Outpatient Mid-Level Provider(s) (i.e. Certified Nurse Practitioner or Certified Physician Assistant) for Outpatient Services at Wagner IHS Healthcare Center

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 whether they meet the definition of an "Indian Economic Enterprise" with "Indian Ownership" throughout the offer, award, and performance periods.
• Notification 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, punishable under 18 U.S.C. 1001, and false claims are subject to penalties under 31 U.S.C. 3729-3731 and 18 U.S.C. 287.
• Representation Section: Includes checkboxes for "does" or "does not" meet the definition, and fields for:
  • Name of Federally Recognized Tribal Entity
  • Name of the 51% owner of IEE Firm
  • Business Name
  • DUNS Number
  • Certifying Signature
  • Print Name

This form is critical for any bidder seeking to participate in opportunities designated under the Buy Indian Act. Bidders must accurately complete this self-certification to demonstrate their eligibility. Failure to meet the criteria or provide accurate information can lead to disqualification or penalties. It also highlights the need for SAM registration.

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

To provide uninterrupted Outpatient Service for the Wagner Indian Health Center.

• Provide a minimum of three (3) Outpatient Mid-Level Providers (Certified Nurse Practitioner or Certified Physician Assistant).

• One provider will cover the tour of duty/work schedule.

• Services include examining and diagnosing health-related conditions, referring individuals for consultation, prescribing therapy, educating patients on health promotion and disease prevention, and documenting consultations.

• Providers will utilize RPMS/EHR computer software for medical orders and documentation.

• Services are for beneficiary patients presenting for care at the Wagner IHS Outpatient Department, which sees approximately 7,500 patient visits per month, ranging from newborn to geriatric.

• Period of Performance: Date of award until one year from the date of award.

• Place of Performance: Wagner IHS Healthcare Center, 111 Washington Ave., NW, Wagner, South Dakota 57380.

• Mid-level Provider Outpatient Clinic: Sunday to Saturday, 7:00 a.m. to 11:00 p.m.

• Regular workweek, weekend, shift coverage, and block scheduling hours are available.

• Contract Type: Non-personal health care services contract; Contractor is an independent contractor.

• Staffing: Minimum of three providers, with one covering the schedule. Must ensure qualified personnel are available for continuity of services and replacement staff.

• Credentialing: Providers must possess specialized knowledge and have completed accredited programs. Must maintain current active and unrestricted license, national certification, and BLS certification. Background checks and health requirements (immunizations, TST, COVID-19 vaccination, PPD/QuantiFERON-TB Gold, Flu vaccine, Fit Test) are mandatory.

• Insurance: Maintain medical liability insurance in an amount acceptable to the Contracting Officer.

• Quality Assurance: Performance will be measured against Government Performance Standards and monitored via a Quality Assurance Surveillance Plan (QASP). Deductions may apply for failure to meet performance requirements.

• Documentation: All patient encounters must be documented legibly in the electronic medical record within 24 hours. Medical records must be completed within 24 hours of the provider's scheduled shift.

• Compliance: Must comply with Federal, State, Indian Health Service, CMS regulations, and departmental regulations. Strict compliance with HIPAA and privacy regulations is required.

• Orientation: New contract providers must participate in the Wagner IHS Facility Orientation.

• Invoicing: Invoices must be submitted through the Invoice Processing Platform (IPP).

• Background Checks: Mandatory background and security clearance requirements, including FBI National Criminal History Check (Fingerprint Check), are applicable.

• Excluded Individuals: Contractor personnel must not be listed on the HHS Office of Inspector General List of Excluded Individuals/Entities (LEIE).