Veterans Affairs

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5. PROJECT NUMBER (if applicable)CODE7. ADMINISTERED BY2. AMENDMENT/MODIFICATION NUMBERCODE6. ISSUED BY8. NAME AND ADDRESS OF CONTRACTOR4. REQUISITION/PURCHASE REQ. NUMBER3. EFFECTIVE DATE9A. AMENDMENT OF SOLICITATION NUMBER9B. DATEDPAGEOF PAGES10A. MODIFICATION OF CONTRACT/ORDER NUMBER10B. DATEDBPA NO.1. CONTRACT ID CODEFACILITY CODECODE Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of OffersE. IMPORTANT:is extended, (a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAYis not extended.12. ACCOUNTING AND APPROPRIATION DATA(REV. 11/2016)is required to sign this document and return ___________ copies to the issuing office.is not,A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.15C. DATE SIGNEDB. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b). RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:D. OTHERBYContractor16C. DATE SIGNED14. DESCRIPTION OF AMENDMENT/MODIFICATION16B. UNITED STATES OF AMERICAExcept as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.15A. NAME AND TITLE OF SIGNER16A. NAME AND TITLE OF CONTRACTING OFFICER15B. CONTRACTOR/OFFERORSTANDARD FORM 30 PREVIOUS EDITION NOT USABLEPrescribed by GSA - FAR (48 CFR) 53.243(Type or print)(Type or print)(Organized by UCF section headings, including solicitation/contract subject matter where feasible.)(Number, street, county, State and ZIP Code)(If other than Item 6)(Specify type of modification and authority)(such as changes in paying office, appropriation date, etc.)(If required)(SEE ITEM 11)(SEE ITEM 13)(X)CHECKONE13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONSAMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT(Signature of person authorized to sign)(Signature of Contracting Officer)12A0000208-11-2017noneDepartment of Veterans AffairsVeterans Health AdministrationNetwork Contracting Office 162575 Keystone CrossingFayetteville AR 72703Department of Veterans AffairsVeterans Healthcare System of the OzarksNetwork Contracting Office 162575 Keystone CrossingFayetteville AR 72703To all Offerors/Bidders VA256-16-R-0620 Xxx1September 6, 2017 3PM CSTx1The purpose of this amendment is to replace attachment D 11 "Past Performance Questionaire" A. Attachment D 11 Past Performance Questionaire is hereby replaced with Attachment D 11 Past Performance Questionairedated August 11, 2017. B. The solicitation proposal due date is hereby extended to September 6, 2017, 3PM CST. C. All other terms and conditions remain unchanged. Joseph WarrenContracting Officer, Services Team D CONTINUATION PAGEPAST PERFORMANCE QUESTIONNAIRE (August 11, 2017) 1. The Contractor identified below has requested that you complete a past performance questionnaire on their behalf. This questionnaire will be used by the Contracting Officer to assess the likelihood that the Offeror will perform successfully on an impending requirement for a Community Based Outpatient Clinic in Meridian, Mississippi for the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi. Your prompt completion and return of this questionnaire is greatly appreciated. CONTRACTOR NAME _________________________________________REFERENCED CONTRACT # _________________________________________2. Background. The G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi, has a need for the provision of Primary Care and Mental Health services for eligible Veterans living in Lauderdale County and the surrounding counties of Mississippi. The contractor shall furnish health care providers, medical facilities, equipment and supplies, and administrative functions to fulfill the support of enrolled patients.3. GENERAL INFORMATION: (Completed by Reference of Contractor being evaluated)Name of Government or Commercial Organization:______________________________Address:_____________________________________________________________________Contract Number:______________________________Brief Description:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Contractor Performed as: FORMCHECKBOX Prime Contractor FORMCHECKBOX Sub-ContractorDates of Performance (if current include expiration):_____________________________Total Value of Contract:__________________Any terminations for cause or default? Circle YES or NOIf yes, brief explanation:______________________________________________________________________________________________________________________________________________________Any contract discrepancy reports filed? Circle YES or NOIf yes, brief explanation: ____________________________________________________________________________________________________________________________________________________Point Of Contact/Contracting Officer’s Representative:________________________________Title:___________________________________Telephone Number:____________________________Point of Contact’s email address:____________________________4. Please answer the following questions pertaining to the relevancy of the services provided to you as compared to the description in paragraph 2.Q1. Did the contractor provide Primary Care Services and Mental Health Services (Y/N)? ___________ Q2. If no, please provide a short description of the type of services provided.Q3. Did the contractor provide any additional services (Y/N)?_________ If so, what types?5. Please use the below matrix to answer questions relating to performance using the following template. Please evaluate the past performance using only the following ratings without variation. If the rating is Excellent, Good, Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.“E” = Excellent = Performance greatly exceeded the contract requirements“G” = Good = Performance exceeded the contract requirements“S” = Satisfactory = Performance met the contract requirements“M” = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory“U” = Unsatisfactory = Performance was poor and/or did not satisfy contract requirementsPlease write in “not applicable” or “neutral” if unable to rate a certain question. For any E, G, M, or U rating, please provide a short summary explanation of rating.Please rate and provide information/comments for the following:Circle oneQ1. To what extent did the contractor comply with overall contract requirements?E G S M UQ2. How successful was the Contractor in filling all requirements? E G S M UQ3. How would you rate the quality of the Physicians provided by this Contractor in terms of technical competence, reliability, and demeanor with patients and staff.E G S M UQ4. To what extent was the Contractor able to meet unexpected and short notice changes and/or requirements (e.g. unexpected shift vacancies, training requirements). E G S M UQ5. How would you rate the Contractor’s administrative staff as pertains to communication with your organization’s key personnel, their ability to complete credentialing and privileging, billing and invoicing processes, and overall contract management?E G S M UQ6. Did you issue any cure notices, show cause letters, or suspension of payment? If yes, please explain. Yes NoQ7. Would you award another contract to the Contractor being evaluated? If no, please explain: Yes NoQ8. Additional Comments pertaining to contractor performance:Printed Name & Signature of Evaluator Date6. Thank you for your time. Please return completed questionnaire to Joseph L. Warren, Contracting Officer for this acquisition, at HYPERLINK "mailto:joseph.warren@" joseph.warren@ not later than 3:00 pm Central, September 6, 2017. For any questions, please call 479-444-5011. ................
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