Outpatient Physician Services THC

Form / Attachment / Pricing Sheet

This document is the "Indian Health Service Buy Indian Act Indian Economic Enterprise Representation Form." It serves as a self-certification for offerors to confirm they meet the definition of an "Indian Economic Enterprise" as required by the Buy Indian Act. This form is to be submitted in response to a Sources Sought Notice, Request for Information (RFI), or Solicitation.

• Eligibility Criteria: Offerors must certify that they meet the definition of an "Indian Economic Enterprise" throughout the offer period, contract award, and the full contract performance period.
• Reporting Requirement: Contractors must immediately notify the Contracting Officer if they no longer meet eligibility requirements.
• Documentation: Contracting Officers may require documentation of eligibility, and awards may be subject to protest.
• Registration: Successful offerors must be registered with the System of Award Management (SAM).
• Penalties: False or misleading information is a violation of law and punishable under 18 U.S.C. 1001, with false claims subject to penalties under 31 U.S.C. 3729-3731 and 18 U.S.C. 287.
• Representation Section: Requires the offeror to check a box indicating whether they do or do not meet the definition of an "Indian Economic Enterprise" with "Indian Ownership."
• Information Fields: Includes spaces for "Name of Federally Recognized Tribal Entity," "Name of the 51% owner of IEE Firm," "Business Name," "Certifying Signature," "Print Name," and "UEI Number."

This form is critical for any bidder seeking to participate in opportunities designated for or influenced by the Buy Indian Act. Bidders must accurately complete this self-certification to demonstrate their eligibility. Failure to meet the criteria or complete the form correctly could disqualify an offer. It also highlights the need for ongoing compliance and registration with SAM.

Statement of Work (SOW) / Performance Work Statement (PWS)

This Performance Work Statement (PWS) outlines the requirements for non-personal physician services in Family Medicine, Internal Medicine, and Pediatrics to support the mission of the Tohatchi Health Center (THC) within the Indian Health Service (IHS).

• Provide outpatient physician services to IHS patients presenting for treatment at the Tohatchi Health Center.

• May be requested to provide care at other Gallup Service Unit clinics during patient surges or staffing shortages.

• Services include consultation and telehealth.

• Perform diagnosis, care, and treatment of medical patients, including medical consults.

• Interview, examine, and review patient history; order diagnostic tests and examinations.

• Make preliminary diagnoses, direct, prescribe, or provide treatment, and arrange for specialized care or patient referral.

• Consult with other medical disciplines as needed.

• Provide emergency care.

• Provide definitive management for cases not requiring referral, including health maintenance, early diagnosis, treatment, and follow-up.

• Refer medical patients to appropriate contracted medical or other governmental facilities, ensuring coordinated care and timely follow-up.

• Prepare comprehensive medical records in compliance with Joint Commission and CMS standards.

• Evaluate patient symptoms, design treatment plans, and educate patients and families.

• Prepare accurate prescriptions and ensure appropriateness of drug therapy.

• Perform in accordance with approved privileges.

• Flexible period of performance, allowing for short-term, long-term (1 year), and intermittent support.

• Services are primarily at the Tohatchi Health Center, located approximately 25 miles north of Gallup, NM.

• Tour of Duty is an 8-hour day, from 8:00 am to 5:00 pm. No overtime, comp-time, calls, or holidays.

• Services must be provided in accordance with The Joint Commission (TJC) standards and professional standards of American Boards.

• Participate in THC's peer review system and make practice modifications as recommended.

• Participate in THC's performance improvement program.

• Maintain patient records in the Problem Oriented Medical Record format using the Patient Care Component of the Resource Patient Management System.

• 100% of medical records and documentation must meet established IHS Medical Facility, TJC, and CMS standards for timeliness, legibility, accuracy, content, date, time, signature, and profession.

• No reports of breached patient safety, infection control, or other procedures adversely affecting patient outcome.

• Performance characterized by continual cultural awareness and focus on customer service.

• 100% adherence to the Federal Code of Conduct.

• Uninterrupted credentialing as defined in Section 5.0.

• Contractor Qualification: Minimum 24 months of experience in specialty (unless approved otherwise), current/valid/active/unrestricted medical license, Board certification or eligibility in Family Medicine or Internal Medicine, completion of residency, valid driver's license, current BLS and ACLS certifications.

• Health Requirements: Fitness for duty certificate, COVID vaccine series, immunity to Rubella, Mumps, Measles, Hepatitis B series, history of chicken pox or positive titer, Tdap vaccine, TB Mantoux skin test (PPD) within 12 months with follow-up, or signed declination for Hepatitis B, current influenza vaccination.

• Background Checks: Required for all personnel.

• Information Technology: Must adapt to and utilize IHS IT systems, including EHR, and adhere to IT security policies.

• Business Associate Agreement: Required for handling Protected Health Information (PHI).

• Language & Cultural Awareness: Must read, understand, speak, and write English; be respectful of American Indian and Alaska Native culture; work through interpreters if necessary; and work with a diverse workforce.

• Orientation: Mandatory orientation and training required.

• Identification: Wear government-issued contractor identification badge.

• Government Furnished: Information, equipment, supplies, clinic space, PPE, and facility-specific identification badges will be provided. Training specific to IHS systems and operational procedures will be provided if necessary.

• Contractor Furnished: Uniforms, lab coats, and personal medical instruments (e.g., stethoscope, scissors) are required. Contractor-owned equipment must be approved by the COR.

• Billing: Tohatchi will bill for reimbursement; Contractor must provide NPI and DEA numbers.