disclose a personal conflict of interest;(ii) Use by a covered employee of non-public information accessed through performance of a Government contract for personal gain; and(iii) Failure of a covered employee to comply with the terms of a non-disclosure agreement.(c) Mitigation or waiver. (1) In exceptional circumstances, if the Contractor cannot satisfactorily prevent a personal conflict of interest as required by paragraph (b)(2)(i) of this clause, the Contractor may submit a request through the Contracting Officer to the Head of the Contracting Activity for—(i) Agreement to a plan to mitigate the personal conflict of interest; or(ii) A waiver of the requirement.(2) The Contractor shall include in the request any proposed mitigation of the personal conflict of interest.(3) The Contractor shall—(i) Comply, and require compliance by the covered employee, with any conditions imposed by the Government as necessary to mitigate the personal conflict of interest; or(ii) Remove the Contractor employee or subcontractor employee from performance of the contract or terminate the applicable subcontract.(d) Subcontract flowdown. The Contractor shall include the substance of this clause, including this paragraph (d), in subcontracts— (1) That exceed $150,000; and(2) In which subcontractor employees will perform acquisition functions closely associated with inherently governmental functions (i.e., instead of performance only by a self-employed individual). (End of clause)C.2 52.203-99 PROHIBITION ON CONTRACTING WITH ENTITIES THAT REQUIRE CERTAIN INTERNAL CONFIDENTIALITY AGREEMENTS (DEVIATION) (FEB 2015) (a) The Contractor shall not require employees or contractors seeking to report fraud, waste, or abuse to sign or comply with internal confidentiality agreements or statements prohibiting or otherwise restricting such employees or subcontractors from lawfully reporting such waste, fraud, or abuse to a designated investigative or law enforcement representative of a Federal department or agency authorized to receive such information. (b) The contractor shall notify employees that the prohibitions and restrictions of any internal confidentiality agreements covered by this clause are no longer in effect. (c) The prohibition in paragraph (a) of this clause does not contravene requirements applicable to Standard Form 312, Form 4414, or any other form issued by a Federal department or agency governing the nondisclosure of classified information. (d)(1) In accordance with section 743 of Division E, Title VII, of the Consolidated and Further Continuing Resolution Appropriations Act, 2015 (Pub. L. 113-235), use of funds appropriated (or otherwise made available) under that or any other Act may be prohibited, if the Government determines that the Contractor is not in compliance with the provisions of this clause. (2) The Government may seek any available remedies in the event the contractor fails to comply with the provisions of this clause.(End of Clause)C.3 52.204-4 PRINTED OR COPIED DOUBLE-SIDED ON POSTCONSUMER FIBER CONTENT PAPER (MAY 2011)(a) Definitions. As used in this clause— “Postconsumer fiber” means—(1) Paper, paperboard, and fibrous materials from retail stores, office buildings, homes, and so forth, after they have passed through their end-usage as a consumer item, including: used corrugated boxes; old newspapers; old magazines; mixed waste paper; tabulating cards; and used cordage; or(2) All paper, paperboard, and fibrous materials that enter and are collected from municipal solid waste; but not(3) Fiber derived from printers’ over-runs, converters’ scrap, and over-issue publications.(b) The Contractor is required to submit paper documents, such as offers, letters, or reports that are printed or copied double-sided on paper containing at least 30 percent postconsumer fiber, whenever practicable, when not using electronic commerce methods to submit information or data to the Government.(End of clause)C.4 52.204-9 PERSONAL IDENTITY VERIFICATION OF CONTRACTOR PERSONNEL (JAN 2011)(a) The Contractor shall comply with agency personal identity verification procedures identified in the contract that implement Homeland Security Presidential Directive-12 (HSPD-12), Office of Management and Budget (OMB) guidance M-05-24 and Federal Information Processing Standards Publication (FIPS PUB) Number 201.(b) The Contractor shall account for all forms of Government-provided identification issued to the Contractor employees in connection with performance under this contract. The Contractor shall return such identification to the issuing agency at the earliest of any of the following, unless otherwise determined by the Government:(1) When no longer needed for contract performance.(2) Upon completion of the Contractor employee’s employment.(3) Upon contract completion or termination.(c) The Contracting Officer may delay final payment under a contract if the Contractor fails to comply with these requirements.(d) The Contractor shall insert the substance of this clause, including this paragraph (d), in all subcontracts when the subcontractor’s employees are required to have routine physical access to a Federally-controlled facility and/or routine access to a Federally-controlled information system. It shall be the responsibility of the prime Contractor to return such identification to the issuing agency in accordance with the terms set forth in paragraph (b) of this section, unless otherwise approved in writing by the Contracting Officer.(End of clause)C.5 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL ITEMS (MAY 2015) (a) Inspection/Acceptance. The Contractor shall only tender for acceptance those items that conform to the requirements of this contract. The Government reserves the right to inspect or test any supplies or services that have been tendered for acceptance. The Government may require repair or replacement of nonconforming supplies or reperformance of nonconforming services at no increase in contract price. If repair/replacement or reperformance will not correct the defects or is not possible, the Government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming supplies or services. The Government must exercise its post-acceptance rights— (1) Within a reasonable time after the defect was discovered or should have been discovered; and (2) Before any substantial change occurs in the condition of the item, unless the change is due to the defect in the item. (b) Assignment. The Contractor or its assignee may assign its rights to receive payment due as a result of performance of this contract to a bank, trust company, or other financing institution, including any Federal lending agency in accordance with the Assignment of Claims Act (31 U.S.C. 3727). However, when a third party makes payment (e.g., use of the Governmentwide commercial purchase card), the Contractor may not assign its rights to receive payment under this contract. (c) Changes. Changes in the terms and conditions of this contract may be made only by written agreement of the parties. (d) Disputes. This contract is subject to 41 U.S.C. chapter 71, Contract Disputes. Failure of the parties to this contract to reach agreement on any request for equitable adjustment, claim, appeal or action arising under or relating to this contract shall be a dispute to be resolved in accordance with the clause at FAR 52.233-1, Disputes, which is incorporated herein by reference. The Contractor shall proceed diligently with performance of this contract, pending final resolution of any dispute arising under the contract. (e) Definitions. The clause at FAR 52.202-1, Definitions, is incorporated herein by reference. (f) Excusable delays. The Contractor shall be liable for default unless nonperformance is caused by an occurrence beyond the reasonable control of the Contractor and without its fault or negligence such as, acts of God or the public enemy, acts of the Government in either its sovereign or contractual capacity, fires, floods, epidemics, quarantine restrictions, strikes, unusually severe weather, and delays of common carriers. The Contractor shall notify the Contracting Officer in writing as soon as it is reasonably possible after the commencement of any excusable delay, setting forth the full particulars in connection therewith, shall remedy such occurrence with all reasonable dispatch, and shall promptly give written notice to the Contracting Officer of the cessation of such occurrence. (g) Invoice. (1) The Contractor shall submit an original invoice and three copies (or electronic invoice, if authorized) to the address designated in the contract to receive invoices. An invoice must include— (i) Name and address of the Contractor; (ii) Invoice date and number; (iii) Contract number, contract line item number and, if applicable, the order number; (iv) Description, quantity, unit of measure, unit price and extended price of the items delivered; (v) Shipping number and date of shipment, including the bill of lading number and weight of shipment if shipped on Government bill of lading; (vi) Terms of any discount for prompt payment offered; (vii) Name and address of official to whom payment is to be sent; (viii) Name, title, and phone number of person to notify in event of defective invoice; and (ix) Taxpayer Identification Number (TIN). The Contractor shall include its TIN on the invoice only if required elsewhere in this contract. (x) Electronic funds transfer (EFT) banking information. (A) The Contractor shall include EFT banking information on the invoice only if required elsewhere in this contract. (B) If EFT banking information is not required to be on the invoice, in order for the invoice to be a proper invoice, the Contractor shall have submitted correct EFT banking information in accordance with the applicable solicitation provision, contract clause (e.g., 52.232-33, Payment by Electronic Funds Transfer—System for Award Management, or 52.232-34, Payment by Electronic Funds Transfer—Other Than System for Award Management), or applicable agency procedures. (C) EFT banking information is not required if the Government waived the requirement to pay by EFT. (2) Invoices will be handled in accordance with the Prompt Payment Act (31 U.S.C. 3903) and Office of Management and Budget (OMB) prompt payment regulations at 5 CFR part 1315. (h) Patent indemnity. The Contractor shall indemnify the Government and its officers, employees and agents against liability, including costs, for actual or alleged direct or contributory infringement of, or inducement to infringe, any United States or foreign patent, trademark or copyright, arising out of the performance of this contract, provided the Contractor is reasonably notified of such claims and proceedings. (i) Payment.— (1) Items accepted. Payment shall be made for items accepted by the Government that have been delivered to the delivery destinations set forth in this contract. (2) Prompt payment. The Government will make payment in accordance with the Prompt Payment Act (31 U.S.C. 3903) and prompt payment regulations at 5 CFR part 1315. (3) Electronic Funds Transfer (EFT). If the Government makes payment by EFT, see 52.212-5(b) for the appropriate EFT clause. (4) Discount. In connection with any discount offered for early payment, time shall be computed from the date of the invoice. For the purpose of computing the discount earned, payment shall be considered to have been made on the date which appears on the payment check or the specified payment date if an electronic funds transfer payment is made. (5) Overpayments. If the Contractor becomes aware of a duplicate contract financing or invoice payment or that the Government has otherwise overpaid on a contract financing or invoice payment, the Contractor shall— (i) Remit the overpayment amount to the payment office cited in the contract along with a description of the overpayment including the— (A) Circumstances of the overpayment (e.g., duplicate payment, erroneous payment, liquidation errors, date(s) of overpayment); (B) Affected contract number and delivery order number, if applicable; (C) Affected contract line item or subline item, if applicable; and (D) Contractor point of contact. (ii) Provide a copy of the remittance and supporting documentation to the Contracting Officer. (6) Interest. (i) All amounts that become payable by the Contractor to the Government under this contract shall bear simple interest from the date due until paid unless paid within 30 days of becoming due. The interest rate shall be the interest rate established by the Secretary of the Treasury as provided in 41 U.S.C. 7109, which is applicable to the period in which the amount becomes due, as provided in (i)(6)(v) of this clause, and then at the rate applicable for each six-month period as fixed by the Secretary until the amount is paid. (ii) The Government may issue a demand for payment to the Contractor upon finding a debt is due under the contract. (iii) Final decisions. The Contracting Officer will issue a final decision as required by 33.211 if— (A) The Contracting Officer and the Contractor are unable to reach agreement on the existence or amount of a debt within 30 days; (B) The Contractor fails to liquidate a debt previously demanded by the Contracting Officer within the timeline specified in the demand for payment unless the amounts were not repaid because the Contractor has requested an installment payment agreement; or (C) The Contractor requests a deferment of collection on a debt previously demanded by the Contracting Officer (see 32.607-2). (iv) If a demand for payment was previously issued for the debt, the demand for payment included in the final decision shall identify the same due date as the original demand for payment. (v) Amounts shall be due at the earliest of the following dates: (A) The date fixed under this contract. (B) The date of the first written demand for payment, including any demand for payment resulting from a default termination. (vi) The interest charge shall be computed for the actual number of calendar days involved beginning on the due date and ending on— (A) The date on which the designated office receives payment from the Contractor; (B) The date of issuance of a Government check to the Contractor from which an amount otherwise payable has been withheld as a credit against the contract debt; or (C) The date on which an amount withheld and applied to the contract debt would otherwise have become payable to the Contractor. (vii) The interest charge made under this clause may be reduced under the procedures prescribed in 32.608-2 of the Federal Acquisition Regulation in effect on the date of this contract. (j) Risk of loss. Unless the contract specifically provides otherwise, risk of loss or damage to the supplies provided under this contract shall remain with the Contractor until, and shall pass to the Government upon: (1) Delivery of the supplies to a carrier, if transportation is f.o.b. origin; or (2) Delivery of the supplies to the Government at the destination specified in the contract, if transportation is f.o.b. destination. (k) Taxes. The contract price includes all applicable Federal, State, and local taxes and duties. (l) Termination for the Government's convenience. The Government reserves the right to terminate this contract, or any part hereof, for its sole convenience. In the event of such termination, the Contractor shall immediately stop all work hereunder and shall immediately cause any and all of its suppliers and subcontractors to cease work. Subject to the terms of this contract, the Contractor shall be paid a percentage of the contract price reflecting the percentage of the work performed prior to the notice of termination, plus reasonable charges the Contractor can demonstrate to the satisfaction of the Government using its standard record keeping system, have resulted from the termination. The Contractor shall not be required to comply with the cost accounting standards or contract cost principles for this purpose. This paragraph does not give the Government any right to audit the Contractor's records. The Contractor shall not be paid for any work performed or costs incurred which reasonably could have been avoided. (m) Termination for cause. The Government may terminate this contract, or any part hereof, for cause in the event of any default by the Contractor, or if the Contractor fails to comply with any contract terms and conditions, or fails to provide the Government, upon request, with adequate assurances of future performance. In the event of termination for cause, the Government shall not be liable to the Contractor for any amount for supplies or services not accepted, and the Contractor shall be liable to the Government for any and all rights and remedies provided by law. If it is determined that the Government improperly terminated this contract for default, such termination shall be deemed a termination for convenience. (n) Title. Unless specified elsewhere in this contract, title to items furnished under this contract shall pass to the Government upon acceptance, regardless of when or where the Government takes physical possession. (o) Warranty. The Contractor warrants and implies that the items delivered hereunder are merchantable and fit for use for the particular purpose described in this contract. (p) Limitation of liability. Except as otherwise provided by an express warranty, the Contractor will not be liable to the Government for consequential damages resulting from any defect or deficiencies in accepted items. (q) Other compliances. The Contractor shall comply with all applicable Federal, State and local laws, executive orders, rules and regulations applicable to its performance under this contract. (r) Compliance with laws unique to Government contracts. The Contractor agrees to comply with 31 U.S.C. 1352 relating to limitations on the use of appropriated funds to influence certain Federal contracts; 18 U.S.C. 431 relating to officials not to benefit; 40 U.S.C. chapter 37, Contract Work Hours and Safety Standards; 41 U.S.C. chapter 87, Kickbacks; 41 U.S.C. 4712 and 10 U.S.C. 2409 relating to whistleblower protections; 49 U.S.C. 40118, Fly American; and 41 U.S.C. chapter 21 relating to procurement integrity. (s) Order of precedence. Any inconsistencies in this solicitation or contract shall be resolved by giving precedence in the following order: (1) The schedule of supplies/services. (2) The Assignments, Disputes, Payments, Invoice, Other Compliances, Compliance with Laws Unique to Government Contracts, and Unauthorized Obligations paragraphs of this clause; (3) The clause at 52.212-5. (4) Addenda to this solicitation or contract, including any license agreements for computer software. (5) Solicitation provisions if this is a solicitation. (6) Other paragraphs of this clause. (7) The Standard Form 1449. (8) Other documents, exhibits, and attachments (9) The specification. (t) System for Award Management (SAM). (1) Unless exempted by an addendum to this contract, the Contractor is responsible during performance and through final payment of any contract for the accuracy and completeness of the data within the SAM database, and for any liability resulting from the Government's reliance on inaccurate or incomplete data. To remain registered in the SAM database after the initial registration, the Contractor is required to review and update on an annual basis from the date of initial registration or subsequent updates its information in the SAM database to ensure it is current, accurate and complete. Updating information in the SAM does not alter the terms and conditions of this contract and is not a substitute for a properly executed contractual document. (2)(i) If a Contractor has legally changed its business name, "doing business as" name, or division name (whichever is shown on the contract), or has transferred the assets used in performing the contract, but has not completed the necessary requirements regarding novation and change-of-name agreements in FAR subpart 42.12, the Contractor shall provide the responsible Contracting Officer a minimum of one business day's written notification of its intention to (A) change the name in the SAM database; (B) comply with the requirements of subpart 42.12; and (C) agree in writing to the timeline and procedures specified by the responsible Contracting Officer. The Contractor must provide with the notification sufficient documentation to support the legally changed name. (ii) If the Contractor fails to comply with the requirements of paragraph (t)(2)(i) of this clause, or fails to perform the agreement at paragraph (t)(2)(i)(C) of this clause, and, in the absence of a properly executed novation or change-of-name agreement, the SAM information that shows the Contractor to be other than the Contractor indicated in the contract will be considered to be incorrect information within the meaning of the "Suspension of Payment" paragraph of the electronic funds transfer (EFT) clause of this contract. (3) The Contractor shall not change the name or address for EFT payments or manual payments, as appropriate, in the SAM record to reflect an assignee for the purpose of assignment of claims (see Subpart 32.8, Assignment of Claims). Assignees shall be separately registered in the SAM database. Information provided to the Contractor's SAM record that indicates payments, including those made by EFT, to an ultimate recipient other than that Contractor will be considered to be incorrect information within the meaning of the "Suspension of payment" paragraph of the EFT clause of this contract. (4) Offerors and Contractors may obtain information on registration and annual confirmation requirements via SAM accessed through . (u) Unauthorized Obligations. (1) Except as stated in paragraph (u)(2) of this clause, when any supply or service acquired under this contract is subject to any End User License Agreement (EULA), Terms of Service (TOS), or similar legal instrument or agreement, that includes any clause requiring the Government to indemnify the Contractor or any person or entity for damages, costs, fees, or any other loss or liability that would create an Anti-Deficiency Act violation (31 U.S.C. 1341), the following shall govern: (i) Any such clause is unenforceable against the Government. (ii) Neither the Government nor any Government authorized end user shall be deemed to have agreed to such clause by virtue of it appearing in the EULA, TOS, or similar legal instrument or agreement. If the EULA, TOS, or similar legal instrument or agreement is invoked through an “I agree” click box or other comparable mechanism (e.g., “click-wrap” or “browse-wrap” agreements), execution does not bind the Government or any Government authorized end user to such clause. (iii) Any such clause is deemed to be stricken from the EULA, TOS, or similar legal instrument or agreement. (2) Paragraph (u)(1) of this clause does not apply to indemnification by the Government that is expressly authorized by statute and specifically authorized under applicable agency regulations and procedures.(v) Incorporation by reference. The Contractor’s representations and certifications, including those completed electronically via the System for Award Management (SAM), are incorporated by reference into the contract.(End of Clause)C.6 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT STATUTES OR EXECUTIVE ORDERS—COMMERCIAL ITEMS (MAR 2016)(a) The Contractor shall comply with the following Federal Acquisition Regulation (FAR) clauses, which are incorporated in this contract by reference, to implement provisions of law or Executive orders applicable to acquisitions of commercial items:(1) 52.209-10, Prohibition on Contracting with Inverted Domestic Corporations (Nov 2015) (2) 52.233-3, Protest After Award (Aug 1996) (31 U.S.C. 3553). (3) 52.233-4, Applicable Law for Breach of Contract Claim (Oct 2004)(Public Laws 108-77 and 108-78 (19 U.S.C. 3805 note)). (b) The Contractor shall comply with the FAR clauses in this paragraph (b) that the Contracting Officer has indicated as being incorporated in this contract by reference to implement provisions of law or Executive orders applicable to acquisitions of commercial items:[Contracting Officer check as appropriate.] X_ (1) 52.203-6, Restrictions on Subcontractor Sales to the Government (Sept 2006), with Alternate I (Oct 1995) (41 U.S.C. 4704 and 10 U.S.C. 2402). X_ (2) 52.203-13, Contractor Code of Business Ethics and Conduct (Oct 2015) (41 U.S.C. 3509)). __ (3) 52.203-15, Whistleblower Protections under the American Recovery and Reinvestment Act of 2009 (June 2010) (Section 1553 of Pub. L. 111-5). (Applies to contracts funded by the American Recovery and Reinvestment Act of 2009.) X (4) 52.204-10, Reporting Executive Compensation and First-Tier Subcontract Awards (Oct 2015) (Pub. L. 109-282) (31 U.S.C. 6101 note). __ (5) [Reserved].X (6) 52.204-14, Service Contract Reporting Requirements (Jan 2014) (Pub. L. 111-117, section 743 of Div. C). X (7) 52.204-15, Service Contract Reporting Requirements for Indefinite-Delivery Contracts (Jan 2014) (Pub. L. 111-117, section 743 of Div. C). X (8) 52.209-6, Protecting the Government’s Interest When Subcontracting with Contractors Debarred, Suspended, or Proposed for Debarment. (Oct 2015) (31 U.S.C. 6101 note). X (9) 52.209-9, Updates of Publicly Available Information Regarding Responsibility Matters (Jul 2013) (41 U.S.C. 2313). __ (10) [Reserved].__ (11)(i) 52.219-3, Notice of HUBZone Set-Aside or Sole-Source Award (Nov 2011) (15 U.S.C. 657a). __ (ii) Alternate I (Nov 2011) of 52.219-3. X (12)(i) 52.219-4, Notice of Price Evaluation Preference for HUBZone Small Business Concerns (Oct 2014) (if the offeror elects to waive the preference, it shall so indicate in its offer) (15 U.S.C. 657a). __ (ii) Alternate I (Jan 2011) of 52.219-4. __ (13) [Reserved]__ (14)(i) 52.219-6, Notice of Total Small Business Set-Aside (Nov 2011) (15 U.S.C. 644). __ (ii) Alternate I (Nov 2011).__ (iii) Alternate II (Nov 2011).__ (15)(i) 52.219-7, Notice of Partial Small Business Set-Aside (June 2003) (15 U.S.C. 644). __ (ii) Alternate I (Oct 1995) of 52.219-7. __ (iii) Alternate II (Mar 2004) of 52.219-7. X (16) 52.219-8, Utilization of Small Business Concerns (Oct 2014) (15 U.S.C. 637(d)(2) and (3)). __ (17)(i) 52.219-9, Small Business Subcontracting Plan (Oct 2015) (15 U.S.C. 637(d)(4)). __ (ii) Alternate I (Oct 2001) of 52.219-9. X (iii) Alternate II (Oct 2001) of 52.219-9. __ (iv) Alternate III (Oct 2015) of 52.219-9. X (18) 52.219-13, Notice of Set-Aside of Orders (Nov 2011) (15 U.S.C. 644(r)). __ (19) 52.219-14, Limitations on Subcontracting (Nov 2011) (15 U.S.C. 637(a)(14)). __ (20) 52.219-16, Liquidated Damages—Subcon-tracting Plan (Jan 1999) (15 U.S.C. 637(d)(4)(F)(i)). __ (21) 52.219-27, Notice of Service-Disabled Veteran-Owned Small Business Set-Aside (Nov 2011) (15 U.S.C. 657 f). X (22) 52.219-28, Post Award Small Business Program Rerepresentation (Jul 2013) (15 U.S.C. 632(a)(2)). __ (23) 52.219-29, Notice of Set-Aside for, or Sole Source Award to, Economically Disadvantaged Women-Owned Small Business Concerns (Dec 2015) (15 U.S.C. 637(m)). __ (24) 52.219-30, Notice of Set-Aside for, or Sole Source Award to, Women-Owned Small Business Concerns Eligible Under the Women-Owned Small Business Program (Dec 2015) (15 U.S.C. 637(m)). X (25) 52.222-3, Convict Labor (June 2003) (E.O. 11755). __ (26) 52.222-19, Child Labor—Cooperation with Authorities and Remedies (Feb 2016) (E.O. 13126). X (27) 52.222-21, Prohibition of Segregated Facilities (Apr 2015). X (28) 52.222-26, Equal Opportunity (Apr 2015) (E.O. 11246). X (29) 52.222-35, Equal Opportunity for Veterans (Oct 2015)(38 U.S.C. 4212). X (30) 52.222-36, Equal Opportunity for Workers with Disabilities (Jul 2014) (29 U.S.C. 793). X (31) 52.222-37, Employment Reports on Veterans (Feb 2016) (38 U.S.C. 4212). X (32) 52.222-40, Notification of Employee Rights Under the National Labor Relations Act (Dec 2010) (E.O. 13496). _X(33)(i) 52.222-50, Combating Trafficking in Persons (Mar 2015) (22 U.S.C. chapter 78 and E.O. 13627). __ (ii) Alternate I (Mar 2015) of 52.222-50 (22 U.S.C. chapter 78 and E.O. 13627). _X(34) 52.222-54, Employment Eligibility Verification (Oct 2015). (Executive Order 12989). (Not applicable to the acquisition of commercially available off-the-shelf items or certain other types of commercial items as prescribed in 22.1803.) __ (35)(i) 52.223-9, Estimate of Percentage of Recovered Material Content for EPA–Designated Items (May 2008) (42 U.S.C. 6962(c)(3)(A)(ii)). (Not applicable to the acquisition of commercially available off-the-shelf items.) __ (ii) Alternate I (May 2008) of 52.223-9 (42 U.S.C. 6962(i)(2)(C)). (Not applicable to the acquisition of commercially available off-the-shelf items.) __ (36)(i) 52.223-13, Acquisition of EPEAT?-Registered Imaging Equipment (Jun 2014) (E.O.s 13423 and 13514). __ (ii) Alternate I (Oct 2015) of 52.223-13. __ (37)(i) 52.223-14, Acquisition of EPEAT?-Registered Televisions (Jun 2014) (E.O.s 13423 and 13514). __ (ii) Alternate I (Jun 2014) of 52.223-14. X (38) 52.223-15, Energy Efficiency in Energy-Consuming Products (Dec 2007) (42 U.S.C. 8259b). __ (39)(i) 52.223-16, Acquisition of EPEAT?-Registered Personal Computer Products (Oct 2015) (E.O.s 13423 and 13514). __ (ii) Alternate I (Jun 2014) of 52.223-16. X (40) 52.223-18, Encouraging Contractor Policies to Ban Text Messaging While Driving (Aug 2011) (E.O. 13513). X (41) 52.225-1, Buy American—Supplies (May 2014) (41 U.S.C. chapter 83). __ (42)(i) 52.225-3, Buy American—Free Trade Agreements—Israeli Trade Act (May 2014) (41 U.S.C. chapter 83, 19 U.S.C. 3301 note, 19 U.S.C. 2112 note, 19 U.S.C. 3805 note, 19 U.S.C. 4001 note, Pub. L. 103-182, 108-77, 108-78, 108-286, 108-302, 109-53, 109-169, 109-283, 110-138, 112-41, 112-42, and 112-43. __ (ii) Alternate I (May 2014) of 52.225-3. __ (iii) Alternate II (May 2014) of 52.225-3. __ (iv) Alternate III (May 2014) of 52.225-3. X (43) 52.225-5, Trade Agreements (Feb 2016) (19 U.S.C. 2501, et seq., 19 U.S.C. 3301 note). X (44) 52.225-13, Restrictions on Certain Foreign Purchases (June 2008) (E.O.’s, proclamations, and statutes administered by the Office of Foreign Assets Control of the Department of the Treasury). __ (45) 52.225-26, Contractors Performing Private Security Functions Outside the United States (Jul 2013) (Section 862, as amended, of the National Defense Authorization Act for Fiscal Year 2008; 10 U.S.C. 2302 Note). __ (46) 52.226-4, Notice of Disaster or Emergency Area Set-Aside (Nov 2007) (42 U.S.C. 5150). __ (47) 52.226-5, Restrictions on Subcontracting Outside Disaster or Emergency Area (Nov 2007) (42 U.S.C. 5150). __ (48) 52.232-29, Terms for Financing of Purchases of Commercial Items (Feb 2002) (41 U.S.C. 4505, 10 U.S.C. 2307(f)). X (49) 52.232-30, Installment Payments for Commercial Items (Oct 1995) (41 U.S.C. 4505, 10 U.S.C. 2307(f)). __ (50) 52.232-33, Payment by Electronic Funds Transfer—System for Award Management (Jul 2013) (31 U.S.C. 3332). X (51) 52.232-34, Payment by Electronic Funds Transfer—Other than System for Award Management (Jul 2013) (31 U.S.C. 3332). __ (52) 52.232-36, Payment by Third Party (May 2014) (31 U.S.C. 3332). __ (53) 52.239-1, Privacy or Security Safeguards (Aug 1996) (5 U.S.C. 552a). __ (54)(i) 52.247-64, Preference for Privately Owned U.S.-Flag Commercial Vessels (Feb 2006) (46 U.S.C. Appx. 1241(b) and 10 U.S.C. 2631). __ (ii) Alternate I (Apr 2003) of 52.247-64. (c) The Contractor shall comply with the FAR clauses in this paragraph (c), applicable to commercial services, that the Contracting Officer has indicated as being incorporated in this contract by reference to implement provisions of law or Executive orders applicable to acquisitions of commercial items:[Contracting Officer check as appropriate.] __ (1) 52.222-17, Nondisplacement of Qualified Workers (May 2014)(E.O. 13495)._X(2) 52.222-41, Service Contract Labor Standards (May 2014) (41 U.S.C. chapter 67). _X(3) 52.222-42, Statement of Equivalent Rates for Federal Hires (May 2014) (29 U.S.C. 206 and 41 U.S.C. chapter 67)._X(4) 52.222-43, Fair Labor Standards Act and Service Contract Labor Standards-Price Adjustment (Multiple Year and Option Contracts) (May 2014) (29 U.S.C. 206 and 41 U.S.C. chapter 67). __ (5) 52.222-44, Fair Labor Standards Act and Service Contract Labor Standards—Price Adjustment (May 2014) (29 U.S.C. 206 and 41 U.S.C. chapter 67). __ (6) 52.222-51, Exemption from Application of the Service Contract Labor Standards to Contracts for Maintenance, Calibration, or Repair of Certain Equipment—Requirements (May 2014) (41 U.S.C. chapter 67). __ (7) 52.222-53, Exemption from Application of the Service Contract Labor Standards to Contracts for Certain Services—Requirements (May 2014) (41 U.S.C. chapter 67). X (8) 52.222-55, Minimum Wages Under Executive Order 13658 (Dec 2015). __ (9) 52.226-6, Promoting Excess Food Donation to Nonprofit Organizations (May 2014) (42 U.S.C. 1792). X (10) 52.237-11, Accepting and Dispensing of $1 Coin (Sept 2008) (31 U.S.C. 5112(p)(1)). (d) Comptroller General Examination of Record. The Contractor shall comply with the provisions of this paragraph (d) if this contract was awarded using other than sealed bid, is in excess of the simplified acquisition threshold, and does not contain the clause at 52.215-2, Audit and Records—Negotiation. (1) The Comptroller General of the United States, or an authorized representative of the Comptroller General, shall have access to and right to examine any of the Contractor’s directly pertinent records involving transactions related to this contract.(2) The Contractor shall make available at its offices at all reasonable times the records, materials, and other evidence for examination, audit, or reproduction, until 3 years after final payment under this contract or for any shorter period specified in FAR Subpart 4.7, Contractor Records Retention, of the other clauses of this contract. If this contract is completely or partially terminated, the records relating to the work terminated shall be made available for 3 years after any resulting final termination settlement. Records relating to appeals under the disputes clause or to litigation or the settlement of claims arising under or relating to this contract shall be made available until such appeals, litigation, or claims are finally resolved. (3) As used in this clause, records include books, documents, accounting procedures and practices, and other data, regardless of type and regardless of form. This does not require the Contractor to create or maintain any record that the Contractor does not maintain in the ordinary course of business or pursuant to a provision of law.(e)(1) Notwithstanding the requirements of the clauses in paragraphs (a), (b), (c), and (d) of this clause, the Contractor is not required to flow down any FAR clause, other than those in this paragraph (e)(1) in a subcontract for commercial items. Unless otherwise indicated below, the extent of the flow down shall be as required by the clause— (i) 52.203-13, Contractor Code of Business Ethics and Conduct (Oct 2015) (41 U.S.C. 3509). (ii) 52.219-8, Utilization of Small Business Concerns (Oct 2014) (15 U.S.C. 637(d)(2) and (3)), in all subcontracts that offer further subcontracting opportunities. If the subcontract (except subcontracts to small business concerns) exceeds $700,000 ($1.5 million for construction of any public facility), the subcontractor must include 52.219-8 in lower tier subcontracts that offer subcontracting opportunities. (iii) 52.222-17, Nondisplacement of Qualified Workers (May 2014) (E.O. 13495). Flow down required in accordance with paragraph (l) of FAR clause 52.222-17. (iv) 52.222-21, Prohibition of Segregated Facilities (Apr 2015) (v) 52.222-26, Equal Opportunity (Apr 2015) (E.O. 11246). (vi) 52.222-35, Equal Opportunity for Veterans (Oct 2015) (38 U.S.C. 4212). (vii) 52.222-36, Equal Opportunity for Workers with Disabilities (Jul 2014) (29 U.S.C. 793). (viii) 52.222-37, Employment Reports on Veterans (Feb 2016) (38 U.S.C. 4212) (ix) 52.222-40, Notification of Employee Rights Under the National Labor Relations Act (Dec 2010) (E.O. 13496). Flow down required in accordance with paragraph (f) of FAR clause 52.222-40. (x) 52.222-41, Service Contract Labor Standards (May 2014) (41 U.S.C. chapter 67). (xi) __(A) 52.222-50, Combating Trafficking in Persons (Mar 2015) (22 U.S.C. chapter 78 and E.O 13627). __(B) Alternate I (Mar 2015) of 52.222-50 (22 U.S.C. chapter 78 and E.O 13627). (xii) 52.222-51, Exemption from Application of the Service Contract Labor Standards to Contracts for Maintenance, Calibration, or Repair of Certain Equipment-Requirements (May 2014) (41 U.S.C. chapter 67). (xiii) 52.222-53, Exemption from Application of the Service Contract Labor Standards to Contracts for Certain Services-Requirements (May 2014) (41 U.S.C. chapter 67). (xiv) 52.222-54, Employment Eligibility Verification (Oct 2015) (E.O. 12989). (xv) 52.222-55, Minimum Wages Under Executive Order 13658 (Dec 2015). (xvi) 52.225-26, Contractors Performing Private Security Functions Outside the United States (Jul 2013) (Section 862, as amended, of the National Defense Authorization Act for Fiscal Year 2008; 10 U.S.C. 2302 Note). (xvii) 52.226-6, Promoting Excess Food Donation to Nonprofit Organizations (May 2014) (42 U.S.C. 1792). Flow down required in accordance with paragraph (e) of FAR clause 52.226-6. (xviii) 52.247-64, Preference for Privately Owned U.S.-Flag Commercial Vessels (Feb 2006) (46 U.S.C. Appx. 1241(b) and 10 U.S.C. 2631). Flow down required in accordance with paragraph (d) of FAR clause 52.247-64. (2) While not required, the Contractor may include in its subcontracts for commercial items a minimal number of additional clauses necessary to satisfy its contractual obligations.(End of clause)C.7 52.216-18 ORDERING (OCT 1995) (a) Any supplies and services to be furnished under this contract shall be ordered by issuance of delivery orders or task orders by the individuals or activities designated in the Schedule. Such orders may be issued from the effective date of the contract through the end of the effective period. (b) All delivery orders or task orders are subject to the terms and conditions of this contract. In the event of conflict between a delivery order or task order and this contract, the contract shall control. (c) If mailed, a delivery order or task order is considered "issued" when the Government deposits the order in the mail. Orders may be issued orally, by facsimile, or by electronic commerce methods only if authorized in the Schedule.(End of Clause)C.8 52.216-19 ORDER LIMITATIONS (OCT 1995) (a) Minimum order. When the Government requires supplies or services covered by this contract in an amount less than $250,000.00 for one year, the Government is not obligated to purchase, nor is the Contractor obligated to furnish, those supplies or services under the contract. (b) Maximum order. The Contractor is not obligated to honor— (1) Any order for a combination of services in excess of $3.6 million for one year; or (2) A series of orders from the same ordering office within 365 days that together call for quantities exceeding the limitation in paragraph (b)(1) or (2) of this section. (c) If this is a requirements contract (i.e., includes the Requirements clause at subsection 52.216-21 of the Federal Acquisition Regulation (FAR)), the Government is not required to order a part of any one requirement from the Contractor if that requirement exceeds the maximum-order limitations in paragraph (b) of this section. (d) Notwithstanding paragraphs (b) and (c) of this section, the Contractor shall honor any order exceeding the maximum order limitations in paragraph (b), unless that order (or orders) is returned to the ordering office within 5 days after issuance, with written notice stating the Contractor's intent not to ship the item (or items) called for and the reasons. Upon receiving this notice, the Government may acquire the supplies or services from another source.(End of Clause)C.9 52.216-22 INDEFINITE QUANTITY (OCT 1995)(a) This is an indefinite-quantity contract for the supplies or services specified, and effective for the period stated, in the Schedule. The quantities of supplies and services specified in the Schedule are estimates only and are not purchased by this contract.(b) Delivery or performance shall be made only as authorized by orders issued in accordance with the Ordering clause. The Contractor shall furnish to the Government, when and if ordered, the supplies or services specified in the Schedule up to and including the quantity designated in the Schedule as the maximum. The Government shall order at least the quantity of supplies or services designated in the Schedule as the minimum.(c) Except for any limitations on quantities in the Order Limitations clause or in the Schedule, there is no limit on the number of orders that may be issued. The Government may issue orders requiring delivery to multiple destinations or performance at multiple locations.(d) Any order issued during the effective period of this contract and not completed within that period shall be completed by the Contractor within the time specified in the order. The contract shall govern the Contractor’s and Government’s rights and obligations with respect to that order to the same extent as if the order were completed during the contract’s effective period; provided, that the Contractor shall not be required to make any deliveries under this contract after 11/14/2021.(End of Clause)C.10 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999) The Government may require continued performance of any services within the limits and at the rates specified in the contract. These rates may be adjusted only as a result of revisions to prevailing labor rates provided by the Secretary of Labor. The option provision may be exercised more than once, but the total extension of performance hereunder shall not exceed 6 months. The Contracting Officer may exercise the option by written notice to the Contractor within 30 days.(End of Clause)C.11 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000) (a) The Government may extend the term of this contract by written notice to the Contractor within 15 days; provided that the Government gives the Contractor a preliminary written notice of its intent to extend at least 30 days before the contract expires. The preliminary notice does not commit the Government to an extension. (b) If the Government exercises this option, the extended contract shall be considered to include this option clause. (c) The total duration of this contract, including the exercise of any options under this clause, shall not exceed Five (5) years.(End of Clause)C.12 52.224-1 PRIVACY ACT NOTIFICATION (APR 1984) The Contractor will be required to design, develop, or operate a system of records on individuals, to accomplish an agency function subject to the Privacy Act of 1974, Public Law 93-579, December 31, 1974 (5 U.S.C. 552a) and applicable agency regulations. Violation of the Act may involve the imposition of criminal penalties.(End of Clause)C.13 52.224-2 PRIVACY ACT (APR 1984) (a) The Contractor agrees to— (1) Comply with the Privacy Act of 1974 (the Act) and the agency rules and regulations issued under the Act in the design, development, or operation of any system of records on individuals to accomplish an agency function when the contract specifically identifies— (i) The systems of records; and (ii) The design, development, or operation work that the contractor is to perform; (2) Include the Privacy Act notification contained in this contract in every solicitation and resulting subcontract and in every subcontract awarded without a solicitation, when the work statement in the proposed subcontract requires the design, development, or operation of a system of records on individuals that is subject to the Act; and (3) Include this clause, including this subparagraph (3), in all subcontracts awarded under this contract which requires the design, development, or operation of such a system of records. (b) In the event of violations of the Act, a civil action may be brought against the agency involved when the violation concerns the design, development, or operation of a system of records on individuals to accomplish an agency function, and criminal penalties may be imposed upon the officers or employees of the agency when the violation concerns the operation of a system of records on individuals to accomplish an agency function. For purposes of the Act, when the contract is for the operation of a system of records on individuals to accomplish an agency function, the Contractor and any employee of the Contractor is considered to be an employee of the agency. (c) (1) "Operation of a system of records," as used in this clause, means performance of any of the activities associated with maintaining the system of records, including the collection, use, and dissemination of records. (2) "Record," as used in this clause, means any item, collection, or grouping of information about an individual that is maintained by an agency, including, but not limited to, education, financial transactions, medical history, and criminal or employment history and that contains the person's name, or the identifying number, symbol, or other identifying particular assigned to the individual, such as a fingerprint or voiceprint or a photograph. (3) "System of records on individuals," as used in this clause, means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual.(End of Clause)C.14 52.227-17 RIGHTS IN DATA – SPECIAL WORKS (DEC 2007)(a) Definitions. As used in this clause— “Data” means recorded information, regardless of form or the media on which it may be recorded. The term includes technical data and computer software. The term does not include information incidental to contract administration, such as financial, administrative, cost or pricing, or management information.“Unlimited rights” means the rights of the Government to use, disclose, reproduce, prepare derivative works, distribute copies to the public, and perform publicly and display publicly, in any manner and for any purpose, and to have or permit others to do so.(b) Allocation of Rights. (1) The Government shall have—(i) Unlimited rights in all data delivered under this contract, and in all data first produced in the performance of this contract, except as provided in paragraph (c) of this clause.(ii) The right to limit assertion of copyright in data first produced in the performance of this contract, and to obtain assignment of copyright in that data, in accordance with paragraph (c)(1) of this clause.(iii) The right to limit the release and use of certain data in accordance with paragraph (d) of this clause.(2) The Contractor shall have, to the extent permission is granted in accordance with paragraph (c)(1) of this clause, the right to assert claim to copyright subsisting in data first produced in the performance of this contract.(c) Copyright— (1) Data first produced in the performance of this contract.(i) The Contractor shall not assert or authorize others to assert any claim to copyright subsisting in any data first produced in the performance of this contract without prior written permission of the Contracting Officer. When copyright is asserted, the Contractor shall affix the appropriate copyright notice of 17 U.S.C. 401 or 402 and acknowledgment of Government sponsorship (including contract number) to the data when delivered to the Government, as well as when the data are published or deposited for registration as a published work in the U.S. Copyright Office. The Contractor grants to the Government, and others acting on its behalf, a paid-up, nonexclusive, irrevocable, worldwide license for all delivered data to reproduce, prepare derivative works, distribute copies to the public, and perform publicly and display publicly, by or on behalf of the Government. (ii) If the Government desires to obtain copyright in data first produced in the performance of this contract and permission has not been granted as set forth in paragraph (c)(1)(i) of this clause, the Contracting Officer shall direct the Contractor to assign (with or without registration), or obtain the assignment of, the copyright to the Government or its designated assignee.(2) Data not first produced in the performance of this contract. The Contractor shall not, without prior written permission of the Contracting Officer, incorporate in data delivered under this contract any data not first produced in the performance of this contract and that contain the copyright notice of 17 U.S.C. 401 or 402, unless the Contractor identifies such data and grants to the Government, or acquires on its behalf, a license of the same scope as set forth in paragraph (c)(1) of this clause. (d) Release and use restrictions. Except as otherwise specifically provided for in this contract, the Contractor shall not use, release, reproduce, distribute, or publish any data first produced in the performance of this contract, nor authorize others to do so, without written permission of the Contracting Officer. (e) Indemnity. The Contractor shall indemnify the Government and its officers, agents, and employees acting for the Government against any liability, including costs and expenses, incurred as the result of the violation of trade secrets, copyrights, or right of privacy or publicity, arising out of the creation, delivery, publication, or use of any data furnished under this contract; or any libelous or other unlawful matter contained in such data. The provisions of this paragraph do not apply unless the Government provides notice to the Contractor as soon as practicable of any claim or suit, affords the Contractor an opportunity under applicable laws, rules, or regulations to participate in the defense of the claim or suit, and obtains the Contractor’s consent to the settlement of any claim or suit other than as required by final decree of a court of competent jurisdiction; and these provisions do not apply to material furnished to the Contractor by the Government and incorporated in data to which this clause applies. (End of clause)C.15 52.232-19 AVAILABILITY OF FUNDS FOR THE NEXT FISCAL YEAR (APR 1984) Funds are not presently available for performance under this contract beyond September 30th, 2016. The Government's obligation for performance of this contract beyond that date is contingent upon the availability of appropriated funds from which payment for contract purposes can be made. No legal liability on the part of the Government for any payment may arise for performance under this contract beyond September 30th, 2016, until funds are made available to the Contracting Officer for performance and until the Contractor receives notice of availability, to be confirmed in writing by the Contracting Officer.(End of Clause)C.16 52.232-37 MULTIPLE PAYMENT ARRANGEMENTS (MAY 1999)This contract or agreement provides for payments to the Contractor through several alternative methods. The applicability of specific methods of payment and the designation of the payment office(s) are either stated— (a) Elsewhere in this contract or agreement; or(b) In individual orders placed under this contract or agreement.(End of clause)C.17 52.237-3 CONTINUITY OF SERVICES (JAN 1991)(a) The Contractor recognizes that the services under this contract are vital to the Government and must be continued without interruption and that, upon contract expiration, a successor, either the Government or another contractor, may continue them. The Contractor agrees to— (1) Furnish phase-in training; and (2) Exercise its best efforts and cooperation to effect an orderly and efficient transition to a successor.(b) The Contractor shall, upon the Contracting Officer’s written notice, (1) furnish phase-in, phase-out services for up to 90 days after this contract expires and (2) negotiate in good faith a plan with a successor to determine the nature and extent of phase-in, phase-out services required. The plan shall specify a training program and a date for transferring responsibilities for each division of work described in the plan, and shall be subject to the Contracting Officer’s approval. The Contractor shall provide sufficient experienced personnel during the phase-in, phase-out period to ensure that the services called for by this contract are maintained at the required level of proficiency.(c) The Contractor shall allow as many personnel as practicable to remain on the job to help the successor maintain the continuity and consistency of the services required by this contract. The Contractor also shall disclose necessary personnel records and allow the successor to conduct on-site interviews with these employees. If selected employees are agreeable to the change, the Contractor shall release them at a mutually agreeable date and negotiate transfer of their earned fringe benefits to the successor.(d) The Contractor shall be reimbursed for all reasonable phase-in, phase-out costs (i.e., costs incurred within the agreed period after contract expiration that result from phase-in, phase-out operations) and a fee (profit) not to exceed a pro rata portion of the fee (profit) under this contract. (End of clause)C.18 52.242-13 BANKRUPTCY (JULY 1995)In the event the contractor enters into proceedings relating to bankruptcy, whether voluntary or involuntary, the contractor agrees to furnish, by certified mail or electronic commerce method authorized by the contract, written notification of the bankruptcy to the contracting officer responsible for administering the contract. This notification shall be furnished within five days of the initiation of the proceedings relating to bankruptcy filing. This notification shall include the date on which the bankruptcy petition was filed, the identity of the court in which the bankruptcy petition was filed, and a listing of government contract numbers and contracting offices for all government contracts against which final payment has not been made. This obligation remains in effect until final payment under this contract.(End of Clause)C.19 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998) This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this/these address(es): FAR 52.204-18 FAR 52.219-6 FAR 51.219-14 FAR 52.222-40 FAR 52.222.54 FAR 52.228-5 FAR 52.232-4 (End of Clause)C.20 VAAR 852.203-70 COMMERCIAL ADVERTISING (JAN 2008) The bidder or offeror agrees that if a contract is awarded to him/her, as a result of this solicitation, he/she will not advertise the award of the contract in his/her commercial advertising in such a manner as to state or imply that the Department of Veterans Affairs endorses a product, project or commercial line of endeavor.(End of Clause)C.21 VAAR 852.203-71 DISPLAY OF DEPARTMENT OF VETERAN AFFAIRS HOTLINE POSTER (DEC 1992) (a) Except as provided in paragraph (c) below, the Contractor shall display prominently, in common work areas within business segments performing work under VA contracts, Department of Veterans Affairs Hotline posters prepared by the VA Office of Inspector General. (b) Department of Veterans Affairs Hotline posters may be obtained from the VA Office of Inspector General (53E), P.O. Box 34647, Washington, DC 20043-4647. (c) The Contractor need not comply with paragraph (a) above if the Contractor has established a mechanism, such as a hotline, by which employees may report suspected instances of improper conduct, and instructions that encourage employees to make such reports.(End of Clause)C.22 VAAR 852.215-70 SERVICE-DISABLED VETERAN-OWNED AND VETERAN-OWNED SMALL BUSINESS EVALUATION FACTORS (DEC 2009) (a) In an effort to achieve socioeconomic small business goals, depending on the evaluation factors included in the solicitation, VA shall evaluate offerors based on their service-disabled veteran-owned or veteran-owned small business status and their proposed use of eligible servicedisabled veteran-owned small businesses and veteran-owned small businesses as subcontractors. (b) Eligible service-disabled veteran-owned offerors will receive full credit, and offerors qualifying as veteran-owned small businesses will receive partial credit for the Service-Disabled Veteran-Owned and Veteran-owned Small Business Status evaluation factor.? To receive credit, an offeror must be registered and verified in Vendor Information Pages (VIP) database.? (). (c) Non-veteran offerors proposing to use service-disabled veteran-owned small businesses or veteran-owned small businesses as subcontractors will receive some consideration under this evaluation factor.? Offerors must state in their proposals the names of the SDVOSBs and VOSBs with whom they intend to subcontract and provide a brief description of the proposed subcontracts and the approximate dollar values of the proposed subcontracts.? In addition, the proposed subcontractors must be registered and verified in the VIP database ().(End of Clause)C.23 VAAR 852.215-71 EVALUATION FACTOR COMMITMENTS (DEC 2009) The offeror agrees, if awarded a contract, to use the service-disabled veteran-owned small businesses or veteran-owned small businesses proposed as subcontractors in accordance with 852.215-70, Service-Disabled Veteran-Owned and Veteran-Owned Small Business Evaluation Factors, or to substitute one or more service-disabled veteran-owned small businesses or veteran-owned small businesses for subcontract work of the same or similar value.(End of Clause)C.24 VAAR 852.219-9 VA SMALL BUSINESS SUBCONTRACTING PLAN MINIMUM REQUIREMENTS (DEC 2009) (a) This clause does not apply to small business concerns. (b) If the offeror is required to submit an individual subcontracting plan, the minimum goals for award of subcontracts to service-disabled veteran-owned small business concerns and veteran-owned small business concerns shall be at least commensurate with the Department's annual service-disabled veteran-owned small business and veteran-owned small business prime contracting goals for the total dollars planned to be subcontracted. (c) For a commercial plan, the minimum goals for award of subcontracts to service-disabled veteran-owned small business concerns and veteran-owned small businesses shall be at least commensurate with the Department's annual service-disabled veteran-owned small business and veteran-owned small business prime contracting goals for the total value of projected subcontracts to support the sales for the commercial plan. (d) To be credited toward goal achievements, businesses must be verified as eligible in the Vendor Information Pages database. The contractor shall annually submit a listing of service-disabled veteran-owned small businesses and veteran-owned small businesses for which credit toward goal achievement is to be applied for the review of personnel in the Office of Small and Disadvantaged Business Utilization. (e) The contractor may appeal any businesses determined not eligible for crediting toward goal achievements by following the procedures contained in 819.407.(End of Clause)C.25 VAAR 852.219-71 VA MENTOR-PROT?G? PROGRAM (DEC 2009) (a) Large businesses are encouraged to participate in the VA Mentor-Protégé Program for the purpose of providing developmental assistance to eligible service-disabled veteran-owned small businesses and veteran-owned small businesses to enhance the small businesses' capabilities and increase their participation as VA prime contractors and as subcontractors. (b) The program consists of: (1) Mentor firms, which are contractors capable of providing developmental assistance; (2) Protégé firms, which are service-disabled veteran-owned small business concerns or veteran-owned small business concerns; and (3) Mentor-Protégé Agreements approved by the VA Office of Small and Disadvantaged Business Utilization. (c) Mentor participation in the program means providing business developmental assistance to aid protégés in developing the requisite expertise to effectively compete for and successfully perform VA prime contracts and subcontracts. (d) Large business prime contractors serving as mentors in the VA Mentor-Protégé Program are eligible for an incentive for subcontracting plan credit. VA will recognize the costs incurred by a mentor firm in providing assistance to a protégé firm and apply those costs for purposes of determining whether the mentor firm attains its subcontracting plan participation goals under a VA contract. The amount of credit given to a mentor firm for these protégé developmental assistance costs shall be calculated on a dollar-for-dollar basis and reported by the large business prime contractor via the Electronic Subcontracting Reporting System (eSRS). (e) Contractors interested in participating in the program are encouraged to contact the VA Office of Small and Disadvantaged Business Utilization for more information.(End of Clause)C.26 VAAR 852.219-72 EVALUATION FACTOR FOR PARTICIPATION IN THE VA MENTOR-PROT?G? PROGRAM (DEC 2009)This solicitation contains an evaluation factor or sub-factor regarding participation in the VA Mentor-Protégé Program.? In order to receive credit under the evaluation factor or sub-factor, the offeror must provide with its proposal a copy of a signed letter issued by the VA Office of Small and Disadvantaged Business Utilization approving the offeror’s Mentor-Protégé Agreement.(End of Clause)C.27 VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS (NOV 2012) (a) Definitions. As used in this clause— (1) Contract financing payment has the meaning given in FAR 32.001. (2) Designated agency office has the meaning given in 5 CFR 1315.2(m). (3) Electronic form means an automated system transmitting information electronically according to the Accepted electronic data transmission methods and formats identified in paragraph (c) of this clause. Facsimile, email, and scanned documents are not acceptable electronic forms for submission of payment requests. (4) Invoice payment has the meaning given in FAR 32.001. (5) Payment request means any request for contract financing payment or invoice payment submitted by the contractor under this contract. (b) Electronic payment requests. Except as provided in paragraph (e) of this clause, the contractor shall submit payment requests in electronic form. Purchases paid with a Government-wide commercial purchase card are considered to be an electronic transaction for purposes of this rule, and therefore no additional electronic invoice submission is required. (c) Data transmission. A contractor must ensure that the data transmission method and format are through one of the following: (1) VA’s Electronic Invoice Presentment and Payment System. (See Web site at .) (2) Any system that conforms to the X12 electronic data interchange (EDI) formats established by the Accredited Standards Center (ASC) and chartered by the American National Standards Institute (ANSI). The X12 EDI Web site () includes additional information on EDI 810 and 811 formats. (d) Invoice requirements. Invoices shall comply with FAR 32.905. (e) Exceptions. If, based on one of the circumstances below, the contracting officer directs that payment requests be made by mail, the contractor shall submit payment requests by mail through the United States Postal Service to the designated agency office. Submission of payment requests by mail may be required for: (1) Awards made to foreign vendors for work performed outside the United States; (2) Classified contracts or purchases when electronic submission and processing of payment requests could compromise the safeguarding of classified or privacy information; (3) Contracts awarded by contracting officers in the conduct of emergency operations, such as responses to national emergencies; (4) Solicitations or contracts in which the designated agency office is a VA entity other than the VA Financial Services Center in Austin, Texas; or (5) Solicitations or contracts in which the VA designated agency office does not have electronic invoicing capability as described above.(End of Clause)C.28 VAAR 852.237-7 INDEMNIFICATION AND MEDICAL LIABILITY INSURANCE (JAN 2008) (a) It is expressly agreed and understood that this is a non- personal services contract, as defined in Federal Acquisition Regulation (FAR) 37.101, under which the professional services rendered by the Contractor or its health-care providers are rendered in its capacity as an independent contractor. The Government may evaluate the quality of professional and administrative services provided but retains no control over professional aspects of the services rendered, including by example, the Contractor's or its health-care providers' professional medical judgment, diagnosis, or specific medical treatments. The Contractor and its health-care providers shall be liable for their liability-producing acts or omissions. The Contractor shall maintain or require all health-care providers performing under this contract to maintain, during the term of this contract, professional liability insurance issued by a responsible insurance carrier of not less than the following amount(s) per specialty per occurrence: *__________________. However, if the Contractor is an entity or a subdivision of a State that either provides for self-insurance or limits the liability or the amount of insurance purchased by State entities, then the insurance requirement of this contract shall be fulfilled by incorporating the provisions of the applicable State law.* Amounts are listed below: (b) An apparently successful offeror, upon request of the Contracting Officer, shall, prior to contract award, furnish evidence of the insurability of the offeror and/or of all health- care providers who will perform under this contract. The submission shall provide evidence of insurability concerning the medical liability insurance required by paragraph (a) of this clause or the provisions of State law as to self-insurance, or limitations on liability or insurance. (c) The Contractor shall, prior to commencement of services under the contract, provide to the Contracting Officer Certificates of Insurance or insurance policies evidencing the required insurance coverage and an endorsement stating that any cancellation or material change adversely affecting the Government's interest shall not be effective until 30 days after the insurer or the Contractor gives written notice to the Contracting Officer. Certificates or policies shall be provided for the Contractor and/or each health- care provider who will perform under this contract. (d) The Contractor shall notify the Contracting Officer if it, or any of the health-care providers performing under this contract, change insurance providers during the performance period of this contract. The notification shall provide evidence that the Contractor and/or health-care providers will meet all the requirements of this clause, including those concerning liability insurance and endorsements. These requirements may be met either under the new policy, or a combination of old and new policies, if applicable. (e) The Contractor shall insert the substance of this clause, including this paragraph (e), in all subcontracts for health-care services under this contract. The Contractor shall be responsible for compliance by any subcontractor or lower-tier subcontractor with the provisions set forth in paragraph (a) of this clause.* Amounts from paragraph (a) above:$1,000,000.00 per occurance/$3,000,000.00 aggregate (End of Clause)C.29 VAAR 852.237-70 CONTRACTOR RESPONSIBILITIES (APR 1984) The contractor shall obtain all necessary licenses and/or permits required to perform this work. He/she shall take all reasonable precautions necessary to protect persons and property from injury or damage during the performance of this contract. He/she shall be responsible for any injury to himself/herself, his/her employees, as well as for any damage to personal or public property that occurs during the performance of this contract that is caused by his/her employees fault or negligence, and shall maintain personal liability and property damage insurance having coverage for a limit as required by the laws of the State of Florida. Further, it is agreed that any negligence of the Government, its officers, agents, servants and employees, shall not be the responsibility of the contractor hereunder with the regard to any claims, loss, damage, injury, and liability resulting there from.(End of Clause)C.30 MANDATORY WRITTEN DISCLOSURES Mandatory written disclosures required by FAR clause 52.203-13 to the Department of Veterans Affairs, Office of Inspector General (OIG) must be made electronically through the VA OIG Hotline at and clicking on "FAR clause 52.203-13 Reporting." If you experience difficulty accessing the website, call the Hotline at 1-800-488-8244 for further instructions.SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTSLIST OF ATTACHMENTSATTACHMENT 1:D.1 CONTRACTOR CERTIFICATIONATTACHMENT 2:D.2 CONTRACTOR RULES OF BEHAVIORATTACHMENT 3:D.3 ORGANIZATIONAL CONFLICT OF INTERESTATTACHMENT 4:D.4 SUBCONTRACTING PLAN MODULEATTACHMENT 5:D.5 WAGE DETERMINATIONATTACHMENT 6:D.6 SUBCONTRACTING GOALS MEMOATTACHMENT 7:D.7 QUALITY ASSURANCE SURVEILLANCE PLAND.1 CONTRACTOR CERTIFICATIONCONTRACTOR CERTIFICATION: Immigration and Nationality Act of 1952, As AmendedThe Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to Department of Veterans Affairs patient referrals;While performing services for the Department of Veterans Affairs, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United States. Additionally, the Contractor is required to comply with all “E-Verify” requirements consistent with “Executive Order 12989” and any related pertinent Amendments, as well as applicable Federal Acquisition Regulations.If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the Department of Veterans Affairs may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor, shall be prohibited from working at the Contractor’s place of business that services Department of Veterans Affairs patient referrals; or other place where the Contractor provides services to veterans who have been referred by the Department of Veterans Affairs; and shall form the basis for termination of this contract for breach.The Contractor agrees to obtain a similar certification from its subcontractors.Signature:?????????? ____________________________________________Date:???? ____________________________________________Typed Name and Title: ___________________________________Company Name:????????????? ___________________________________________________________________________________________This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001.D.2 CONTRACTOR RULES OF BEHAVIORMARCH 12, 2010VA HANDBOOK 6500.6APPENDIX DCONTRACTOR RULES OF BEHAVIORThis User Agreement contains rights and authorizations regarding my access to and use of any information assets or resources associated with my performance of services under the contract terms with the Department of Veterans Affairs (VA). This User Agreement covers my access to all VA data whether electronic or hard copy ("Data"), VA information systems and resources ("Systems"), and VA sites ("Sites"). This User Agreement incorporates Rules of Behavior for using VA, and other information systems and resources under the contract.GENERAL TERMS AND CONDITIONS FOR ALL ACTIONS AND ACTIVITIES UNDER THE CONTRACT:I understand and agree that I have no reasonable expectation of privacy in accessing or using any VA, or other Federal Government information systems.I consent to reviews and actions by the Office of Information & Technology (OI&T) staff designated and authorized by the VA Chief Information Officer (CIO) and to the VA OIG regarding my access to and use of any information assets or resources associated with my performance of services under the contract terms with the VA. These actions may include monitoring, recording, copying, inspecting, restricting access, blocking, tracking, and disclosing to all authorized OI&T, VA, and law enforcement personnel as directed by the VA CIO without my prior consent or notification.I consent to reviews and actions by authorized VA systems administrators and Information Security Officers solely for protection of the VA infrastructure, including, but not limited to monitoring, recording, auditing, inspecting, investigating, restricting access, blocking, tracking, disclosing to authorized personnel, or any other authorized actions by all authorized OI&T, VA, and law enforcement personnel.I understand and accept that unauthorized attempts or acts to access, upload, change, or delete information on Federal Government systems; modify Federal government systems; deny access to Federal government systems; accrue resources for unauthorized use on Federal government systems; or otherwise misuse Federal government systems or resources are prohibited.I understand that such unauthorized attempts or acts are subject to action that may result in criminal, civil, or administrative penalties. This includes penalties for violations of Federal laws including, but not limited to, 18 U.S.C. §1030 (fraud and related activity in connection with computers) and 18 U.S.C. §2701 (unlawful access to storedcommunications).I agree that OI&T staff, in the course of obtaining access to information or systems on my behalf for performance under the contract, may provide information about me including, but not limited to, appropriate unique personal identifiers such as date of birth and social security number to other system administrators, Information Security Officers (ISOs), or other authorized staff without further notifying me or obtaining additional written or verbal permission from me.I understand I must comply with VA’s security and data privacy directives and handbooks. I understand that copies of those directives and handbooks can be obtained from the Contracting Officer's Technical Representative (COTR). If the contractor believes the policies and guidance provided by the COTR is a material unilateral change to the contract, the contractor must elevate such concerns to the Contracting Officer for resolution.I will report suspected or identified information security/privacy incidents to the COTR and to the local ISO or Privacy Officer as appropriate.GENERAL RULES OF BEHAVIORRules of Behavior are part of a comprehensive program to provide complete information security. These rules establish standards of behavior in recognition of the fact that knowledgeable users are the foundation of a successful security program. Users must understand that taking personal responsibility for the security of their computer and the information it contains is an essential part of their job.The following rules apply to all VA contractors. I agree to:Follow established procedures for requesting, accessing, and closing user accounts and access. I will not request or obtain access beyond what is normally granted to users or by what is outlined in the contract.Use only systems, software, databases, and data which I am authorized to use, including any copyright restrictions.I will not use other equipment (OE) (non-contractor owned) for the storage, transfer, or processing of VA sensitive information without a VA CIO approved waiver, unless it has been reviewed and approved by local management and is included in the language of the contract. If authorized to use OE IT equipment, I must ensure that the system meets all applicable 6500 Handbook requirements for OE.Not use my position of trust and access rights to exploit system controls or access information for any reason other than in the performance of the contract.Not attempt to override or disable security, technical, or management controls unless expressly permitted to do so as an explicit requirement under the contract or at the direction of the COTR or ISO. If I am allowed or required to have a local administrator account on a government-owned computer, that local administrative account does notconfer me unrestricted access or use, nor the authority to bypass security or other controls except as expressly permitted by the VA CIO or CIO's designee.Contractors’ use of systems, information, or sites is strictly limited to fulfill the terms of the contract. I understand no personal use is authorized. I will only use other Federal government information systems as expressly authorized by the terms of those systems. I accept that the restrictions under ethics regulations and criminal law still apply.Grant access to systems and information only to those who have an official need to know.Protect passwords from access by other individuals.Create and change passwords in accordance with VA Handbook 6500 on systems and any devices protecting VA information as well as the rules of behavior and security settings for the particular system in question.Protect information and systems from unauthorized disclosure, use, modification, or destruction. I will only use encryption that is FIPS 140-2 validated to safeguard VA sensitive information, both safeguarding VA sensitive information in storage and in transit regarding my access to and use of any information assets or resources associated with my performance of services under the contract terms with the VA.Follow VA Handbook 6500.1, Electronic Media Sanitization to protect VA information. I will contact the COTR for policies and guidance on complying with this requirement and will follow the COTR's orders.Ensure that the COTR has previously approved VA information for public dissemination, including e-mail communications outside of the VA as appropriate. I will not make any unauthorized disclosure of any VA sensitive information through the use of any means of communication including but not limited to e-mail, instant messaging, online chat, and web bulletin boards or logs.Not host, set up, administer, or run an Internet server related to my access to and use of any information assets or resources associated with my performance of services under the contract terms with the VA unless explicitly authorized under the contract or in writing by the COTR.Protect government property from theft, destruction, or misuse. I will follow VA directives and handbooks on handling Federal government IT equipment, information, and systems. I will not take VA sensitive information from the workplace without authorization from the COTR.Only use anti-virus software, antispyware, and firewall/intrusion detection software authorized by VA. I will contact the COTR for policies and guidance on complying with this requirement and will follow the COTR's orders regarding my access to and use of any information assets or resources associated with my performance of services under the contract terms with VA.Not disable or degrade the standard anti-virus software, antispyware, and/or firewall/intrusion detection software on the computer I use to access and use information assets or resources associated with my performance of services under the contract terms with VA. I will report anti-virus, antispyware, firewall or intrusion detection software errors, or significant alert messages to the COTR.Understand that restoration of service of any VA system is a concern of all users of the plete required information security and privacy training, and complete required training for the particular systems to which I require access.ADDITIONAL CONDITIONS FOR USE OF NON- VA INFORMATION TECHNOLOGY RESOURCESWhen required to complete work under the contract, I will directly connect to the VA network whenever possible. If a direct connection to the VA network is not possible, then I will use VA approved remote access software and services.Remote access to non-public VA information technology resources is prohibited from publicly-available IT computers, such as remotely connecting to the internal VA network from computers in a public library.I will not have both a VA network line and any kind of non-VA network line including a wireless network card, modem with phone line, or other network device physically connected to my computer at the same time, unless the dual connection is explicitly authorized by the COTR.I understand that I may not obviate or evade my responsibility to adhere to VA security requirements by subcontracting any work under any given contract or agreement with VA, and that any subcontractor(s) I engage shall likewise be bound by the same security requirements and penalties for violating the same.STATEMENT ON LITIGATIONThis User Agreement does not and should not be relied upon to create any other right or benefit, substantive or procedural, enforceable by law, by a party to litigation with the United States Government.5. ACKNOWLEDGEMENT AND ACCEPTANCEI acknowledge receipt of this User Agreement. I understand and accept all terms and conditions of this User Agreement, and I will comply with the terms and conditions of this agreement and any additional VA warning banners, directives, handbooks, notices, or directions regarding access to or use of information systems or information. The terms and conditions of this document do not supersede the terms and conditions of the signatory’s employer and VA.__________________________________________________Print or type your full name Signature___________________________________________________Last 4 digits of SSN Date___________________________________________________Office Phone Position TitleContractor’s Company NamePlease complete and return the original signed document to the COTR within the timeframe stated in the terms of the contract.D.3 ORGANIZATIONAL CONFLICT OF INTEREST852.209-ANIZATIONAL CONFLICTS OF INTEREST (JAN 2008)All healthcare contracts require response to the following provision as prescribed in VAAR 809.507-1(b). Please use the form in APPENDIX A to provide response. 852.209-ANIZATIONAL CONFLICTS OF INTEREST (JAN 2008)(a) It is in the best interest of the Government to avoid situations which might create an organizational conflict of interest or where the offeror’s performance of work under the contract may provide the contractor with an unfair competitive advantage.? The term “organizational conflict of interest” means that because of other activities or relationships with other persons, a person is unable to render impartial assistance or advice to the Government, or the person’s objectivity in performing the contract work is or might be otherwise impaired, or the person has an unfair competitive advantage.(b) The offeror shall provide a statement with its offer which describes, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation.? The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation.? The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.(c) Based on this information and any other information solicited or obtained by the contracting officer, the contracting officer may determine that an organizational conflict of interest exists which would warrant disqualifying the contractor for award of the contract unless the organizational conflict of interest can be mitigated to the contracting officer's satisfaction by negotiating terms and conditions of the contract to that effect.? If the conflict of interest cannot be mitigated and if the contracting officer finds that it is in the best interest of the United States to award the contract, the contracting officer shall request a waiver in accordance with FAR 9.503 and 48 CFR 809.503.(d) Nondisclosure or misrepresentation of actual or potential organizational conflicts of interest at the time of the offer, or arising as a result of a modification to the contract, may result in the termination of the contract at no expense to the Government.APPENDIX A[CONTRACTOR NAME][ADDRESS]SOLICITATION #CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT [ ] ____[CONTRACTOR NAME]________________ represents that the individuals listed in the Key Personnel and Temporary Emergency Substitutions section of the solicitation [____Solicitation # and Service Type___] in have no present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the ___[NAME OF VAMC] _________ Veterans Administration under the referenced solicitation.None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the___NAME OF VAMC _________ Veterans Administration under the referenced solicitation.OR[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation.? The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation.? The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest._________________________________NAME OF CERTIFYING OFFICIALTITLE__________________________________SIGNATURE DATED.4 SUBCONTRACTING PLAN MODULEU.S. Department of Veterans Affairs (VA)Office of Small and Disadvantaged Business Utilization (00SB)Subcontracting Plan ModelFebruary 2012 In accordance with FAR 19.704, 52.219 and P.L. 109-461Prime Contractor: Address: City: State: Zipcode:Solicitation/Contract Number: Description of Requirement: Total Contract Amount (Including Option Years): $Period of Contract Performance Including Option Years (Month and Year): Activity Awarding Contract: Contracting Officer Name:Prime Contractor is:[ ] Architect-Engineer [ ] Janitorial[ ] Blood [ ] Laboratory Testing Services[ ] Bulk Oxygen Services [ ] Laundry and Linen Services[ ] Clinical Diagnostic Equipment[ ] Medical Equipment[ ] Community Based Outpatient Clinic [ ] Medical Equipment and Supplies[ ] Construction [ ] Medical Equipment and Supplies[ ] Consulting Services and Pharmaceuticals[ ] Dental Equipment[ ] Medical Gas and Medical Bulk[ ] Dental Equipment and Supplies Oxygen[ ] Dental Supplies[ ] Medical Healthcare Services[ ] Diagnostic Imaging Equipment and Supplies[ ] Medical Surgical Prime Vendor[ ] Diagnostic X-Ray and Related Systems and Equipment[ ] Niche Markers Including Installation[ ] Pharmaceuticals[ ] Dietary Supplements[ ] Pharmaceutical and Cost Per Test[ ] Digital Hearing Aids and Batteries[ ] Prosthetics[ ] Elevator Maintenance[ ] Publisher/Subscription Services[ ] External Peer Review [ ] Radiation Therapy Systems[ ] Healthcare Staffing[ ] Real Estate[ ] Home Healthcare Services[ ] Studies[ ] Home Medical Equipment[ ] Support Services[ ] Home Oxygen[ ] Telephone System Hardware/[ ] Information Technology Software Maintenance[ ] InVitro Diagnostics Reagents[ ] Transportation[ ] InVitro Diagnostics Substances Reagents, Test Kits and[ ] Other (Not Checked) Blood Laboratory ___________________________Prime Contractor (Please check if you are):[ ] Manufacturer[ ] Distributor[ ] Manufacturer/DistributorType of Plan (Check One)___Commercial Plan - means a subcontracting plan (including goals) that covers the offeror’s fiscal year and that applies to the entire production of commercial items sold by either the entire company or a portion thereof (e.g., division, plant, or product line).(Represents ______% of Total Annual Sales)____Individual Plan - means a subcontracting plan that covers the entire contract period (including option periods), applies to a specific contract, and has goals that are based on the offeror’s planned subcontracting in support of the specific contract, except that indirect costs incurred for common or joint purposes may be allocated on a prorated basis to the contract.1 - 2.GOALS - Please state separate dollar and percentage goals for Small Business (including Alaska Native Corporation’s (ANCs)); Service-Disabled Veteran-Owned Small Business, Veteran-Owned Small Business; Small Disadvantaged, Women-Owned, and Historically Underutilized Business Zone (HUBZone) Business Concerns. QUESTION: What level of subcontracting tier counts towards the prime contractor subcontracting plan goals?”? Example: The prime subcontracts to a large business at a value of $5.0 mil.? The subcontracted large business then, subcontract to a VOSB for $1.5mil.? Does this 2nd tier subcontract amount count towards the prime contractor’s subcontracting goals?ANSWER: FAR 52.219-9(l): The Contractor shall submit ISRs and SSRs using the web-based eSRS at . Purchases from a corporation, company, or subdivision that is an affiliate of the prime contractor or subcontractor are not included in these reports. Subcontract award data reported by Prime contractors and subcontractors shall be limited to awards made to their immediate next-tier subcontractors. Credit cannot be taken for awards made to lower tier subcontractors, unless the contractor or subcontractor has been designated to receive a small business or small disadvantaged business credit from an ANC or Indian tribe. Only direct subcontracting can be counted. For instance, the prime contractor can only count what it directly subcontracts. If the prime contractor subcontracts to a LB over $650,000 and there is flow down subcontracting plan, this LB subcontractor can only count who they directly subcontract too.NOTE: VA’s required percentage goals are shown below. “Zero” percent value for goals or “N/A” are unacceptable. Goals and percentages must be rounded to the nearst dollar and tenth of a percent. Example of how to calculate the goals:DOLLARSPERCENTTotal Contract Price$1,500,000Total to be Subcontracted 1,000,000100%Subcontract to Small Business (including Alaska Native Corporations (ANC) and Indian tribes) 177,00017.7%Subcontract to Service Disabled Veteran-Owned Small Business 30,000 3.0%Subcontract to Veteran-Owned Small Business 50,000 5.0%Small Disadvantaged Business (including ANC and Indian tribes) 50,000 5.0%Women-Owned Small Business 50,000 5.0%Subcontract to HUBZone Small Businesses 30,000 3.0%If percentage goals below are lower than example above, please submit justification as to why.Please enter the information listed below:Total dollars to be subcontracted:$____________________________ Total dollars to be subcontracted to Small Business (SB) (including Alaska Native Corporation’s (ANCs) and Indian tribes):$_______________ ______%Total dollars to be subcontracted to Service-Disabled Veteran-Owned Small Business (SDVOSB) – P.L. 109-461 signed by the President December 22, 2006. Goal shall not be less than 3.0%. NOTE: In accordance with VA Acquisition Regulations 852.219-9(d): To be credited toward goal achievements, businesses must be Verified as eligible in the Vendor Information Pages database.? The contractor shall annually submit a listing of Service-Disabled Veteran-Owned Small Businesses and Veteran-Owned Small Businesses for which credit toward goal achievement is to be applied for the review of personnel in the Office of Small and Disadvantaged Business Utilization.$_______________ ______%Total dollars to be subcontracted to Veteran-Owned Small Business (VOSB) – P.L. 109-461 signed by the President December 22, 2006. Goal shall not be less than the 7.0% as mandated by the Secretary, Department of Veterans Affairs: NOTE: In accordance with VA Acquisition Regulations 852.219-9(d): To be credited toward goal achievements, businesses must be Verified as eligible in the Vendor Information Pages database.? The contractor shall annually submit a listing of Service-Disabled Veteran-Owned Small Businesses and Veteran-Owned Small Businesses for which credit toward goal achievement is to be applied for the review of personnel in the Office of Small and Disadvantaged Business Utilization. $_______________ ______%Total dollars to be subcontracted to Small Disadvantaged Business (SDB) (including Alaska Native Corporation’s (ANCs) and Indian tribes): $_______________ ______%Total dollars to be subcontracted to Women-Owned Small Business (WOSB): $_______________ ______%Total dollars to be subcontracted to HUBZone Small Business Concerns: $_______________ ______%Total dollars to be subcontracted to Large Business: $_______________ ______%3.Provide a description of the principal types of supplies and services to be subcontracted under this contract, and an identification of the types planned for subcontracting to small (including ANCs and Indian tribes), Service-Disabled Veteran-Owned and Veteran-Owned Small Business concerns), Small Disadvantaged (including ANCs and Indian tribes), Women-Owned, HUBZone Business.You must identify the products/services to be subcontracted in each category. (Example: office supplies, maintenance and repair)Products/ServicesLarge BusinessSmall businessSmall disadvantaged businessWomen-Owned Small businessHUBZone Small businessService-Disabled Veteran-Owned Small Business (sdvosb) – in accordance with P.L. 109-461, signed by the President December 22, 2006, please list the name, address, and telephone number for each Service-Disabled and Veteran-Owned Small Business concerns as follows. Please ensure that the Service-Disabled Veteran-Owned Small Business concerns are registered in the System for Award Management and the Vendor Information Pages . If more than one, please utilize the format listed below to indicate additional Service-Disabled Veteran-Owned Small Business: NOTE: In accordance with VA Acquisition Regulations 852.219-9(d): To be credited toward goal achievements, businesses must be Verified as eligible in the Vendor Information Pages database.? The contractor shall annually submit a listing of Service-Disabled Veteran-Owned Small Businesses and Veteran-Owned Small Businesses for which credit toward goal achievement is to be applied for the review of personnel in the Office of Small and Disadvantaged Business Utilization.Name of SDVOSB:Address:City/State/Zipcode:Email address of point of contact:Telephone: FAX: Veteran-Owned Small Business (vosb) - In accordance with P.L. 109-461, signed by President December 22, 2006, please list the name, address, and telephone number for each Veteran-Owned Small Business concerns as follows. Please ensure that the Veteran-Owned Small Business Concerns are registered in the System for Award Management (SAM) and the Vendor Information Pages .. If more than one, please utilize the format listed below to indicate additional Veteran-Owned Small Business: NOTE: In accordance with VA Acquisition Regulations 852.219-9(d): To be credited toward goal achievements, businesses must be Verified as eligible in the Vendor Information Pages (VIP) database.? The contractor shall annually submit a listing of Service-Disabled Veteran-Owned Small Businesses and Veteran-Owned Small Businesses for which credit toward goal achievement is to be applied for the review of personnel in the Office of Small and Disadvantaged Business Utilization.Name of VOSB:Address:City/State/Zipcode:Email address of point of contact:Telephone: FAX: In accordance with P.L. 109-461, Verification Process is mandated to certify that the Service-Disabled and Veteran-Owned Small Business concerns listed for subcontracting opportunities do have a subcontract with you as the prime contractor.This information will be a report to the Department of Veterans Affairs, Office of Small and Disadvantaged Business Utilization (00SB) on a quarterly basis, (form attached) for the Service-Disabled and Veteran-Owned Small Business concerns to report.4.A description of the method used to develop the subcontracting goals. 5. A description of the method used to identify potential sources for solicitation purposes (e.g., existing company source lists, the System for Award Management (SAM), Dynamic Small Business Search (DSBS), Veteran’s service organizations, the National Minority Purchasing Council Vendor Information Service, the Research and Information Division of the Minority Business Development Agency in the U.S. Department of Commerce, or Small, HUBZone, Small Disadvantaged and Women-Owned Small Business trade associations).A firm may rely on the information contained in SAM as an accurate representation of a concern’s size and ownership characteristics for the purposes of maintaining a Small, Veteran-Owned Small, Service-Disabled Veteran-Owned Small, HUBZone Business, Small Disadvantaged, and Women-Owned Small Business source list. Use of SAM as its source list does not relieve a firm of its responsibilities (e.g., outreach, assistance, counseling, or publicizing subcontracting opportunities)NOTE: VA expects contractors to advertise subcontracting opportunities at: . Contractors should also search the Vendor Information Pages (VIP) Database at the web portal ), to ensure maximum practicable consideration in subcontracting with Veteran-Owned and Service-Disabled Veteran-Owned Small Businesses. 6. A statement as to whether or not the offeror included indirect costs in establishing subcontracting goals, and a description of the method used to determine the proportionate share of indirect costs to be incurred with Small Business (including ANC and Indian tribes); Service-Disabled Veteran-Owned Small Business; Veteran-Owned Small Business; Small Disadvantaged Business concern (including ANC and Indian tribes); Women-Owned Small Business, and HUBZone Business concerns.[ ] Yes[ ] No7.Name of the individual employed by the offeror who will administer the offeror’s subcontracting program and a description of the duties of the individual.SUBCONTRACTING PLAN ADMINISTRATORNAME:TITLE:ADDRESS:CITY: STATE: ZIPCODE: TELEPHONE: FAX NUMBER:E-MAIL: DUTIES: List duties and responsibilities of the Plan Administrator and a statement of the extent and scope of the Plan Administrator’s authority in subcontracting source selections: Attach duties of the Subcontracting Plan Administrator8. A description of the efforts the offeror will make to assure that Small Business, Service-Disabled Veteran-Owned Small Business; Veteran-Owned Small Business, Small Disadvantaged Business, Women-Owned Small Business and HUBZone Business concerns have an equitable opportunity to compete for subcontracts.9. Assurances that the offeror will include the clause of this contract entitled “Utilization of Small Business Concerns” in all subcontracts that offer further subcontracting opportunities, and that the offeror will require all subcontractors (except Small Business concerns) that receive subcontracts in excess of $650,000 ($1,5000,000 for construction) to adopt a subcontracting plan that complies with the requirements of this clause.[ ] Yes[ ] No10. Assurances that the offeror will—(i) cooperate in any studies or surveys as may be required; (ii) Submit periodic reports so that the Government can determine the extent of co)mpliance by the offeror with the subcontracting plan; Submit the Subcontracting Report for Individual Contracts (ISR) and/or the Summary Subcontract Report (SSR), in accordance using the Electronic Subcontracting Reporting System (eSRS) at following the instruction in the eSRS;Ensure that its subcontractors with subcontracting plans agree to submit the ISR and/or the SSR using eSRS; (v) Provide its prime contract number, its DUNS number, and the e-mail address of the Government or Contractor official responsible for acknowledging or rejecting the reports, to all first-tier subcontractors with subcontracting plans so they can enter this information into the eSRS when submitting their reports; and Require that each subcontractor with a subcontracting plan provide the prime contract number, its own DUNS number, and the e-mail address of the Government or Contractor official responsible for acknowledging or rejecting the reports, to its subcontractors with subcontracting plans. [ ] Yes[ ] NoNOTE:When entering your subcontracting information, you must include the email address of the following individuals whom will be reviewing the Subcontracting Report for Individual Contracts ISR 294, as well as, SSR 295 “Summary Subcontracting Report”.Reporting Agency (Veterans Affairs, Department of (3600))Please enter the contracting officer’s email address: ____________________________________11. A description of the types of records that will be maintained concerning procedures that have been adopted to comply with the requirements and goals in the plan, includingestablishing source lists; and a description of the offeror’s efforts to locate Small Business, Veteran-Owned Small Business, Service-Disabled Veteran-Owned Small Business, HUBZone Business, Small Disadvantaged Business, and Women-Owned Small Business concerns and award subcontracts to them. The records shall include at least the following (on a plant-wide or company-wide basis, unless otherwise indicated): (i) Source lists (e.g., SAM, Vendor Information Pages (VIP) Database at the web portal (), to ensure maximum practicable consideration of Veteran-Owned and Service-Disabled Veteran-Owned Small Businesses:), guides, and other data that identify Small Business, Veteran-Owned Small Business, Service-Disabled Veteran-Owned Small Business, HUBZone Business, Small Disadvantaged Business, and Women-Owned Small Business concerns. (ii) Organizations contacted in an attempt to locate sources that are Small Business, Veteran-Owned Small Business, Service-Disabled Veteran-Owned Small Business, HUBZone Business, Small Disadvantaged Business, or Women-Owned Small Business concerns. (iii) Records on each subcontract solicitation resulting in an award of more than $150,000, indicating:(A) Whether Small Business concerns were solicited and, if not, why not;(B) Whether Veteran-Owned Small Business concerns were solicited and, if not, why not; (C) Whether Service-Disabled Veteran-Owned Small Business concerns were solicited and, if not, why not; (D) Whether HUBZone Business concerns were solicited and, if not, why not;(E) Whether Small Disadvantaged Business concerns were solicited and, if not, why not;(F) Whether Women-Owned Small Business concerns were solicited and, if not, why not; and (G) If applicable, the reason award was not made to a Small Business concern. (iv) Records of any outreach efforts to contact:(A) Trade associations;(B) Business development organizations;(C) Conferences and trade fairs to locate Small, HUBZone, Small Disadvantaged, and Women-Owned Small Business sources; and (D) Veteran’s service organizations. (v) Records of internal guidance and encouragement provided to buyers through:Workshops, seminars, training, etc.; Monitoring performance to evaluate compliance with the program requirements.(vi) On a contract-by-contract basis, records to support award data submitted by the offeror to the Government, including the name, address, and business size of each subcontractor.(vii) Contractors having commercial plans need not comply with this requirement. (e) In order to effectively implement this plan to the extent consistent with efficient contract performance, the Contractor shall perform the following functions:(1) Assist Small Business, Veteran-Owned Small Business, Service-Disabled Veteran-Owned Small Business, HUBZone Business, Small Disadvantaged Business, and Women-Owned Small Business concerns by arranging solicitations, time for the preparation of bids, quantities, specifications, and delivery schedules so as to facilitate the participation by such concerns. Where the Contractor’s lists of potential Small Business, Veteran-Owned Small Business, Service-Disabled Veteran-Owned Small Business, HUBZone Business, Small Disadvantaged Business, and Women-Owned Small Business subcontractors are excessively long, reasonable effort shall be made to give all such Small Business concerns an opportunity to compete over a period of time. (2) Provide adequate and timely consideration of the potentialities of Small Business, Veteran-Owned Small Business, Service-Disabled Veteran-Owned Small Business, HUBZone Business, Small Disadvantaged Business, and Women-Owned Small Business concerns in all “make-or-buy” decisions. (3) Counsel and discuss subcontracting opportunities with representatives of Small Business, Veteran-Owned Small Business, Service-Disabled Veteran-Owned Small Business, HUBZone Business, Small Disadvantaged Business, and Women-Owned Small Business firms. (4) Confirm that a subcontractor representing itself as a HUBZone Business is identified as a certified HUBZone Small Business Concern by accessing the SAM database or by contacting SBA. (5) Provide notice to subcontractors concerning penalties and remedies for misrepresentations of business status as Small, Veteran-Owned Small Business, HUBZone, Small Disadvantaged, or Women-Owned Small Business for the purpose of obtaining a subcontract that is to be included as part or all of a goal contained in the Contractor’s subcontracting plan.SIGNATURES REQUIREDPRIME CONTRACTOR: _____________________________DATE: ______________PRINT/TYPE NAME: TITLE: DATE: EMAIL: CONTRACTING OFFICER NAME WHOAPPROVED BY: __________________________________DATE: _________TYPE NAME: TITLE: EMAIL: For Commercial Plans OnlyEffective period of this subcontracting plan is:______________________________________thru__________________________CONTRACTING OFFICER NAME WHOAPPROVED BY: __________________________________DATE: _________TYPE NAME: TITLE: EMAIL: PAST PERFORMANCESUBCONTRACTING ACCOMPLISHMENTS PRIOR YEAR PRIOR YEAR GOALS ACCOMPLISHMENTSTOTAL SUBCONTRACTING $______________$__________________SMALL BUSINESS $______________$__________________PERCENT ______________% __________________%SMALL DISADVANTAGED $______________$__________________PERCENT ______________% __________________%WOMEN-OWNED SMALL BUSINESS$______________$__________________PERCENT ______________% __________________%HUBZONE BUSINESS $ ______________$__________________PERCENT ______________% __________________%SERVICE-DISABLED VETERAN-OWNED$______________$__________________PERCENT ______________% __________________%VETERAN-OWNED $______________$__________________PERCENT ______________% __________________%CERTIFY THAT THE ABOVE SUBCONTRACTING ACCOMPLISHMENTS ARE ACCURATE AND WAS ALSO ENTERED IN THE ELECTRONIC SUBCONTRACTING REPORTING SYSTEM (eSRS) FOR REPORT PERIOD:YEAR: ___________________[ ] YES[ ] NOD.5 WAGE DETERMINATIONWD 05-2126 (Rev.-22) was first posted on on 07/14/2015************************************************************************************REGISTER OF WAGE DETERMINATIONS UNDER | U.S. DEPARTMENT OF LABOR THE SERVICE CONTRACT ACT | EMPLOYMENT STANDARDS ADMINISTRATIONBy direction of the Secretary of Labor | WAGE AND HOUR DIVISION | WASHINGTON D.C. 20210 | | | | Wage Determination No.: 2005-2126Daniel W. Simms Division of | Revision No.: 22Director Wage Determinations| Date Of Revision: 07/08/2015_______________________________________|____________________________________________Note: Executive Order (EO) 13658 establishes an hourly minimum wage of $10.10for 2015 that applies to all contracts subject to the Service Contract Act forwhich the solicitation is issued on or after January 1, 2015. If this contractis covered by the EO, the contractor must pay all workers in anyclassification listed on this wage determination at least $10.10 (or theapplicable wage rate listed on this wage determination, if it is higher) forall hours spent performing on the contract. The EO minimum wage rate will beadjusted annually. Additional information on contractor requirements andworker protections under the EO is available at whd/govcontracts.____________________________________________________________________________________State: FloridaArea: Florida Counties of Charlotte, De Soto, Hardee, Hernando, Highlands,Hillsborough, Lee, Manatee, Pasco, Pinellas, Polk, Sarasota____________________________________________________________________________________ **Fringe Benefits Required Follow the Occupational Listing**OCCUPATION CODE - TITLE FOOTNOTE RATE01000 - Administrative Support And Clerical Occupations 01011 - Accounting Clerk I 14.55 01012 - Accounting Clerk II 16.15 01013 - Accounting Clerk III 18.08 01020 - Administrative Assistant 21.10 01040 - Court Reporter 18.36 01051 - Data Entry Operator I 12.05 01052 - Data Entry Operator II 13.33 01060 - Dispatcher, Motor Vehicle 15.88 01070 - Document Preparation Clerk 12.08 01090 - Duplicating Machine Operator 12.08 01111 - General Clerk I 12.58 01112 - General Clerk II 13.73 01113 - General Clerk III 15.09 01120 - Housing Referral Assistant 19.46 01141 - Messenger Courier 11.26 01191 - Order Clerk I 12.42 01192 - Order Clerk II 13.94 01261 - Personnel Assistant (Employment) I 14.67 01262 - Personnel Assistant (Employment) II 18.22 01263 - Personnel Assistant (Employment) III 18.84 01270 - Production Control Clerk 19.92 01280 - Receptionist 11.91 01290 - Rental Clerk 14.73 01300 - Scheduler, Maintenance 15.31 01311 - Secretary I 15.31 01312 - Secretary II 17.12 01313 - Secretary III 19.41 01320 - Service Order Dispatcher 14.23 01410 - Supply Technician 21.10 01420 - Survey Worker 13.68 01531 - Travel Clerk I 12.46 01532 - Travel Clerk II 13.56 01533 - Travel Clerk III 14.75 01611 - Word Processor I 13.15 01612 - Word Processor II 14.76 01613 - Word Processor III 16.4805000 - Automotive Service Occupations 05005 - Automobile Body Repairer, Fiberglass 20.27 05010 - Automotive Electrician 20.79 05040 - Automotive Glass Installer 19.87 05070 - Automotive Worker 19.87 05110 - Mobile Equipment Servicer 18.02 05130 - Motor Equipment Metal Mechanic 21.75 05160 - Motor Equipment Metal Worker 19.87 05190 - Motor Vehicle Mechanic 20.88 05220 - Motor Vehicle Mechanic Helper 17.00 05250 - Motor Vehicle Upholstery Worker 18.94 05280 - Motor Vehicle Wrecker 19.87 05310 - Painter, Automotive 20.79 05340 - Radiator Repair Specialist 19.87 05370 - Tire Repairer 12.68 05400 - Transmission Repair Specialist 21.5307000 - Food Preparation And Service Occupations 07010 - Baker 11.08 07041 - Cook I 10.83 07042 - Cook II 12.08 07070 - Dishwasher 8.52 07130 - Food Service Worker 10.34 07210 - Meat Cutter 14.06 07260 - Waiter/Waitress 9.5109000 - Furniture Maintenance And Repair Occupations 09010 - Electrostatic Spray Painter 16.65 09040 - Furniture Handler 12.13 09080 - Furniture Refinisher 15.90 09090 - Furniture Refinisher Helper 12.38 09110 - Furniture Repairer, Minor 13.92 09130 - Upholsterer 16.6511000 - General Services And Support Occupations 11030 - Cleaner, Vehicles 9.05 11060 - Elevator Operator 9.05 11090 - Gardener 14.30 11122 - Housekeeping Aide 11.32 11150 - Janitor 11.32 11210 - Laborer, Grounds Maintenance 10.84 11240 - Maid or Houseman 8.70 11260 - Pruner 9.76 11270 - Tractor Operator 13.14 11330 - Trail Maintenance Worker 10.84 11360 - Window Cleaner 12.4612000 - Health Occupations 12010 - Ambulance Driver 17.13 12011 - Breath Alcohol Technician 17.88 12012 - Certified Occupational Therapist Assistant 26.35 12015 - Certified Physical Therapist Assistant 26.35 12020 - Dental Assistant 16.89 12025 - Dental Hygienist 26.04 12030 - EKG Technician 21.37 12035 - Electroneurodiagnostic Technologist 21.37 12040 - Emergency Medical Technician 17.13 12071 - Licensed Practical Nurse I 17.44 12072 - Licensed Practical Nurse II 19.51 12073 - Licensed Practical Nurse III 21.75 12100 - Medical Assistant 13.09 12130 - Medical Laboratory Technician 16.70 12160 - Medical Record Clerk 14.11 12190 - Medical Record Technician 15.52 12195 - Medical Transcriptionist 15.02 12210 - Nuclear Medicine Technologist 30.98 12221 - Nursing Assistant I 9.46 12222 - Nursing Assistant II 10.63 12223 - Nursing Assistant III 11.60 12224 - Nursing Assistant IV 13.02 12235 - Optical Dispenser 19.04 12236 - Optical Technician 13.00 12250 - Pharmacy Technician 14.03 12280 - Phlebotomist 12.65 12305 - Radiologic Technologist 25.53 12311 - Registered Nurse I 23.88 12312 - Registered Nurse II 27.55 12313 - Registered Nurse II, Specialist 27.55 12314 - Registered Nurse III 33.08 12315 - Registered Nurse III, Anesthetist 33.08 12316 - Registered Nurse IV 39.89 12317 - Scheduler (Drug and Alcohol Testing) 22.1513000 - Information And Arts Occupations 13011 - Exhibits Specialist I 21.45 13012 - Exhibits Specialist II 26.22 13013 - Exhibits Specialist III 30.49 13041 - Illustrator I 18.88 13042 - Illustrator II 23.39 13043 - Illustrator III 28.61 13047 - Librarian 27.59 13050 - Library Aide/Clerk 10.78 13054 - Library Information Technology Systems 24.65 Administrator 13058 - Library Technician 13.74 13061 - Media Specialist I 17.98 13062 - Media Specialist II 20.11 13063 - Media Specialist III 22.43 13071 - Photographer I 18.09 13072 - Photographer II 20.23 13073 - Photographer III 25.08 13074 - Photographer IV 29.18 13075 - Photographer V 35.30 13110 - Video Teleconference Technician 18.1814000 - Information Technology Occupations 14041 - Computer Operator I 15.66 14042 - Computer Operator II 17.71 14043 - Computer Operator III 19.54 14044 - Computer Operator IV 21.70 14045 - Computer Operator V 23.54 14071 - Computer Programmer I (see 1) 22.92 14072 - Computer Programmer II (see 1) 27.56 14073 - Computer Programmer III (see 1) 14074 - Computer Programmer IV (see 1) 14101 - Computer Systems Analyst I (see 1) 14102 - Computer Systems Analyst II (see 1) 14103 - Computer Systems Analyst III (see 1) 14150 - Peripheral Equipment Operator 15.66 14160 - Personal Computer Support Technician 21.7015000 - Instructional Occupations 15010 - Aircrew Training Devices Instructor (Non-Rated) 28.58 15020 - Aircrew Training Devices Instructor (Rated) 34.55 15030 - Air Crew Training Devices Instructor (Pilot) 40.18 15050 - Computer Based Training Specialist / Instructor 29.03 15060 - Educational Technologist 26.16 15070 - Flight Instructor (Pilot) 40.18 15080 - Graphic Artist 22.03 15090 - Technical Instructor 19.47 15095 - Technical Instructor/Course Developer 25.39 15110 - Test Proctor 16.75 15120 - Tutor 16.7516000 - Laundry, Dry-Cleaning, Pressing And Related Occupations 16010 - Assembler 9.04 16030 - Counter Attendant 9.04 16040 - Dry Cleaner 11.35 16070 - Finisher, Flatwork, Machine 9.04 16090 - Presser, Hand 9.04 16110 - Presser, Machine, Drycleaning 9.04 16130 - Presser, Machine, Shirts 9.04 16160 - Presser, Machine, Wearing Apparel, Laundry 9.04 16190 - Sewing Machine Operator 12.15 16220 - Tailor 12.91 16250 - Washer, Machine 9.8019000 - Machine Tool Operation And Repair Occupations 19010 - Machine-Tool Operator (Tool Room) 16.33 19040 - Tool And Die Maker 19.2321000 - Materials Handling And Packing Occupations 21020 - Forklift Operator 16.62 21030 - Material Coordinator 17.77 21040 - Material Expediter 18.02 21050 - Material Handling Laborer 10.87 21071 - Order Filler 11.42 21080 - Production Line Worker (Food Processing) 16.62 21110 - Shipping Packer 13.06 21130 - Shipping/Receiving Clerk 13.06 21140 - Store Worker I 9.94 21150 - Stock Clerk 13.53 21210 - Tools And Parts Attendant 16.50 21410 - Warehouse Specialist 16.6223000 - Mechanics And Maintenance And Repair Occupations 23010 - Aerospace Structural Welder 26.29 23021 - Aircraft Mechanic I 25.04 23022 - Aircraft Mechanic II 26.29 23023 - Aircraft Mechanic III 27.60 23040 - Aircraft Mechanic Helper 19.58 23050 - Aircraft, Painter 18.32 23060 - Aircraft Servicer 21.80 23080 - Aircraft Worker 22.87 23110 - Appliance Mechanic 17.67 23120 - Bicycle Repairer 12.68 23125 - Cable Splicer 22.88 23130 - Carpenter, Maintenance 17.07 23140 - Carpet Layer 16.68 23160 - Electrician, Maintenance 18.62 23181 - Electronics Technician Maintenance I 18.96 23182 - Electronics Technician Maintenance II 20.76 23183 - Electronics Technician Maintenance III 24.93 23260 - Fabric Worker 15.47 23290 - Fire Alarm System Mechanic 17.61 23310 - Fire Extinguisher Repairer 13.68 23311 - Fuel Distribution System Mechanic 17.66 23312 - Fuel Distribution System Operator 15.87 23370 - General Maintenance Worker 17.25 23380 - Ground Support Equipment Mechanic 25.04 23381 - Ground Support Equipment Servicer 21.80 23382 - Ground Support Equipment Worker 22.87 23391 - Gunsmith I 14.96 23392 - Gunsmith II 17.39 23393 - Gunsmith III 19.30 23410 - Heating, Ventilation And Air-Conditioning 17.61 Mechanic 23411 - Heating, Ventilation And Air Contditioning 18.45 Mechanic (Research Facility) 23430 - Heavy Equipment Mechanic 19.76 23440 - Heavy Equipment Operator 17.06 23460 - Instrument Mechanic 19.79 23465 - Laboratory/Shelter Mechanic 18.32 23470 - Laborer 11.48 23510 - Locksmith 16.65 23530 - Machinery Maintenance Mechanic 20.38 23550 - Machinist, Maintenance 17.94 23580 - Maintenance Trades Helper 14.98 23591 - Metrology Technician I 19.79 23592 - Metrology Technician II 20.78 23593 - Metrology Technician III 21.82 23640 - Millwright 19.28 23710 - Office Appliance Repairer 18.68 23760 - Painter, Maintenance 17.67 23790 - Pipefitter, Maintenance 17.70 23810 - Plumber, Maintenance 16.93 23820 - Pneudraulic Systems Mechanic 18.75 23850 - Rigger 17.75 23870 - Scale Mechanic 16.63 23890 - Sheet-Metal Worker, Maintenance 17.67 23910 - Small Engine Mechanic 16.34 23931 - Telecommunications Mechanic I 20.34 23932 - Telecommunications Mechanic II 24.13 23950 - Telephone Lineman 23.50 23960 - Welder, Combination, Maintenance 17.42 23965 - Well Driller 17.75 23970 - Woodcraft Worker 18.75 23980 - Woodworker 14.3024000 - Personal Needs Occupations 24570 - Child Care Attendant 9.21 24580 - Child Care Center Clerk 14.10 24610 - Chore Aide 9.49 24620 - Family Readiness And Support Services 13.23 Coordinator 24630 - Homemaker 17.3325000 - Plant And System Operations Occupations 25010 - Boiler Tender 20.86 25040 - Sewage Plant Operator 19.33 25070 - Stationary Engineer 20.86 25190 - Ventilation Equipment Tender 14.64 25210 - Water Treatment Plant Operator 19.3327000 - Protective Service Occupations 27004 - Alarm Monitor 17.49 27007 - Baggage Inspector 10.36 27008 - Corrections Officer 22.81 27010 - Court Security Officer 21.45 27030 - Detection Dog Handler 16.69 27040 - Detention Officer 22.81 27070 - Firefighter 19.59 27101 - Guard I 10.36 27102 - Guard II 16.29 27131 - Police Officer I 24.05 27132 - Police Officer II 26.8028000 - Recreation Occupations 28041 - Carnival Equipment Operator 10.35 28042 - Carnival Equipment Repairer 11.02 28043 - Carnival Equpment Worker 8.13 28210 - Gate Attendant/Gate Tender 12.85 28310 - Lifeguard 11.15 28350 - Park Attendant (Aide) 14.37 28510 - Recreation Aide/Health Facility Attendant 7.98 28515 - Recreation Specialist 15.47 28630 - Sports Official 11.45 28690 - Swimming Pool Operator 14.4929000 - Stevedoring/Longshoremen Occupational Services 29010 - Blocker And Bracer 18.40 29020 - Hatch Tender 18.40 29030 - Line Handler 18.40 29041 - Stevedore I 16.51 29042 - Stevedore II 20.1230000 - Technical Occupations 30010 - Air Traffic Control Specialist, Center (HFO) (see 2) 35.77 30011 - Air Traffic Control Specialist, Station (HFO) (see 2) 24.66 30012 - Air Traffic Control Specialist, Terminal (HFO) (see 2) 27.16 30021 - Archeological Technician I 15.80 30022 - Archeological Technician II 18.16 30023 - Archeological Technician III 22.52 30030 - Cartographic Technician 24.49 30040 - Civil Engineering Technician 22.98 30061 - Drafter/CAD Operator I 14.36 30062 - Drafter/CAD Operator II 18.16 30063 - Drafter/CAD Operator III 18.41 30064 - Drafter/CAD Operator IV 24.93 30081 - Engineering Technician I 16.69 30082 - Engineering Technician II 18.74 30083 - Engineering Technician III 21.23 30084 - Engineering Technician IV 24.45 30085 - Engineering Technician V 26.10 30086 - Engineering Technician VI 29.43 30090 - Environmental Technician 18.16 30210 - Laboratory Technician 17.50 30240 - Mathematical Technician 21.76 30361 - Paralegal/Legal Assistant I 18.01 30362 - Paralegal/Legal Assistant II 22.31 30363 - Paralegal/Legal Assistant III 27.29 30364 - Paralegal/Legal Assistant IV 33.02 30390 - Photo-Optics Technician 22.93 30461 - Technical Writer I 18.74 30462 - Technical Writer II 22.95 30463 - Technical Writer III 27.73 30491 - Unexploded Ordnance (UXO) Technician I 22.34 30492 - Unexploded Ordnance (UXO) Technician II 27.03 30493 - Unexploded Ordnance (UXO) Technician III 32.40 30494 - Unexploded (UXO) Safety Escort 22.34 30495 - Unexploded (UXO) Sweep Personnel 22.34 30620 - Weather Observer, Combined Upper Air Or (see 2) 18.41 Surface Programs 30621 - Weather Observer, Senior (see 2) 19.1031000 - Transportation/Mobile Equipment Operation Occupations 31020 - Bus Aide 10.86 31030 - Bus Driver 15.51 31043 - Driver Courier 11.93 31260 - Parking and Lot Attendant 9.69 31290 - Shuttle Bus Driver 13.12 31310 - Taxi Driver 9.96 31361 - Truckdriver, Light 13.12 31362 - Truckdriver, Medium 14.85 31363 - Truckdriver, Heavy 16.96 31364 - Truckdriver, Tractor-Trailer 16.9699000 - Miscellaneous Occupations 99030 - Cashier 7.97 99050 - Desk Clerk 9.76 99095 - Embalmer 20.28 99251 - Laboratory Animal Caretaker I 9.97 99252 - Laboratory Animal Caretaker II 10.85 99310 - Mortician 26.58 99410 - Pest Controller 13.00 99510 - Photofinishing Worker 11.02 99710 - Recycling Laborer 13.22 99711 - Recycling Specialist 15.51 99730 - Refuse Collector 11.78 99810 - Sales Clerk 12.49 99820 - School Crossing Guard 9.20 99830 - Survey Party Chief 17.05 99831 - Surveying Aide 10.49 99832 - Surveying Technician 16.01 99840 - Vending Machine Attendant 13.04 99841 - Vending Machine Repairer 15.43 99842 - Vending Machine Repairer Helper 13.04____________________________________________________________________________________ALL OCCUPATIONS LISTED ABOVE RECEIVE THE FOLLOWING BENEFITS:HEALTH & WELFARE: Life, accident, and health insurance plans, sick leave, pensionplans, civic and personal leave, severance pay, and savings and thrift plans.Minimum employer contributions costing an average of $4.27 per hour computed on thebasis of all hours worked by service employees employed on the contract.VACATION: 2 weeks paid vacation after 1 year of service with a contractor orsuccessor; and 3 weeks after 5 years. Length of service includes the whole span ofcontinuous service with the present contractor or successor, wherever employed, andwith the predecessor contractors in the performance of similar work at the sameFederal facility. (Reg. 29 CFR 4.173)HOLIDAYS: A minimum of ten paid holidays per year, New Year's Day, Martin LutherKing Jr's Birthday, Washington's Birthday, Memorial Day, Independence Day, LaborDay, Columbus Day, Veterans' Day, Thanksgiving Day, and Christmas Day. (Acontractor may substitute for any of the named holidays another day off with pay inaccordance with a plan communicated to the employees involved.) (See 29 CFR 4174)THE OCCUPATIONS WHICH HAVE NUMBERED FOOTNOTES IN PARENTHESES RECEIVE THE FOLLOWING:1) COMPUTER EMPLOYEES: Under the SCA at section 8(b), this wage determination doesnot apply to any employee who individually qualifies as a bona fide executive,administrative, or professional employee as defined in 29 C.F.R. Part 541. Becausemost Computer System Analysts and Computer Programmers who are compensated at a ratenot less than $27.63 (or on a salary or fee basis at a rate not less than $455 perweek) an hour would likely qualify as exempt computer professionals, (29 C.F.R. 541.400) wage rates may not be listed on this wage determination for all occupationswithin those job families. In addition, because this wage determination may notlist a wage rate for some or all occupations within those job families if the surveydata indicates that the prevailing wage rate for the occupation equals or exceeds$27.63 per hour conformances may be necessary for certain nonexempt employees. Forexample, if an individual employee is nonexempt but nevertheless performs dutieswithin the scope of one of the Computer Systems Analyst or Computer Programmeroccupations for which this wage determination does not specify an SCA wage rate,then the wage rate for that employee must be conformed in accordance with theconformance procedures described in the conformance note included on this wagedetermination.Additionally, because job titles vary widely and change quickly in the computerindustry, job titles are not determinative of the application of the computerprofessional exemption. Therefore, the exemption applies only to computer employeeswho satisfy the compensation requirements and whose primary duty consists of: (1) The application of systems analysis techniques and procedures, includingconsulting with users, to determine hardware, software or system functionalspecifications; (2) The design, development, documentation, analysis, creation, testing ormodification of computer systems or programs, including prototypes, based on andrelated to user or system design specifications; (3) The design, documentation, testing, creation or modification of computerprograms related to machine operating systems; or (4) A combination of the aforementioned duties, the performance of whichrequires the same level of skills. (29 C.F.R. 541.400).2) AIR TRAFFIC CONTROLLERS AND WEATHER OBSERVERS - NIGHT PAY & SUNDAY PAY: If youwork at night as part of a regular tour of duty, you will earn a night differentialand receive an additional 10% of basic pay for any hours worked between 6pm and 6am. If you are a full-time employed (40 hours a week) and Sunday is part of yourregularly scheduled workweek, you are paid at your rate of basic pay plus a Sundaypremium of 25% of your basic rate for each hour of Sunday work which is not overtime(i.e. occasional work on Sunday outside the normal tour of duty is consideredovertime work).HAZARDOUS PAY DIFFERENTIAL: An 8 percent differential is applicable to employeesemployed in a position that represents a high degree of hazard when working with orin close proximity to ordinance, explosives, and incendiary materials. Thisincludes work such as screening, blending, dying, mixing, and pressing of sensitiveordance, explosives, and pyrotechnic compositions such as lead azide, black powderand photoflash powder. All dry-house activities involving propellants or explosives. Demilitarization, modification, renovation, demolition, and maintenance operationson sensitive ordnance, explosives and incendiary materials. All operationsinvolving regrading and cleaning of artillery ranges.A 4 percent differential is applicable to employees employed in a position thatrepresents a low degree of hazard when working with, or in close proximity toordance, (or employees possibly adjacent to) explosives and incendiary materialswhich involves potential injury such as laceration of hands, face, or arms of theemployee engaged in the operation, irritation of the skin, minor burns and thelike; minimal damage to immediate or adjacent work area or equipment being used.All operations involving, unloading, storage, and hauling of ordance, explosive, andincendiary ordnance material other than small arms ammunition. These differentialsare only applicable to work that has been specifically designated by the agency forordance, explosives, and incendiary material differential pay.** UNIFORM ALLOWANCE **If employees are required to wear uniforms in the performance of this contract(either by the terms of the Government contract, by the employer, by the state orlocal law, etc.), the cost of furnishing such uniforms and maintaining (bylaundering or dry cleaning) such uniforms is an expense that may not be borne by anemployee where such cost reduces the hourly rate below that required by the wagedetermination. The Department of Labor will accept payment in accordance with thefollowing standards as compliance:The contractor or subcontractor is required to furnish all employees with anadequate number of uniforms without cost or to reimburse employees for the actualcost of the uniforms. In addition, where uniform cleaning and maintenance is madethe responsibility of the employee, all contractors and subcontractors subject tothis wage determination shall (in the absence of a bona fide collective bargainingagreement providing for a different amount, or the furnishing of contraryaffirmative proof as to the actual cost), reimburse all employees for such cleaningand maintenance at a rate of $3.35 per week (or $.67 cents per day). However, inthose instances where the uniforms furnished are made of "wash and wear"materials, may be routinely washed and dried with other personal garments, and donot require any special treatment such as dry cleaning, daily washing, or commerciallaundering in order to meet the cleanliness or appearance standards set by the termsof the Government contract, by the contractor, by law, or by the nature of the work,there is no requirement that employees be reimbursed for uniform maintenance costs.The duties of employees under job titles listed are those described in the"Service Contract Act Directory of Occupations", Fifth Edition, April 2006,unless otherwise indicated. Copies of the Directory are available on the Internet. Alinks to the Directory may be found on the WHD home page at or through the Wage Determinations On-Line (WDOL) Web site at FOR AUTHORIZATION OF ADDITIONAL CLASSIFICATION AND WAGE RATE {Standard Form1444 (SF 1444)}Conformance Process:The contracting officer shall require that any class of service employee which isnot listed herein and which is to be employed under the contract (i.e., the work tobe performed is not performed by any classification listed in the wagedetermination), be classified by the contractor so as to provide a reasonablerelationship (i.e., appropriate level of skill comparison) between such unlistedclassifications and the classifications listed in the wage determination. Suchconformed classes of employees shall be paid the monetary wages and furnished thefringe benefits as are determined. Such conforming process shall be initiated bythe contractor prior to the performance of contract work by such unlisted class(es)of employees. The conformed classification, wage rate, and/or fringe benefits shallbe retroactive to the commencement date of the contract. {See Section 4.6 (C)(vi)}When multiple wage determinations are included in a contract, a separate SF 1444should be prepared for each wage determination to which a class(es) is to beconformed.The process for preparing a conformance request is as follows:1) When preparing the bid, the contractor identifies the need for a conformedoccupation(s) and computes a proposed rate(s).2) After contract award, the contractor prepares a written report listing in orderproposed classification title(s), a Federal grade equivalency (FGE) for eachproposed classification(s), job description(s), and rationale for proposed wagerate(s), including information regarding the agreement or disagreement of theauthorized representative of the employees involved, or where there is no authorizedrepresentative, the employees themselves. This report should be submitted to thecontracting officer no later than 30 days after such unlisted class(es) of employeesperforms any contract work.3) The contracting officer reviews the proposed action and promptly submits a reportof the action, together with the agency's recommendations and pertinentinformation including the position of the contractor and the employees, to the Wageand Hour Division, Employment Standards Administration, U.S. Department of Labor,for review. (See section 4.6(b)(2) of Regulations 29 CFR Part 4).4) Within 30 days of receipt, the Wage and Hour Division approves, modifies, ordisapproves the action via transmittal to the agency contracting officer, ornotifies the contracting officer that additional time will be required to processthe request.5) The contracting officer transmits the Wage and Hour decision to the contractor.6) The contractor informs the affected rmation required by the Regulations must be submitted on SF 1444 or bond paper.When preparing a conformance request, the "Service Contract Act Directory ofOccupations" (the Directory) should be used to compare job definitions to insurethat duties requested are not performed by a classification already listed in thewage determination. Remember, it is not the job title, but the required tasks thatdetermine whether a class is included in an established wage determination.Conformances may not be used to artificially split, combine, or subdivideclassifications listed in the wage determination.D.6 SUBCONTRACTING GOALS MEMOSmall Business Procurement - FINAL FY2015 Goals AGENCYPrime ContractingSubcontractingSmall BusinessSDBWOSBSDVOSBHUBZoneSmall BusinessSDBWOSBSDVOSBHUBZoneDEPT OF DEFENSE (9700)21.60%5%5%3%3%36.00%5%5%3%3%ENERGY, DEPARTMENT OF (8900)6.00%5%5%3%3%50.00%5%5%3%3%HEALTH AND HUMAN SERVICES, DEPARTMENT OF (7500)23.00%5%5%3%3%33.00%5%5%3%3%VETERANS AFFAIRS, DEPARTMENT OF (3600)32.00%5%5%3%3%17.50%5%5%3%3%NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (8000)17.00%5%5%3%3%36.00%5%5%3%3%HOMELAND SECURITY, DEPARTMENT OF (7000)32.00%5%5%3%3%41.00%5%5%3%3%GENERAL SERVICES ADMINISTRATION (4700)32.00%5%5%3%3%29.00%5%5%3%3%AGRICULTURE, DEPARTMENT OF (1200)53.00%5%5%3%3%23.00%5%5%3%3%JUSTICE, DEPARTMENT OF (1500)27.50%5%5%3%3%42.00%5%5%3%3%INTERIOR, DEPARTMENT OF THE (1400)53.00%5%5%3%3%44.50%5%5%3%3%STATE, DEPARTMENT OF (1900)39.00%5%5%3%3%32.00%5%5%3%3%COMMERCE, DEPARTMENT OF (1300)37.00%5%5%3%3%30.00%5%5%3%3%TREASURY, DEPARTMENT OF THE (2000)35.00%5%5%3%3%21.67%5%5%3%3%LABOR, DEPARTMENT OF (1600)30.00%5%5%3%3%55.00%5%5%3%3%TRANSPORTATION, DEPARTMENT OF (6900)44.00%5%5%3%3%50.00%5%5%3%3%ENVIRONMENTAL PROTECTION AGENCY (6800)40.00%5%5%3%3%55.00%5%5%3%3%EDUCATION, DEPARTMENT OF (9100)20.00%5%5%3%3%33.00%5%5%3%3%HOUSING AND URBAN DEVELOPMENT, DEPARTMENT OF (8600)38.00%5%5%3%3%55.00%5%5%3%3%AGENCY FOR INTERNATIONAL DEVELOPMENT (7200)14.00%5%5%3%3%19.00%5%5%3%3%SOCIAL SECURITY ADMINISTRATION (2800)33.50%5%5%3%3%50.00%5%5%3%3%OFFICE OF PERSONNEL MANAGEMENT (2400)25.00%5%5%3%3%55.00%5%5%3%3%NATIONAL SCIENCE FOUNDATION (4900)18.00%5%5%3%3%24.00%5%5%3%3%NUCLEAR REGULATORY COMMISSION (3100)29.00%5%5%3%3%45.00%5%5%3%3%SMALL BUSINESS ADMINISTRATION (7300)69.00%5%5%3%3%7.00%5%5%3%3% D.7 QUALITY ASSURANCE SURVEILLANCE PLANThe contractor will be evaluated in accordance with the following:1.PURPOSEThis Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:What will be monitored.How monitoring will take place.Who will conduct the monitoring.How monitoring efforts and results will be documented.This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance.This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the contractor through contract modification. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.ernment Roles and ResponsibilitiesThe following personnel shall oversee and coordinate surveillance activities.a.Contracting Officer (CO) – The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.Assigned CO: Brett Cook, Contracting Officer, Network Contracting Activity 8Organization or Agency: Department of Veterans Affairs, VHAb.Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.Assigned COR(s): Sandra Garrido, Surgery Administrative OfficerOrganization or Agency: Department of Veterans Affairs, VHA, James A. Haley Veterans Hospital3.Contractor RepresentativesThe following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.Primary: __________Alternate: __________4.Performance StandardsThe contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined.Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.5. Incentives/DEDUCTSThe Government shall use past performance as incentives. Incentives shall be based on ratings received on the performance standards. Incentives shall be based on exceeding, meeting, or not meeting performance standards. 6. Methods of QA Surveillance Various methods exist to monitor performance. The COR shall use the surveillance method listed below in the administration of this QASP. a. Validationb. 100% Inspectionc. Random InspectionPERFORMANCE MEASURES MeasuresPWSReferencePerformanceRequirementStandardAcceptable Quality LevelSurveillanceMethodIncentiveDisincentive/Deduct1 – Quality of Care4.6.2.1Pg. 171Accreditation of facilityAmbulatory Surgery Facility must be accredited by JCAHO or equivalent,.i.e. Accreditation Association of Ambulatory Health Care (AAAHC)100%Documentation of accreditation.Favorable contactor performance evaluation and Task Order awards.Unfavorable contractor performance evaluation2 – Quality of Care4.6.2.2Pg. 171PrivilegesAnesthesiologist and CRNA providers must be privileged within the scope of their training and experience.100%Documentation of accreditation.Favorable contactor performance evaluation and Task Order awardsUnfavorable contractor performance evaluation3 – Quality of Care4.6.2.3Pg. 172Contractors complianceContractors shall be in compliance with Medicare, Medicaid and any other related federal and state statures, regulations, rules and policies100%Documentation of complianceFavorable contactor performance evaluation and Task Order awards.Unfavorable contractor performance evaluation4 – Patient Safety4.6.2.4Pg. 172Patient Safety incidents must be reported to the authorizing VA medical center and COR. This should include, but are not limited to: Airway event, Regional/MAC Adverse event, CNS/PNS event, Cardio respiratory event, unplanned admissions and mortality.All incidents reported immediately (within 24 hours)95%Observation and random inspection (auditing) or any other method that was proposed in your solution.Favorable contactor performance evaluation and Task Order awards.Unfavorable contractor performance evaluation5 – Equipment, Supplies, Staffing4.6.2.5Pg. 172The contractors will provide all necessary equipment and supplies needed to perform the operation and qualified OR nurses and technicians. Equipment will be in proper working conditions, supplies readily available and have licensed and/or certified staff.95%Observation and review of staff documentation along with physician feedback and surveys.Favorable contactor performance evaluation and Task Order awards.Unfavorable contractor performance evaluation.6 – Patient Care4.6.2.6Pg. 172Patients will not require hospital admission or Emergency Department visit related to surgery and/or anesthesia after their outpatient ambulatory procedure.All unplanned admissions or Emergency Department visits – with none to be from adverse event from surgery and/or anesthesia will be monitored on a quarterly base for review.95%Quarterly Reports will be submitted and reviewed from the Contract Facility to the COR.Favorable contactor performance evaluation and Task Order awards.Unfavorable contractor performance evaluation.7 – Surgical Complications4.6.2.7Pg. 173Patients will not experience post-operative infections or other surgical complications after their outpatient ambulatory procedure.All surgical infections and complications per patient will be monitored on the quarterly report and followed for patient satisfaction and case by case peer review.95%Quarterly Reports will be submitted and reviewed from the Contract Facility to the COR.Favorable contactor performance evaluation and Task Order awards.Unfavorable contractor performance evaluation.8 - Documentation4.6.2.8Pg. 173Anesthesia recordAll anesthesia post-operative notes will be documented and be readily available after the surgical procedure.95%Direct observation and review of documentationFavorable contactor performance evaluation and Task Order awardsUnfavorable contractor performance evaluation.9 – Provider Quality4.6.2.9Pg. 173Anesthesia ServiceAnesthesia services are accorder through the provision of adequate space, equipment, supplies, medications, and appropriately trained personnel.95%Direct observation and review of documentationFavorable contactor performance evaluation and Task Order awards.Unfavorable contractor performance evaluation.7.RatingsMetrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:Exceeds StandardMeets Standard Random Inspection8.DOCUMENTING PERFORMANCEa.Acceptance Performanceb. Unacceptable PerformanceWhen unacceptable performance occurs, the COR shall inform the contractors. This will normally be in writing unless circumstances necessitate verbal communication. In any case, the COR shall document the discussion and place it in the COR file.When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to the contractor’s program manager.The contractor shall acknowledge receipt of the CDR in writing. The CDR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The CDR will also state how long after receipt the contractor has to present this corrective action plan to the CO. The Government shall review the contractor's corrective action plan to determine acceptability. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance and the acceptability of the Contractor’s corrective action plan.Any CDRs may become a part of the supporting documentation for any contract action deemed necessary by the CO. 9. Frequency of Measurementa.Frequency of Measurement.During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the workbeing performed. Reports will be complete on a monthly basis and a copy will be provided to the contractor. b.Frequency of Assessment Meetings.The COR shall meet with the contractor biannually to assess performance and shall provide a written assessment10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASPSIGNED: ________________________________________Sandra Garrido, Surgery Administrative Officer, James A. Haley VA HospitalSIGNED: SIGNED:________________________________________ ________________________________________Brett Cook, DVA VHA Network Contracting Office 8 Contractor Program Manager SECTION E - SOLICITATION PROVISIONSE.1 52.203-98 PROHIBITION ON CONTRACTING WITH ENTITIES THAT REQUIRE CERTAIN INTERNAL CONFIDENTIALITY AGREEMENTS—REPRESENTATION (DEVIATION) (FEB 2015) (a) In accordance with section 743 of Division E, Title VII, of the Consolidated and Further Continuing Resolution Appropriations Act, 2015 (Pub. L. 113-235), Government agencies are not permitted to use funds appropriated (or otherwise made available) under that or any other Act for contracts with an entity that requires employees or subcontractors of such entity seeking to report fraud, waste, or abuse to sign internal confidentiality agreements or statements prohibiting or otherwise restricting such employees or contactors from lawfully reporting such waste, fraud, or abuse to a designated investigative or law enforcement representative of a Federal department or agency authorized to receive such information. (b) The prohibition in paragraph (a) of this provision does not contravene requirements applicable to Standard Form 312, Form 4414, or any other form issued by a Federal department or agency governing the nondisclosure of classified information. (c) Representation. By submission of its offer, the Offeror represents that it does not require employees or subcontractors of such entity seeking to report fraud, waste, or abuse to sign internal confidentiality agreements or statements prohibiting or otherwise restricting such employees or subcontractors from lawfully reporting such waste, fraud, or abuse to a designated investigative or law enforcement representative of a Federal department or agency authorized to receive such information.(End of Provision)E.2 52.209-5 CERTIFICATION REGARDING RESPONSIBILITY MATTERS (OCT 2015) (a)(1) The Offeror certifies, to the best of its knowledge and belief, that— (i) The Offeror and/or any of its Principals— (A) Are [ ] are not [ ] presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency; (B) Have [ ] have not [ ], within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) contract or subcontract; violation of Federal or State antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws, or receiving stolen property (if offeror checks "have," the offeror shall also see 52.209-7, if included in this solicitation); (C) Are [ ] are not [ ] presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subdivision (a)(1)(i)(B) of this provision; and (D) Have [ ], have not [ ], within a three-year period preceding this offer, been notified of any delinquent Federal taxes in an amount that exceeds $3,500 for which the liability remains unsatisfied. (1) Federal taxes are considered delinquent if both of the following criteria apply: (i) The tax liability is finally determined. The liability is finally determined if it has been assessed. A liability is not finally determined if there is a pending administrative or judicial challenge. In the case of a judicial challenge to the liability, the liability is not finally determined until all judicial appeal rights have been exhausted. (ii) The taxpayer is delinquent in making payment. A taxpayer is delinquent if the taxpayer has failed to pay the tax liability when full payment was due and required. A taxpayer is not delinquent in cases where enforced collection action is precluded. (2) Examples. (i) The taxpayer has received a statutory notice of deficiency, under I.R.C. Sec. 6212, which entitles the taxpayer to seek Tax Court review of a proposed tax deficiency. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek Tax Court review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal rights. (ii) The IRS has filed a notice of Federal tax lien with respect to an assessed tax liability, and the taxpayer has been issued a notice under I.R.C. Sec. 6320 entitling the taxpayer to request a hearing with the IRS Office of Appeals contesting the lien filing, and to further appeal to the Tax Court if the IRS determines to sustain the lien filing. In the course of the hearing, the taxpayer is entitled to contest the underlying tax liability because the taxpayer has had no prior opportunity to contest the liability. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek tax court review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal rights. (iii) The taxpayer has entered into an installment agreement pursuant to I.R.C. Sec. 6159. The taxpayer is making timely payments and is in full compliance with the agreement terms. The taxpayer is not delinquent because the taxpayer is not currently required to make full payment. (iv) The taxpayer has filed for bankruptcy protection. The taxpayer is not delinquent because enforced collection action is stayed under 11 U.S.C. 362 (the Bankruptcy Code). (ii) The Offeror has [ ] has not [ ], within a 3-year period preceding this offer, had one or more contracts terminated for default by any Federal agency. (2) Principal, for the purposes of this certification, means an officer, director, owner, partner, or a person having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a division or business segment; and similar positions). THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER SECTION 1001, TITLE 18, UNITED STATES CODE. (b) The Offeror shall provide immediate written notice to the Contracting Officer if, at any time prior to contract award, the Offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. (c) A certification that any of the items in paragraph (a) of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Offeror's responsibility. Failure of the Offeror to furnish a certification or provide such additional information as requested by the Contracting Officer may render the Offeror nonresponsible. (d) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of an Offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. (e) The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Offeror knowingly rendered an erroneous certification, in addition to other remedies available to the Government, the Contracting Officer may terminate the contract resulting from this solicitation for default.(End of Provision)E.3 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (JUL 2013) (a) Definitions. As used in this provision— "Administrative proceeding" means a non-judicial process that is adjudicatory in nature in order to make a determination of fault or liability (e.g., Securities and Exchange Commission Administrative Proceedings, Civilian Board of Contract Appeals Proceedings, and Armed Services Board of Contract Appeals Proceedings). This includes administrative proceedings at the Federal and State level but only in connection with performance of a Federal contract or grant. It does not include agency actions such as contract audits, site visits, corrective plans, or inspection of deliverables. "Federal contracts and grants with total value greater than $10,000,000" means— (1) The total value of all current, active contracts and grants, including all priced options; and (2) The total value of all current, active orders including all priced options under indefinite-delivery, indefinite-quantity, 8(a), or requirements contracts (including task and delivery and multiple-award Schedules). "Principal" means an officer, director, owner, partner, or a person having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a division or business segment; and similar positions). (b) The offeror [ ] has [ ] does not have current active Federal contracts and grants with total value greater than $10,000,000. (c) If the offeror checked "has" in paragraph (b) of this provision, the offeror represents, by submission of this offer, that the information it has entered in the Federal Awardee Performance and Integrity Information System (FAPIIS) is current, accurate, and complete as of the date of submission of this offer with regard to the following information: (1) Whether the offeror, and/or any of its principals, has or has not, within the last five years, in connection with the award to or performance by the offeror of a Federal contract or grant, been the subject of a proceeding, at the Federal or State level that resulted in any of the following dispositions: (i) In a criminal proceeding, a conviction. (ii) In a civil proceeding, a finding of fault and liability that results in the payment of a monetary fine, penalty, reimbursement, restitution, or damages of $5,000 or more. (iii) In an administrative proceeding, a finding of fault and liability that results in— (A) The payment of a monetary fine or penalty of $5,000 or more; or (B) The payment of a reimbursement, restitution, or damages in excess of $100,000. (iv) In a criminal, civil, or administrative proceeding, a disposition of the matter by consent or compromise with an acknowledgment of fault by the Contractor if the proceeding could have led to any of the outcomes specified in paragraphs (c)(1)(i), (c)(1)(ii), or (c)(1)(iii) of this provision. (2) If the offeror has been involved in the last five years in any of the occurrences listed in (c)(1) of this provision, whether the offeror has provided the requested information with regard to each occurrence. (d) The offeror shall post the information in paragraphs (c)(1)(i) through (c)(1)(iv) of this provision in FAPIIS as required through maintaining an active registration in the System for Award Management database via (see 52.204-7).(End of Provision)E.4 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL ITEMS (OCT 2015) (a) North American Industry Classification System (NAICS) code and small business size standard. The NAICS code and small business size standard for this acquisition appear in Block 10 of the solicitation cover sheet (SF 1449). However, the small business size standard for a concern which submits an offer in its own name, but which proposes to furnish an item which it did not itself manufacture, is 500 employees. (b) Submission of offers. Submit signed and dated offers to the office specified in this solicitation at or before the exact time specified in this solicitation. Offers may be submitted on the SF 1449, letterhead stationery, or as otherwise specified in the solicitation. As a minimum, offers must show— (1) The solicitation number; (2) The time specified in the solicitation for receipt of offers; (3) The name, address, and telephone number of the offeror; (4) A technical description of the items being offered in sufficient detail to evaluate compliance with the requirements in the solicitation. This may include product literature, or other documents, if necessary; (5) Terms of any express warranty; (6) Price and any discount terms; (7) "Remit to" address, if different than mailing address; (8) A completed copy of the representations and certifications at FAR 52.212-3 (see FAR 52.212-3(b) for those representations and certifications that the offeror shall complete electronically); (9) Acknowledgment of Solicitation Amendments; (10) Past performance information, when included as an evaluation factor, to include recent and relevant contracts for the same or similar items and other references (including contract numbers, points of contact with telephone numbers and other relevant information); and (11) If the offer is not submitted on the SF 1449, include a statement specifying the extent of agreement with all terms, conditions, and provisions included in the solicitation. Offers that fail to furnish required representations or information, or reject the terms and conditions of the solicitation may be excluded from consideration. (c) Period for acceptance of offers. The offeror agrees to hold the prices in its offer firm for 30 calendar days from the date specified for receipt of offers, unless another time period is specified in an addendum to the solicitation. (d) Product samples. When required by the solicitation, product samples shall be submitted at or prior to the time specified for receipt of offers. Unless otherwise specified in this solicitation, these samples shall be submitted at no expense to the Government, and returned at the sender's request and expense, unless they are destroyed during preaward testing. (e) Multiple offers. Offerors are encouraged to submit multiple offers presenting alternative terms and conditions or commercial items for satisfying the requirements of this solicitation. Each offer submitted will be evaluated separately. (f) Late submissions, modifications, revisions, and withdrawals of offers. (1) Offerors are responsible for submitting offers, and any modifications, revisions, or withdrawals, so as to reach the Government office designated in the solicitation by the time specified in the solicitation. If no time is specified in the solicitation, the time for receipt is 4:30 p.m., local time, for the designated Government office on the date that offers or revisions are due. (2)(i) Any offer, modification, revision, or withdrawal of an offer received at the Government office designated in the solicitation after the exact time specified for receipt of offers is "late" and will not be considered unless it is received before award is made, the Contracting Officer determines that accepting the late offer would not unduly delay the acquisition; and— (A) If it was transmitted through an electronic commerce method authorized by the solicitation, it was received at the initial point of entry to the Government infrastructure not later than 5:00 p.m. one working day prior to the date specified for receipt of offers; or (B) There is acceptable evidence to establish that it was received at the Government installation designated for receipt of offers and was under the Government's control prior to the time set for receipt of offers; or (C) If this solicitation is a request for proposals, it was the only proposal received. (ii) However, a late modification of an otherwise successful offer, that makes its terms more favorable to the Government, will be considered at any time it is received and may be accepted. (3) Acceptable evidence to establish the time of receipt at the Government installation includes the time/date stamp of that installation on the offer wrapper, other documentary evidence of receipt maintained by the installation, or oral testimony or statements of Government personnel. (4) If an emergency or unanticipated event interrupts normal Government processes so that offers cannot be received at the Government office designated for receipt of offers by the exact time specified in the solicitation, and urgent Government requirements preclude amendment of the solicitation or other notice of an extension of the closing date, the time specified for receipt of offers will be deemed to be extended to the same time of day specified in the solicitation on the first work day on which normal Government processes resume. (5) Offers may be withdrawn by written notice received at any time before the exact time set for receipt of offers. Oral offers in response to oral solicitations may be withdrawn orally. If the solicitation authorizes facsimile offers, offers may be withdrawn via facsimile received at any time before the exact time set for receipt of offers, subject to the conditions specified in the solicitation concerning facsimile offers. An offer may be withdrawn in person by an offeror or its authorized representative if, before the exact time set for receipt of offers, the identity of the person requesting withdrawal is established and the person signs a receipt for the offer. (g) Contract award (not applicable to Invitation for Bids). The Government intends to evaluate offers and award a contract without discussions with offerors. Therefore, the offeror's initial offer should contain the offeror's best terms from a price and technical standpoint. However, the Government reserves the right to conduct discussions if later determined by the Contracting Officer to be necessary. The Government may reject any or all offers if such action is in the public interest; accept other than the lowest offer; and waive informalities and minor irregularities in offers received. (h) Multiple awards. The Government may accept any item or group of items of an offer, unless the offeror qualifies the offer by specific limitations. Unless otherwise provided in the Schedule, offers may not be submitted for quantities less than those specified. The Government reserves the right to make an award on any item for a quantity less than the quantity offered, at the unit prices offered, unless the offeror specifies otherwise in the offer. (i) Availability of requirements documents cited in the solicitation. (1)(i) The GSA Index of Federal Specifications, Standards and Commercial Item Descriptions, FPMR Part 101-29, and copies of specifications, standards, and commercial item descriptions cited in this solicitation may be obtained for a fee by submitting a request to—GSA Federal Supply Service Specifications Section Suite 8100 470 East L'Enfant Plaza, SWWashington, DC 20407Telephone (202) 619-8925 Facsimile (202) 619-8978. (ii) If the General Services Administration, Department of Agriculture, or Department of Veterans Affairs issued this solicitation, a single copy of specifications, standards, and commercial item descriptions cited in this solicitation may be obtained free of charge by submitting a request to the addressee in paragraph (i)(1)(i) of this provision. Additional copies will be issued for a fee. (2) Most unclassified Defense specifications and standards may be downloaded from the following ASSIST websites: (i) ASSIST (); (ii) Quick Search (); (iii) (). (3) Documents not available from ASSIST may be ordered from the Department of Defense Single Stock Point (DoDSSP) by? (i) Using the ASSIST Shopping Wizard (); (ii) Phoning the DoDSSP Customer Service Desk (215) 697-2179, Mon-Fri, 0730 to 1600 EST; or (iii) Ordering from DoDSSP, Building 4, Section D, 700 Robbins Avenue, Philadelphia, PA 19111-5094, Telephone (215) 697-2667/2179, Facsimile (215) 697-1462. (4) Nongovernment (voluntary) standards must be obtained from the organization responsible for their preparation, publication, or maintenance. (j) Data Universal Numbering System (DUNS) Number. (Applies to all offers exceeding $3,500, and offers of $3,500 or less if the solicitation requires the Contractor to be registered in the System for Award Management (SAM) database. The offeror shall enter, in the block with its name and address on the cover page of its offer, the annotation "DUNS" or "DUNS +4" followed by the DUNS or DUNS +4 number that identifies the offeror's name and address. The DUNS +4 is the DUNS number plus a 4-character suffix that may be assigned at the discretion of the offeror to establish additional SAM records for identifying alternative Electronic Funds Transfer (EFT) accounts (see FAR Subpart 32.11) for the same concern. If the offeror does not have a DUNS number, it should contact Dun and Bradstreet directly to obtain one. An offeror within the United States may contact Dun and Bradstreet by calling 1-866-705-5711 or via the internet at . An offeror located outside the United States must contact the local Dun and Bradstreet office for a DUNS number. The offeror should indicate that it is an offeror for a Government contract when contacting the local Dun and Bradstreet office. (k) System for Award Management. Unless exempted by an addendum to this solicitation, by submission of an offer, the offeror acknowledges the requirement that a prospective awardee shall be registered in the SAM database prior to award, during performance and through final payment of any contract resulting from this solicitation. If the Offeror does not become registered in the SAM database in the time prescribed by the Contracting Officer, the Contracting Officer will proceed to award to the next otherwise successful registered Offeror. Offerors may obtain information on registration and annual confirmation requirements via the SAM database accessed through . (l) Debriefing. If a post-award debriefing is given to requesting offerors, the Government shall disclose the following information, if applicable: (1) The agency's evaluation of the significant weak or deficient factors in the debriefed offeror's offer. (2) The overall evaluated cost or price and technical rating of the successful and the debriefed offeror and past performance information on the debriefed offeror. (3) The overall ranking of all offerors, when any ranking was developed by the agency during source selection. (4) A summary of the rationale for award; (5) For acquisitions of commercial items, the make and model of the item to be delivered by the successful offeror. (6) Reasonable responses to relevant questions posed by the debriefed offeror as to whether source-selection procedures set forth in the solicitation, applicable regulations, and other applicable authorities were followed by the agency.(End of Provision)ADDENDUM to FAR 52.212-1 INSTRUCTIONS TO OFFERORS--COMMERCIAL ITEMSProvisions that are incorporated by reference (by Citation Number, Title, and Date), have the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. The following provisions are incorporated into 52.212-1 as an addendum to this RFP:INSTRUCTIONS FOR PROPOSAL SUBMISSIONMethod:a. This acquisition will utilize a best value approach. The Best value is the most advantageous proposal, price and other factors considered, and consistent with the Government’s stated importance of evaluation criteria. This may result in award being made to a high-rated, higher prices schedule contractor where the Contracting Officer determines that the technical capability and past performance of the higher-priced contractor outweighs the cost difference. A contract award will be made to the responsible schedule contractor whose proposal conforms to the RFP requirements and will provide the best value to the Government, considering technical approach, past performance and cost/price.b. For the purpose of this RFP, all non-price evaluation factors, when combined, are significantly more important than price.c. Contractors are cautioned to follow instructions fully and carefully, as the Government reserves the right to make an award based on initial proposals received, without discussions. Therefore, each initial proposal should contain the contractor’s best terms from a cost/price and technical standpoint.d. Understanding the factors and the associated criteria indicated, the excellence of the work offered, and the ability of the contractor to actually accomplish what is offered in the proposal is the objective. Contractor shall submit in detail adequate information for evaluation purposes on the evaluation criteria.e. The Government intends to make one (1) or more awards based on the best value and the contractor’s ability to meet all requirements.f. To provide a basis for sound evaluation by the government, Offerors shall submit a complete proposal. The information provided shall be concise, factual, and complete. Proposals will be considered only from Offerors that are regularly established in the business and in the judgment of the government, are deemed financially responsible and able to show evidence of experience and have submitted the complete documentation requested.g. Offerors shall be registered in the system for award management (SAM) under the applicable North American Industry Classification System (NAICS) prior to contract award. The applicable NAICS shall be identified in the Contractors Online Representations and Certifications Application (ORCA) prior to contract award.h. Offerors are hereby advised that any imposed terms and conditions which deviate from the Government’s material terms and conditions established in the solicitation may render their proposal unacceptable and ineligible for award.i. The offeror agrees to hold the prices in its offer firm for 180 calendar days from the date specified for receipt of offers, unless another time period is specified in an addendum to the solicitation.Submission of Proposals:a. The contractors may e-mail questions regarding the RFP on or before, but no later than April 29th, 2016 12:00 PM EST to Attn: Brett Cook, Contract Specialist at brett.cook@ regarding the RFP.b. The proposals shall be submitted electronically by the due date and time located in block 8 of the SF1449. Electronic quotes shall be submitted to the attention of Brett Cook, Contract Specialist at brett.cook@.c. Telephonic (verbal) questions will not be addressed. Answers to questions will be addressed via an amendment to the solicitation and will be posted to . It is the responsibility of the Offeror to follow up to ensure that the proposal was received no later than the due time of the Request for Proposal (RFP).e. The price proposal shall be submitted as a separate document from the technical proposal.f. This solicitation will utilize FAR Part 15.g. The “best value” contractor will be evaluated based on four evaluation factors; Facility/Geographic location, Past Performance, Personnel Qualifications, Company experience/management approach, and SDVOSB Preference are listed in descending order of importance in accordance with FAR 15.203(a)(4). Non-priced factors when combined being more important than price for the purposes of proposal evaluation.E.5 52.212-2 EVALUATION—COMMERCIAL ITEMS (OCT 2014) (a) The Government will award a contract resulting from this solicitation to the responsible offeror whose offer conforming to the solicitation will be most advantageous to the Government, price and other factors considered. The following factors shall be used to evaluate offers: Evaluation Factors for Award: Factor 1 - Facility/Geographic locationSub-Factor 1: Provide information on the size, physical plant capabilities, and geographic location (within fifteen (15) miles from the James A. Haley Veterans Hospital) of the facility or facilities where contract performance will take place. Sub-Factor 2: Describe the ease of access for JAHVA staff physicians to and from the JAHVA hospital and contractor's locations. Sub-Factor 3: Describe the ease for JAHVA transport of specimens back and forth. Describe the ease of access for patients (e.g. located on bus route, parking space proximity, availability and cost, and handicap accommodations). The proximity of the contractor’s facility location to the JAHVH and the ease of access to and from the JAHVH and the contractor’s facility location will be used to evaluate this factor.Factor 2 - Past PerformanceSub-Factor 1: Identify all federal, state and local government contracts as well as any private/commercial contracts of similar scope, size, complexity that are ongoing or have been completed within the last three years. Include the following information for each contract: company name and address, name and telephone number of responsible individuals who have firsthand knowledge of performance relative to the same type of services, dates of contract performance and total contract value. Offerors may provide information on problems encountered on identified contracts and the offerors' corrective action. Past performance information is one indicator of an offerors' ability to perform the contract successfully.Current and relevant information, source of information, context of data, and general trends inContractor's performance shall be considered as it pertains to the performance of work described in this solicitation. The Government shall consider this information as well as information obtained from any other sources, when evaluating the offerors' past performance. In accordance with FAR 15.305, offerors with no relevant past performance or whom information is not available, shall not be evaluated favorably or unfavorably on past performance. However the proposal of an offeror with no relevant past performance may not represent the most advantageous proposal to the Government.Sub-Factor 2: Provide information regarding past records/patterns for infection rates, mortality and morbidity, adverse events, blood usage, drug usage and overall patient safety.Factor 3 - Personnel QualificationsSub-Factor 1: Provide list of Anesthesiologists, evidence (as applicable) of current licensure, board certification, credentials/privileges, and a brief resume/curriculum vitae for key personnel.Sub-Factor 2: Provide list of Licensed Practical Nurses (LPNs), evidence (as applicable) of current licensure, board certification, credentials/privileges, and a brief resume/curriculum vitae for key personnel.Sub-Factor 3: Provide list of Registered Nurses, evidence (as applicable) of current licensure, board certification, credentials/privileges, and a brief resume/curriculum vitae for key personnel. Sub-Factor 4: Provide list of technicians and all other relevant key personnel, evidence (as applicable) of current licensure, board certification, credentials/privileges, and a brief resume/curriculum vitae for key personnel. Factor 4 - Company experience/management approachSub-Factor 1: Describe the organization's experience in providing ambulatory surgery center space. Sub-Factor 2: Describe the organization’s experience in ambulatory surgery and anesthesia services. Sub-Factor 3: Evidence of organization's compliance with Federal, State and local regulations governing the provision of health care management methods to assure the provision of prompt and quality service, including a description of a quality assurance and customer service plan; certified financial statements or similar documentation that establishes an offerors' financial solvency and stability; historical patient satisfaction data, if available and the type of information system utilized for patient records, scheduling, billing and quality management.Factor 5 - Service Disabled Veteran Owned Small Business and Veteran Owned Small Business Preference In determining the acquisition strategy application to an acquisition, the contracting officer shall consider, in the following order of priority, contracting preferences that ensure contracts may be awarded: (a) To SDVOSBs(b) To VOSB, including but not limited to SDVOSBsThe contractor shall submit SDVOSB and VOSB information documenting this factor. Offeror and proposed subcontractors must be registered and verified in the VIP database () to receive consideration for this factor.Factor 6 – PricePrice/Cost Schedule, page 7 All factors, to include subfactors, are in descending order of importance and non-priced factors, when combined, are significantly more important than price. (b) Options. The Government will evaluate offers for award purposes by adding the total price for all options to the total price for the basic requirement. The Government may determine that an offer is unacceptable if the option prices are significantly unbalanced. Evaluation of options shall not obligate the Government to exercise the option(s). (c) A written notice of award or acceptance of an offer, mailed or otherwise furnished to the successful offeror within the time for acceptance specified in the offer, shall result in a binding contract without further action by either party. Before the offer's specified expiration time, the Government may accept an offer (or part of an offer), whether or not there are negotiations after its receipt, unless a written notice of withdrawal is received before award.(End of Provision)E.6 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL ITEMS (NOV 2015) The offeror shall complete only paragraph (b) of this provision if the offeror has completed the annual representations and certifications electronically via . If an offeror has not completed the annual representations and certifications electronically at the System for Award Management (SAM) website, the offeror shall complete only paragraphs (c) through (p) of this provision. (a) Definitions. As used in this provision— “Economically disadvantaged women-owned small business (EDWOSB) concern” means a small business concern that is at least 51 percent directly and unconditionally owned by, and the management and daily business operations of which are controlled by, one or more women who are citizens of the United States and who are economically disadvantaged in accordance with 13 CFR part 127. It automatically qualifies as a women-owned small business eligible under the WOSB Program. “Forced or indentured child labor” means all work or service— (1) Exacted from any person under the age of 18 under the menace of any penalty for its nonperformance and for which the worker does not offer himself voluntarily; or (2) Performed by any person under the age of 18 pursuant to a contract the enforcement of which can be accomplished by process or penalties. “Highest-level owner” means the entity that owns or controls an immediate owner of the offeror, or that owns or controls one or more entities that control an immediate owner of the offeror. No entity owns or exercises control of the highest level owner. “Immediate owner” means an entity, other than the offeror, that has direct control of the offeror. Indicators of control include, but are not limited to, one or more of the following: Ownership or interlocking management, identity of interests among family members, shared facilities and equipment, and the common use of employees. “Inverted domestic corporation” means a foreign incorporated entity that meets the definition of an inverted domestic corporation under 6 U.S.C. 395(b), applied in accordance with the rules and definitions of 6 U.S.C. 395(c). “Manufactured end product” means any end product in product and service codes (PSCs) 1000-9999, except— (1) PSC 5510, Lumber and Related Basic Wood Materials; (2) Product or Service Group (PSG) 87, Agricultural Supplies; (3) PSG 88, Live Animals; (4) PSG 89, Subsistence; (5) PSC 9410, Crude Grades of Plant Materials; (6) PSC 9430, Miscellaneous Crude Animal Products, Inedible; (7) PSC 9440, Miscellaneous Crude Agricultural and Forestry Products; (8) PSC 9610, Ores; (9) PSC 9620, Minerals, Natural and Synthetic; and (10) PSC 9630, Additive Metal Materials. “Place of manufacture” means the place where an end product is assembled out of components, or otherwise made or processed from raw materials into the finished product that is to be provided to the Government. If a product is disassembled and reassembled, the place of reassembly is not the place of manufacture. “Restricted business operations” means business operations in Sudan that include power production activities, mineral extraction activities, oil-related activities, or the production of military equipment, as those terms are defined in the Sudan Accountability and Divestment Act of 2007 (Pub. L. 110-174). Restricted business operations do not include business operations that the person (as that term is defined in Section 2 of the Sudan Accountability and Divestment Act of 2007) conducting the business can demonstrate— (1) Are conducted under contract directly and exclusively with the regional government of southern Sudan; (2) Are conducted pursuant to specific authorization from the Office of Foreign Assets Control in the Department of the Treasury, or are expressly exempted under Federal law from the requirement to be conducted under such authorization; (3) Consist of providing goods or services to marginalized populations of Sudan; (4) Consist of providing goods or services to an internationally recognized peacekeeping force or humanitarian organization; (5) Consist of providing goods or services that are used only to promote health or education; or (6) Have been voluntarily suspended. “Sensitive technology”— (1) Means hardware, software, telecommunications equipment, or any other technology that is to be used specifically— (i) To restrict the free flow of unbiased information in Iran; or (ii) To disrupt, monitor, or otherwise restrict speech of the people of Iran; and (2) Does not include information or informational materials the export of which the President does not have the authority to regulate or prohibit pursuant to section 203(b)(3) of the International Emergency Economic Powers Act (50 U.S.C. 1702(b)(3)). “Service-disabled veteran-owned small business concern”— (1) Means a small business concern— (i) Not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans; and (ii) The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran. (2) Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined in 38 U.S.C. 101(16). “Small business concern” means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding on Government contracts, and qualified as a small business under the criteria in 13 CFR Part 121 and size standards in this solicitation. “Small disadvantaged business concern”, consistent with 13 CFR 124.1002, means a small business concern under the size standard applicable to the acquisition, that— (1) Is at least 51 percent unconditionally and directly owned (as defined at 13 CFR 124.105) by— (i) One or more socially disadvantaged (as defined at 13 CFR 124.103) and economically disadvantaged (as defined at 13 CFR 124.104) individuals who are citizens of the United States; and (ii) Each individual claiming economic disadvantage has a net worth not exceeding $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104(c)(2); and (2) The management and daily business operations of which are controlled (as defined at 13.CFR 124.106) by individuals, who meet the criteria in paragraphs (1)(i) and (ii) of this definition. “Subsidiary” means an entity in which more than 50 percent of the entity is owned— (1) Directly by a parent corporation; or (2) Through another subsidiary of a parent corporation. “Veteran-owned small business concern” means a small business concern— (1) Not less than 51 percent of which is owned by one or more veterans (as defined at 38 U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans; and (2) The management and daily business operations of which are controlled by one or more veterans. “Women-owned business concern” means a concern which is at least 51 percent owned by one or more women; or in the case of any publicly owned business, at least 51 percent of its stock is owned by one or more women; and whose management and daily business operations are controlled by one or more women. “Women-owned small business concern” means a small business concern— (1) That is at least 51 percent owned by one or more women; or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and (2) Whose management and daily business operations are controlled by one or more women. “Women-owned small business (WOSB) concern eligible under the WOSB Program” (in accordance with 13 CFR part 127), means a small business concern that is at least 51 percent directly and unconditionally owned by, and the management and daily business operations of which are controlled by, one or more women who are citizens of the United States. (b)(1) Annual Representations and Certifications. Any changes provided by the offeror in paragraph (b)(2) of this provision do not automatically change the representations and certifications posted on the SAM website. (2) The offeror has completed the annual representations and certifications electronically via the SAM website access through . After reviewing the SAM database information, the offeror verifies by submission of this offer that the representations and certifications currently posted electronically at FAR 52.212-3, Offeror Representations and Certifications—Commercial Items, have been entered or updated in the last 12 months, are current, accurate, complete, and applicable to this solicitation (including the business size standard applicable to the NAICS code referenced for this solicitation), as of the date of this offer and are incorporated in this offer by reference (see FAR 4.1201), except for paragraphs . (c) Offerors must complete the following representations when the resulting contract will be performed in the United States or its outlying areas. Check all that apply. (1) Small business concern. The offeror represents as part of its offer that it [ ] is, [ ] is not a small business concern. (2) Veteran-owned small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents as part of its offer that it [ ] is, [ ] is not a veteran-owned small business concern. (3) Service-disabled veteran-owned small business concern. [Complete only if the offeror represented itself as a veteran-owned small business concern in paragraph (c)(2) of this provision.] The offeror represents as part of its offer that it [ ] is, [ ] is not a service-disabled veteran-owned small business concern. (4) Small disadvantaged business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents that it [ ] is, [ ] is not a small disadvantaged business concern as defined in 13 CFR 124.1002. (5) Women-owned small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents that it [ ] is, [ ] is not a women-owned small business concern. (6) WOSB concern eligible under the WOSB Program. [Complete only if the offeror represented itself as a women-owned small business concern in paragraph (c)(5) of this provision.] The offeror represents that— (i) It [ ] is, [ ] is not a WOSB concern eligible under the WOSB Program, has provided all the required documents to the WOSB Repository, and no change in circumstances or adverse decisions have been issued that affects its eligibility; and (ii) It [ ] is, [ ] is not a joint venture that complies with the requirements of 13 CFR part 127, and the representation in paragraph (c)(6)(i) of this provision is accurate for each WOSB concern eligible under the WOSB Program participating in the joint venture. [The offeror shall enter the name or names of the WOSB concern eligible under the WOSB Program and other small businesses that are participating in the joint venture: ___________.] Each WOSB concern eligible under the WOSB Program participating in the joint venture shall submit a separate signed copy of the WOSB representation. (7) Economically disadvantaged women-owned small business (EDWOSB) concern. [Complete only if the offeror represented itself as a WOSB concern eligible under the WOSB Program in (c)(6) of this provision.] The offeror represents that— (i) It [ ] is, [ ] is not an EDWOSB concern, has provided all the required documents to the WOSB Repository, and no change in circumstances or adverse decisions have been issued that affects its eligibility; and (ii) It [ ] is, [ ] is not a joint venture that complies with the requirements of 13 CFR part 127, and the representation in paragraph (c)(7)(i) of this provision is accurate for each EDWOSB concern participating in the joint venture. [The offeror shall enter the name or names of the EDWOSB concern and other small businesses that are participating in the joint venture: ___________.] Each EDWOSB concern participating in the joint venture shall submit a separate signed copy of the EDWOSB representation.Note: Complete paragraphs (c)(8) and (c)(9) only if this solicitation is expected to exceed the simplified acquisition threshold. (8) Women-owned business concern (other than small business concern). [Complete only if the offeror is a women-owned business concern and did not represent itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents that it [ ] is a women-owned business concern. (9) Tie bid priority for labor surplus area concerns. If this is an invitation for bid, small business offerors may identify the labor surplus areas in which costs to be incurred on account of manufacturing or production (by offeror or first-tier subcontractors) amount to more than 50 percent of the contract price: ___________________________________________ (10) HUBZone small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents, as part of its offer, that— (i) It [ ] is, [ ] is not a HUBZone small business concern listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration, and no material change in ownership and control, principal office, or HUBZone employee percentage has occurred since it was certified by the Small Business Administration in accordance with 13 CFR Part 126; and (ii) It [ ] is, [ ] is not a joint venture that complies with the requirements of 13 CFR Part 126, and the representation in paragraph (c)(10)(i) of this provision is accurate for the HUBZone small business concern or concerns that are participating in the joint venture. [The offeror shall enter the name or names of the HUBZone small business concern or concerns that are participating in the joint venture:____________.] Each HUBZone small business concern participating in the joint venture shall submit a separate signed copy of the HUBZone representation. (d) Representations required to implement provisions of Executive Order 11246— (1) Previous contracts and compliance. The offeror represents that— (i) It [ ] has, [ ] has not participated in a previous contract or subcontract subject to the Equal Opportunity clause of this solicitation; and (ii) It [ ] has, [ ] has not filed all required compliance reports. (2) Affirmative Action Compliance. The offeror represents that— (i) It [ ] has developed and has on file, [ ] has not developed and does not have on file, at each establishment, affirmative action programs required by rules and regulations of the Secretary of Labor (41 CFR parts 60-1 and 60-2), or (ii) It [ ] has not previously had contracts subject to the written affirmative action programs requirement of the rules and regulations of the Secretary of Labor. (e) Certification Regarding Payments to Influence Federal Transactions (31 U.S.C. 1352). (Applies only if the contract is expected to exceed $150,000.) By submission of its offer, the offeror certifies to the best of its knowledge and belief that no Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress or an employee of a Member of Congress on his or her behalf in connection with the award of any resultant contract. If any registrants under the Lobbying Disclosure Act of 1995 have made a lobbying contact on behalf of the offeror with respect to this contract, the offeror shall complete and submit, with its offer, OMB Standard Form LLL, Disclosure of Lobbying Activities, to provide the name of the registrants. The offeror need not report regularly employed officers or employees of the offeror to whom payments of reasonable compensation were made. (f) Buy American Certificate. (Applies only if the clause at Federal Acquisition Regulation (FAR) 52.225-1, Buy American—Supplies, is included in this solicitation.) (1) The offeror certifies that each end product, except those listed in paragraph (f)(2) of this provision, is a domestic end product and that for other than COTS items, the offeror has considered components of unknown origin to have been mined, produced, or manufactured outside the United States. The offeror shall list as foreign end products those end products manufactured in the United States that do not qualify as domestic end products, i.e., an end product that is not a COTS item and does not meet the component test in paragraph (2) of the definition of “domestic end product.” The terms “commercially available off-the-shelf (COTS) item,” “component,” “domestic end product,” “end product,” “foreign end product,” and “United States” are defined in the clause of this solicitation entitled “Buy American—Supplies.” (2) Foreign End Products: Line Item No Country of Origin ______________ _________________ ______________ _________________ ______________ _________________[List as necessary] (3) The Government will evaluate offers in accordance with the policies and procedures of FAR Part 25. (g)(1) Buy American—Free Trade Agreements—Israeli Trade Act Certificate. (Applies only if the clause at FAR 52.225-3, Buy American—Free Trade Agreements—Israeli Trade Act, is included in this solicitation.) (i) The offeror certifies that each end product, except those listed in paragraph (g)(1)(ii) or (g)(1)(iii) of this provision, is a domestic end product and that for other than COTS items, the offeror has considered components of unknown origin to have been mined, produced, or manufactured outside the United States. The terms “Bahrainian, Moroccan, Omani, Panamanian, or Peruvian end product,” “commercially available off-the-shelf (COTS) item,” “component,” “domestic end product,” “end product,” “foreign end product,” “Free Trade Agreement country,” “Free Trade Agreement country end product,” “Israeli end product,” and “United States” are defined in the clause of this solicitation entitled “Buy American—Free Trade Agreements—Israeli Trade Act.” (ii) The offeror certifies that the following supplies are Free Trade Agreement country end products (other than Bahrainian, Moroccan, Omani, Panamanian, or Peruvian end products) or Israeli end products as defined in the clause of this solicitation entitled “Buy American—Free Trade Agreements—Israeli Trade Act”: Free Trade Agreement Country End Products (Other than Bahrainian, Moroccan, Omani, Panamanian, or Peruvian End Products) or Israeli End Products: Line Item No. Country of Origin ______________ _________________ ______________ _________________ ______________ _________________[List as necessary] (iii) The offeror shall list those supplies that are foreign end products (other than those listed in paragraph (g)(1)(ii) of this provision) as defined in the clause of this solicitation entitled “Buy American—Free Trade Agreements—Israeli Trade Act.” The offeror shall list as other foreign end products those end products manufactured in the United States that do not qualify as domestic end products, i.e., an end product that is not a COTS item and does not meet the component test in paragraph (2) of the definition of “domestic end product.” Other Foreign End Products: Line Item No. Country of Origin ______________ _________________ ______________ _________________ ______________ _________________[List as necessary] (iv) The Government will evaluate offers in accordance with the policies and procedures of FAR Part 25. (2) Buy American—Free Trade Agreements—Israeli Trade Act Certificate, Alternate I. If Alternate I to the clause at FAR 52.225-3 is included in this solicitation, substitute the following paragraph (g)(1)(ii) for paragraph (g)(1)(ii) of the basic provision: (g)(1)(ii) The offeror certifies that the following supplies are Canadian end products as defined in the clause of this solicitation entitled “Buy American—Free Trade Agreements—Israeli Trade Act”: Canadian End Products: Line Item No. __________________________________________ __________________________________________ __________________________________________[List as necessary] (3) Buy American—Free Trade Agreements—Israeli Trade Act Certificate, Alternate II. If Alternate II to the clause at FAR 52.225-3 is included in this solicitation, substitute the following paragraph (g)(1)(ii) for paragraph (g)(1)(ii) of the basic provision: (g)(1)(ii) The offeror certifies that the following supplies are Canadian end products or Israeli end products as defined in the clause of this solicitation entitled “Buy American—Free Trade Agreements—Israeli Trade Act”: Canadian or Israeli End Products: Line Item No. Country of Origin ______________ _________________ ______________ _________________ ______________ _________________[List as necessary] (4) Buy American—Free Trade Agreements—Israeli Trade Act Certificate, Alternate III. If Alternate III to the clause at FAR 52.225-3 is included in this solicitation, substitute the following paragraph (g)(1)(ii) for paragraph (g)(1)(ii) of the basic provision: (g)(1)(ii) The offeror certifies that the following supplies are Free Trade Agreement country end products (other than Bahrainian, Korean, Moroccan, Omani, Panamanian, or Peruvian end products) or Israeli end products as defined in the clause of this solicitation entitled “Buy American—Free Trade Agreements—Israeli Trade Act”: Free Trade Agreement Country End Products (Other than Bahrainian, Korean, Moroccan, Omani, Panamanian, or Peruvian End Products) or Israeli End Products: Line Item No. Country of Origin ______________ _________________ ______________ _________________ ______________ _________________[List as necessary] (5) Trade Agreements Certificate. (Applies only if the clause at FAR 52.225-5, Trade Agreements, is included in this solicitation.) (i) The offeror certifies that each end product, except those listed in paragraph (g)(5)(ii) of this provision, is a U.S.-made or designated country end product, as defined in the clause of this solicitation entitled “Trade Agreements”. (ii) The offeror shall list as other end products those end products that are not U.S.-made or designated country end products. Other End Products: Line Item No. Country of Origin ______________ _________________ ______________ _________________ ______________ _________________[List as necessary] (iii) The Government will evaluate offers in accordance with the policies and procedures of FAR Part 25. For line items covered by the WTO GPA, the Government will evaluate offers of U.S.-made or designated country end products without regard to the restrictions of the Buy American statute. The Government will consider for award only offers of U.S.-made or designated country end products unless the Contracting Officer determines that there are no offers for such products or that the offers for such products are insufficient to fulfill the requirements of the solicitation. (h) Certification Regarding Responsibility Matters (Executive Order 12689). (Applies only if the contract value is expected to exceed the simplified acquisition threshold.) The offeror certifies, to the best of its knowledge and belief, that the offeror and/or any of its principals— (1) [ ] Are, [ ] are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency; (2) [ ] Have, [ ] have not, within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a Federal, state or local government contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or Commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws, or receiving stolen property; (3) [ ] Are, [ ] are not presently indicted for, or otherwise criminally or civilly charged by a Government entity with, commission of any of these offenses enumerated in paragraph (h)(2) of this clause; and (4) [ ] Have, [ ] have not, within a three-year period preceding this offer, been notified of any delinquent Federal taxes in an amount that exceeds $3,500 for which the liability remains unsatisfied. (i) Taxes are considered delinquent if both of the following criteria apply: (A) The tax liability is finally determined. The liability is finally determined if it has been assessed. A liability is not finally determined if there is a pending administrative or judicial challenge. In the case of a judicial challenge to the liability, the liability is not finally determined until all judicial appeal rights have been exhausted. (B) The taxpayer is delinquent in making payment. A taxpayer is delinquent if the taxpayer has failed to pay the tax liability when full payment was due and required. A taxpayer is not delinquent in cases where enforced collection action is precluded. (ii) Examples. (A) The taxpayer has received a statutory notice of deficiency, under I.R.C. Sec. 6212, which entitles the taxpayer to seek Tax Court review of a proposed tax deficiency. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek Tax Court review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal rights. (B) The IRS has filed a notice of Federal tax lien with respect to an assessed tax liability, and the taxpayer has been issued a notice under I.R.C. Sec. 6320 entitling the taxpayer to request a hearing with the IRS Office of Appeals contesting the lien filing, and to further appeal to the Tax Court if the IRS determines to sustain the lien filing. In the course of the hearing, the taxpayer is entitled to contest the underlying tax liability because the taxpayer has had no prior opportunity to contest the liability. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek tax court review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal rights. (C) The taxpayer has entered into an installment agreement pursuant to I.R.C. Sec. 6159. The taxpayer is making timely payments and is in full compliance with the agreement terms. The taxpayer is not delinquent because the taxpayer is not currently required to make full payment. (D) The taxpayer has filed for bankruptcy protection. The taxpayer is not delinquent because enforced collection action is stayed under 11 U.S.C. 362 (the Bankruptcy Code). (i) Certification Regarding Knowledge of Child Labor for Listed End Products (Executive Order 13126). (1) Listed end products.Listed End ProductListed Countries of Origin (2) Certification. [If the Contracting Officer has identified end products and countries of origin in paragraph (i)(1) of this provision, then the offeror must certify to either (i)(2)(i) or (i)(2)(ii) by checking the appropriate block.] [ ] (i) The offeror will not supply any end product listed in paragraph (i)(1) of this provision that was mined, produced, or manufactured in the corresponding country as listed for that product. [ ] (ii) The offeror may supply an end product listed in paragraph (i)(1) of this provision that was mined, produced, or manufactured in the corresponding country as listed for that product. The offeror certifies that it has made a good faith effort to determine whether forced or indentured child labor was used to mine, produce, or manufacture any such end product furnished under this contract. On the basis of those efforts, the offeror certifies that it is not aware of any such use of child labor. (j) Place of manufacture. (Does not apply unless the solicitation is predominantly for the acquisition of manufactured end products.) For statistical purposes only, the offeror shall indicate whether the place of manufacture of the end products it expects to provide in response to this solicitation is predominantly— (1) __ In the United States (Check this box if the total anticipated price of offered end products manufactured in the United States exceeds the total anticipated price of offered end products manufactured outside the United States); or (2) __ Outside the United States. (k) Certificates regarding exemptions from the application of the Service Contract Labor Standards. (Certification by the offeror as to its compliance with respect to the contract also constitutes its certification as to compliance by its subcontractor if it subcontracts out the exempt services.) [ ] (1) Maintenance, calibration, or repair of certain equipment as described in FAR 22.1003-4(c)(1). The offeror [ ] does [ ] does not certify that— (i) The items of equipment to be serviced under this contract are used regularly for other than Governmental purposes and are sold or traded by the offeror (or subcontractor in the case of an exempt subcontract) in substantial quantities to the general public in the course of normal business operations; (ii) The services will be furnished at prices which are, or are based on, established catalog or market prices (see FAR 22.1003- 4(c)(2)(ii)) for the maintenance, calibration, or repair of such equipment; and (iii) The compensation (wage and fringe benefits) plan for all service employees performing work under the contract will be the same as that used for these employees and equivalent employees servicing the same equipment of commercial customers. [ ] (2) Certain services as described in FAR 22.1003- 4(d)(1). The offeror [ ] does [ ] does not certify that— (i) The services under the contract are offered and sold regularly to non-Governmental customers, and are provided by the offeror (or subcontractor in the case of an exempt subcontract) to the general public in substantial quantities in the course of normal business operations; (ii) The contract services will be furnished at prices that are, or are based on, established catalog or market prices (see FAR 22.1003-4(d)(2)(iii)); (iii) Each service employee who will perform the services under the contract will spend only a small portion of his or her time (a monthly average of less than 20 percent of the available hours on an annualized basis, or less than 20 percent of available hours during the contract period if the contract period is less than a month) servicing the Government contract; and (iv) The compensation (wage and fringe benefits) plan for all service employees performing work under the contract is the same as that used for these employees and equivalent employees servicing commercial customers. (3) If paragraph (k)(1) or (k)(2) of this clause applies— (i) If the offeror does not certify to the conditions in paragraph (k)(1) or (k)(2) and the Contracting Officer did not attach a Service Contract Labor Standards wage determination to the solicitation, the offeror shall notify the Contracting Officer as soon as possible; and (ii) The Contracting Officer may not make an award to the offeror if the offeror fails to execute the certification in paragraph (k)(1) or (k)(2) of this clause or to contact the Contracting Officer as required in paragraph (k)(3)(i) of this clause. (l) Taxpayer Identification Number (TIN) (26 U.S.C. 6109, 31 U.S.C. 7701). (Not applicable if the offeror is required to provide this information to the SAM database to be eligible for award.) (1) All offerors must submit the information required in paragraphs (l)(3) through (l)(5) of this provision to comply with debt collection requirements of 31 U.S.C. 7701(c) and 3325(d), reporting requirements of 26 U.S.C. 6041, 6041A, and 6050M, and implementing regulations issued by the Internal Revenue Service (IRS). (2) The TIN may be used by the Government to collect and report on any delinquent amounts arising out of the offeror's relationship with the Government (31 U.S.C. 7701(c)(3)). If the resulting contract is subject to the payment reporting requirements described in FAR 4.904, the TIN provided hereunder may be matched with IRS records to verify the accuracy of the offeror's TIN. (3) Taxpayer Identification Number (TIN). [ ] TIN: _____________________. [ ] TIN has been applied for. [ ] TIN is not required because: [ ] Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the United States and does not have an office or place of business or a fiscal paying agent in the United States; [ ] Offeror is an agency or instrumentality of a foreign government; [ ] Offeror is an agency or instrumentality of the Federal Government. (4) Type of organization. [ ] Sole proprietorship; [ ] Partnership; [ ] Corporate entity (not tax-exempt); [ ] Corporate entity (tax-exempt); [ ] Government entity (Federal, State, or local); [ ] Foreign government; [ ] International organization per 26 CFR 1.6049-4; [ ] Other _________________________. (5) Common parent. [ ] Offeror is not owned or controlled by a common parent; [ ] Name and TIN of common parent: Name _____________________. TIN _____________________. (m) Restricted business operations in Sudan. By submission of its offer, the offeror certifies that the offeror does not conduct any restricted business operations in Sudan. (n) Prohibition on Contracting with Inverted Domestic Corporations. (1) Government agencies are not permitted to use appropriated (or otherwise made available) funds for contracts with either an inverted domestic corporation, or a subsidiary of an inverted domestic corporation, unless the exception at 9.108-2(b) applies or the requirement is waived in accordance with the procedures at 9.108-4. (2) Representation. The Offeror represents that— (i) It [ ] is, [ ] is not an inverted domestic corporation; and (ii) It [ ] is, [ ] is not a subsidiary of an inverted domestic corporation. (o) Prohibition on contracting with entities engaging in certain activities or transactions relating to Iran. (1) The offeror shall email questions concerning sensitive technology to the Department of State at CISADA106@. (2) Representation and certifications. Unless a waiver is granted or an exception applies as provided in paragraph (o)(3) of this provision, by submission of its offer, the offeror— (i) Represents, to the best of its knowledge and belief, that the offeror does not export any sensitive technology to the government of Iran or any entities or individuals owned or controlled by, or acting on behalf or at the direction of, the government of Iran; (ii) Certifies that the offeror, or any person owned or controlled by the offeror, does not engage in any activities for which sanctions may be imposed under section 5 of the Iran Sanctions Act; and (iii) Certifies that the offeror, and any person owned or controlled by the offeror, does not knowingly engage in any transaction that exceeds $3,500 with Iran’s Revolutionary Guard Corps or any of its officials, agents, or affiliates, the property and interests in property of which are blocked pursuant to the International Emergency Economic Powers Act (50 U.S.C. 1701 et seq.) (see OFAC’s Specially Designated Nationals and Blocked Persons List at ). (3) The representation and certification requirements of paragraph (o)(2) of this provision do not apply if— (i) This solicitation includes a trade agreements certification (e.g., 52.212–3(g) or a comparable agency provision); and (ii) The offeror has certified that all the offered products to be supplied are designated country end products. (p) Ownership or Control of Offeror. (Applies in all solicitations when there is a requirement to be registered in SAM or a requirement to have a DUNS Number in the solicitation.) (1) The Offeror represents that it [ ] has or [ ] does not have an immediate owner. If the Offeror has more than one immediate owner (such as a joint venture), then the Offeror shall respond to paragraph (2) and if applicable, paragraph (3) of this provision for each participant in the joint venture. (2) If the Offeror indicates “has” in paragraph (p)(1) of this provision, enter the following information:Immediate owner CAGE code:________________________________________________________________Immediate owner legal name:________________________________________________________________(Do not use a “doing business as” name) Is the immediate owner owned or controlled by another entity: [ ] Yes or [ ] No. (3) If the Offeror indicates “yes” in paragraph (p)(2) of this provision, indicating that the immediate owner is owned or controlled by another entity, then enter the following information:Highest-level owner CAGE code:________________________________________________________________Highest-level owner legal name:________________________________________________________________(Do not use a “doing business as” name)(End of Provision)E.7 52.216-1 TYPE OF CONTRACT (APR 1984) The Government contemplates award of an Indefinite Delivery Indefinite Quantity (IDIQ) with Economic Price Adjustment, contract resulting from this solicitation.(End of Provision)E.8 52.216-27 SINGLE OR MULTIPLE AWARDS (OCT 1995)The Government may elect to award a single delivery order contract or task order contract or to award multiple delivery order contracts or task order contracts for the same or similar supplies or services to two or more sources under this solicitation.(End of Provision)E.9 52.225-25 PROHIBITION ON CONTRACTING WITH ENTITIES ENGAGING IN CERTAIN ACTIVITIES OR TRANSACTIONS RELATING TO IRAN—REPRESENTATION AND CERTIFICATIONS (DEC 2012)(a) Definitions. As used in this provision— Person— (1) Means— (i) A natural person; (ii) A corporation, business association, partnership, society, trust, financial institution, insurer, underwriter, guarantor, and any other business organization, any other nongovernmental entity, organization, or group, and any governmental entity operating as a business enterprise; and (iii) Any successor to any entity described in paragraph (1)(ii) of this definition; and (2) Does not include a government or governmental entity that is not operating as a business enterprise. Sensitive technology— (1) Means hardware, software, telecommunications equipment, or any other technology that is to be used specifically— (i) To restrict the free flow of unbiased information in Iran; or (ii) To disrupt, monitor, or otherwise restrict speech of the people of Iran; and (2) Does not include information or informational materials the export of which the President does not have the authority to regulate or prohibit pursuant to section 203(b)(3) of the International Emergency Economic Powers Act (50 U.S.C. 1702(b)(3)). (b) The offeror shall email questions concerning sensitive technology to the Department of State at CISADA106@. (c) Except as provided in paragraph (d) of this provision or if a waiver has been granted in accordance with 25.703-4, by submission of its offer, the offeror— (1) Represents, to the best of its knowledge and belief, that the offeror does not export any sensitive technology to the government of Iran or any entities or individuals owned or controlled by, or acting on behalf or at the direction of, the government of Iran; (2) Certifies that the offeror, or any person owned or controlled by the offeror, does not engage in any activities for which sanctions may be imposed under section 5 of the Iran Sanctions Act. These sanctioned activities are in the areas of development of the petroleum resources of Iran, production of refined petroleum products in Iran, sale and provision of refined petroleum products to Iran, and contributing to Iran's ability to acquire or develop certain weapons or technologies; and (3) Certifies that the offeror, and any person owned or controlled by the offeror, does not knowingly engage in any transaction that exceeds $3,000 with Iran's Revolutionary Guard Corps or any of its officials, agents, or affiliates, the property and interests in property of which are blocked pursuant to the International Emergency Economic Powers Act (50 U.S.C. 1701 et seq.) (see OFAC's Specially Designated Nationals and Blocked Persons List at ). (d) Exception for trade agreements. The representation requirement of paragraph (c)(1) and the certification requirements of paragraphs (c)(2) and (c)(3) of this provision do not apply if— (1) This solicitation includes a trade agreements notice or certification (e.g., 52.225-4, 52.225-6, 52.225-12, 52.225-24, or comparable agency provision); and (2) The offeror has certified that all the offered products to be supplied are designated country end products or designated country construction material.(End of Provision)E.10 52.233-2 SERVICE OF PROTEST (SEP 2006) Protests, as defined in section 33.101 of the Federal Acquisition Regulation, that are filed directly with an agency, and copies of any protests that are filed with the Government Accountability Office (GAO), shall be served on the Contracting Officer (addressed as follows) by obtaining written and dated acknowledgment of receipt from: Brett Cook Contract Specialist Hand-Carried Address Department of Veterans Affairs Network Contracting Office 8 (NCO 8) 8875 Hidden River Pkwy Tampa FL 33637 Mailing Address: Department of Veterans Affairs Network Contracting Office 8 (NCO 8) 8875 Hidden River Pkwy Tampa FL 33637 (b) The copy of any protest shall be received in the office designated above within one day of filing a protest with the GAO.(End of Provision)E.11 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998) This solicitation incorporates one or more solicitation provisions by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. The offeror is cautioned that the listed provisions may include blocks that must be completed by the offeror and submitted with its quotation or offer. In lieu of submitting the full text of those provisions, the offeror may identify the provision by paragraph identifier and provide the appropriate information with its quotation or offer. Also, the full text of a solicitation provision may be accessed electronically at this/these address(es): (End of Provision)E.12 VAAR 852.209-70 ORGANIZATIONAL CONFLICTS OF INTEREST (JAN 2008) (a) It is in the best interest of the Government to avoid situations which might create an organizational conflict of interest or where the offeror’s performance of work under the contract may provide the contractor with an unfair competitive advantage.? The term “organizational conflict of interest” means that because of other activities or relationships with other persons, a person is unable to render impartial assistance or advice to the Government, or the person’s objectivity in performing the contract work is or might be otherwise impaired, or the person has an unfair competitive advantage.(b) The offeror shall provide a statement with its offer which describes, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation.? The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation.? The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.(c) Based on this information and any other information solicited or obtained by the contracting officer, the contracting officer may determine that an organizational conflict of interest exists which would warrant disqualifying the contractor for award of the contract unless the organizational conflict of interest can be mitigated to the contracting officer's satisfaction by negotiating terms and conditions of the contract to that effect.? If the conflict of interest cannot be mitigated and if the contracting officer finds that it is in the best interest of the United States to award the contract, the contracting officer shall request a waiver in accordance with FAR 9.503 and 48 CFR 809.503.(d) Nondisclosure or misrepresentation of actual or potential organizational conflicts of interest at the time of the offer, or arising as a result of a modification to the contract, may result in the termination of the contract at no expense to the Government.(End of Provision)E.13 VAAR 852.215-70 SERVICE-DISABLED VETERAN-OWNED AND VETERAN-OWNED SMALL BUSINESS EVALUATION FACTORS (DEC 2009) (a) In an effort to achieve socioeconomic small business goals, depending on the evaluation factors included in the solicitation, VA shall evaluate offerors based on their service-disabled veteran-owned or veteran-owned small business status and their proposed use of eligible service-disabled veteran-owned small businesses and veteran-owned small businesses as subcontractors. (b) Eligible service-disabled veteran-owned offerors will receive full credit, and offerors qualifying as veteran-owned small businesses will receive partial credit for the Service-Disabled Veteran-Owned and Veteran-owned Small Business Status evaluation factor. To receive credit, an offeror must be registered and verified in Vendor Information Pages (VIP) database. (). (c) Non-veteran offerors proposing to use service-disabled veteran-owned small businesses or veteran-owned small businesses as subcontractors will receive some consideration under this evaluation factor. Offerors must state in their proposals the names of the SDVOSBs and VOSBs with whom they intend to subcontract and provide a brief description of the proposed subcontracts and the approximate dollar values of the proposed subcontracts. In addition, the proposed subcontractors must be registered and verified in the VIP database ().(End of Provision)E.14 VAAR 852.233-70 PROTEST CONTENT/ALTERNATIVE DISPUTE RESOLUTION (JAN 2008) (a) Any protest filed by an interested party shall: (1) Include the name, address, fax number, and telephone number of the protester; (2) Identify the solicitation and/or contract number; (3) Include an original signed by the protester or the protester's representative and at least one copy; (4) Set forth a detailed statement of the legal and factual grounds of the protest, including a description of resulting prejudice to the protester, and provide copies of relevant documents; (5) Specifically request a ruling of the individual upon whom the protest is served; (6) State the form of relief requested; and (7) Provide all information establishing the timeliness of the protest. (b) Failure to comply with the above may result in dismissal of the protest without further consideration. (c) Bidders/offerors and contracting officers are encouraged to use alternative dispute resolution (ADR) procedures to resolve protests at any stage in the protest process. If ADR is used, the Department of Veterans Affairs will not furnish any documentation in an ADR proceeding beyond what is allowed by the Federal Acquisition Regulation.(End of Provision)E.15 VAAR 852.233-71 ALTERNATE PROTEST PROCEDURE (JAN 1998) As an alternative to filing a protest with the contracting officer, an interested party may file a protest with the Deputy Assistant Secretary for Acquisition and Materiel Management, Acquisition Administration Team, Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, or for solicitations issued by the Office of Construction and Facilities Management, the Director, Office of Construction and Facilities Management, 810 Vermont Avenue, NW., Washington, DC 20420. The protest will not be considered if the interested party has a protest on the same or similar issues pending with the contracting officer.(End of Provision)E.16 VAAR 852.270-1 REPRESENTATIVES OF CONTRACTING OFFICERS (JAN 2008)The contracting officer reserves the right to designate representatives to act for him/her in furnishing technical guidance and advice or generally monitor the work to be performed under this contract.? Such designation will be in writing and will define the scope and limitation of the designee’s authority.? A copy of the designation shall be furnished to the contractor.(End of Provision)E.17 VAAR 852.271-70 NONDISCRIMINATION IN SERVICES PROVIDED TO BENEFICIARIES (JAN 2008) The contractor agrees to provide all services specified in this contract for any person determined eligible by the Department of Veterans Affairs, regardless of the race, color, religion, sex, or national origin of the person for whom such services are ordered. The contractor further warrants that he/she will not resort to subcontracting as a means of circumventing this provision.(End of Provision)E.18 VAAR 852.273-70 LATE OFFERS (JAN 2003)This provision replaces paragraph (f) of FAR provision 52.212-1 .? Offers or modifications of offers received after the time set forth in a request for quotations or request for proposals may be considered, at the discretion of the contracting officer, if determined to be in the best interest of the Government IAW FAR 15.208(b)(1).? Late bids submitted in response to an invitation for bid (IFB) will not be considered.(End of Provision) ................
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