**PLEASE NOTE "HELPFUL HINTS" FROM THE SEVEN STEPS TEAM AT THE END OF
THIS DOCUMENT.**

**Attachment 1**

**PERFORMANCE WORK STATEMENT FOR**

**Emergency Room Physician Services**

**(NONPERSONAL SERVICE)**

**TABLE OF CONTENTS**

###### SECTION TITLE PAGE

1 Description of Services 2

2 Service Delivery Summary 6

3 Government Furnished Property and Services 6

4 General Information 7

5 Appendixes

A - Definitions 14

B - Applicable Publications and Forms 16

C - Historical Data 18

D - 366th Medical Group Credentialing Procedures 19

**1. DESCRIPTION OF SERVICES.** The Contractor shall provide Emergency
Department (ED) Physician services required for Government
beneficiaries. The Contractor shall provide care at the 366th Medical
Group, also referred to as the "Medical Treatment Facility" (MTF)
herein. Contractor shall furnish all labor, management, supervision,
teaching, consultations and reports, except as provided in Section 3.
Contractor care shall cover the range of services provided in a civilian
medical treatment facility. Performance shall be according to the
requirements contained in this Performance Work Statement (PWS) and
professional standards of the Joint Commission on Accreditation of
Healthcare Organization (JCAHO). The Contractor shall provide physicians
to perform the professional health care services required for estimated
13,175 patients per year (see Appendix C). Care shall be appropriately
documented in medical records in accordance with standard commercial
practice. The quality of medical practice shall meet or exceed
reasonable standards of professional practice for emergency services
health care as determined by the same authority that governs military
medical professionals in emergency medicine and will be audited by the
Executive Committee of the Medical Staff (ECOMS).

**1.1. CONTRACTOR RESPONSIBILITY.**

1.1.1. Provides emergency (level 1) urgent (level 2), non-urgent (level
3,4,5) medical care to approximately 1,097 patients visits per month to
a patient population that includes active duty, their dependents,
retired military members and their dependents, and civilian emergencies,
ranging in age from newborn (emergency deliveries) to geriatrics
(dependent parents).

1.1.2. The ED physician's actual clinical activity shall be a function
of the Commander/Commanding Officer's clinical privileging process and
the overall demand for emergency services.

1.1.3. The ED physician shall practice within the MDGI 44-172, "Plan for
Provision of Patient Care" guidelines set by the credentialing office of
the MTF and the Emergency Services Medical Director with additional
guidance in AFI 44-119, "Clinical Performance Improvement".

1.1.4. Provides direct hands-on patient care, in a Level III Emergency
Services Department. Performs triages, assesses, and re-assesses
patients throughout the patient visits. Ensures documentation of medical
assessments and observations are documented accurately on the Emergency
Records Standard Form 558.

1.1.5. Responsible for the proper delegation of duties, teaching and
medical supervision of subordinate personnel.

1.1.6. Implements, evaluates and is consulted on medical emergency room
policies, procedures and instructions.

1.1.7. Provides after-duty hour home care advice via telephone to MTF
beneficiaries as needed. The physician will document all advice provided
on the Standard Form 600, Chronological Record of Medical Care. If the
physician is unable to provide home care advice when the patient
initially calls, the physician will make every attempt to call the
patient back within one hour of initial call. If the ED physician on
duty is unable to call the patient within one hour due to patient care,
the adult on call provider or pediatric on call provider will be
utilized to provide the patient with home care advice.

1.1.8. Performs duties as Medical Officer of the Day and code team
member, when on duty in the hospital in accordance with MDGI 44-172,
"Plan for Provision of Patient Care" and MDGI 44-122, "Code Blue
Response".

1.1.9. Establishes inter-personal and intra-departmental relationships
to enhance optimal patient care.

1.1.10. If a patient's condition is urgent/emergent and the Family Care
Unit is unable to provide support, the physician may direct the shift
leader to call the nurse-on-call in to administer medications and assist
with patient stabilization. Administration of critical medications will
not be delayed by waiting on the arrival of the nurse-on-call.

1.1.11. Demonstrates competent and effective oral and written
communication.

1.1.12. Provides appropriate patient/family member teaching and
education; evaluates effectiveness and level of patient/family member
understanding of teaching provider.

1.1.13. Utilizes the MTF e-mail system to maintain communication with
the Chief, Hospital Services, Medical Director, Emergency Services, and
the Element Chief, Emergency Services. Contractor personnel shall adhere
to the use of electronic mail in accordance with AFI 33-119, *Electronic
Mail (E-Mail) Management and Use* and as directed by the 366th Medical
Group.

1.1.14. Utilizes the MTF computer software/program for entering and
signing of medical orders such as laboratory studies, radiological
studies, etc.

1.1.15. Obtain necessary information on patients seen in the ED, such as
medical records, x-ray films and reports, and pathology slides and
reports.

1.1.16. Maintain familiarity and comply with hospital antiseptic polices
and procedures, ensuring the use of antiseptic methods of all in-clinic
procedures (Ref: MDGI 44-163, Hospital Infection Control). Maintain
familiarity and comply with all Federal, State, Air Force, 366th Medical
Group, and departmental regulation and requirements.

1.1.17. Ensure a safe work environment and employee safe work habits
(Ref: MDGI 91-101, Unit Safety Program).

1.1.18. REFERRALS AND CONSULTS**.** The provider shall follow DoD, Air
Force and 366th Medical Group regulations and policies when arranging
for a referral or consult. The ED physician shall be required to consult
with other specialty practitioners for consultative opinions and
continuation of care. The provider shall inform patients of the required
referral or consult by indicating the specialty involved. All consults
and referrals will adhere to the 366th Medical Group approved Consult
Management process.

1.1.19. PRESCRIPTIONS. The provider shall use and follow the 366th
Medical Group formulary for prescriptions for all patients that received
care at 366th Medical Group. The formulary list is approved and
maintained by the 366th Medical Group Pharmacy and Therapeutics
Committee. Any drug not listed on the formulary must be approved by the
Pharmacy and Therapeutics Committee.

**1.2. PROCEDURE GUIDANCE.** Contractor providers shall perform
procedures compatible with the medical facility\'s operating capacity
and equipment. New medical procedures/services shall not be introduced
without prior recommendation to, and approval of, the MTF Commander or
authorized representative.

**1.3. PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.** The
Contractor health care providers shall provide patients with the utmost
care and attention. All patients shall be assured of their privacy and
personal dignity. The Contractor shall ensure strict compliance to the
release of Protected Health Information in accordance with the Code of
Federal Regulation, Title 45, Public Welfare, Subtitle A, Department of
Health and Human Services, Part 164, Security and Privacy (45 CFR 164)
and AFI 41-210, \"Patient Administration Functions\" paragraph 2.2.3,
\"Health Insurance Portability and Accountability Act (HIPPA)\" and
paragraph 2.3, \"General Guidelines on Releasing Medical Information\".

**1.4.** **COMMUNICATION**. The Contractor shall ensure contract
providers maintain open and professional communication with members of
the MTF. Complaints validated by the Quality Assurance Personnel (QAP)
and Chief of the Medical Staff shall be reported in writing to the
Contracting Officer (CO) and the Contractor for action.

1.4.1. ENGLISH LANGUAGE REQUIREMENT. The contractor provider(s) shall
read, understand, speak, and write English fluently.

**1.5. DOCUMENTATION.** For continuity within MTF, Contractor personnel
shall prepare all documentation to meet or exceed established standards
within AFPD41-2, \"Medical Support\", AFI 41-210, \"Patient
Administration Functions\" and Joint Commission on Accreditation of
Healthcare Organization (JCAHO) standards. (Ref: www.jcaho.org)

**1.6. AVAILABILITY:**

1.6.1. HOURS OF OPERATION: The ED physician shall be on duty in the ED
department located in the 366th Medical Group. Services are 1700
Thursday to 0700 Monday (Continuous); 14 Hour Shifts beginning 1700
Monday to 0700 Tuesday, 1700 Tuesday to 0700 Wednesday, 1700 Wednesday
to 0700 Thursday; and provide a full 24 hour shift on Federal Holidays
and Wing down days. Routine work hours will be scheduled by the Medical
Director to correspond to the needs of the department. Shifts include
days and nights. The ED physician shall arrive for each scheduled shift
in a well-rested condition and shall have had at least six hours rest
from all other duties.

1.6.2. FEDERAL HOLIDAYS. When the holiday is on a Saturday, the
preceding Friday will be the federal holiday. When the holiday is on a
Sunday, the following Monday will be the federal holiday. Asterisk (\*)
indicates the dates change each year. The Base Commander sometimes
declares "family days" or other days for base personnel to take a
holiday.

List of Federal Holidays

\(a\) 1 January New Year's Day

\(b\) 3^rd^ Monday in January \* Martin Luther King's Day

\(c\) 3^rd^ Monday in February\* President's Day

\(d\) Last Monday in May \* Memorial Day

\(e\) 4 July Independence Day

\(f\) 1^st^ Monday in September \* Labor Day

\(g\) 2^nd^ Monday in October \* Columbus Day

\(h\) 11 November Veteran's Day

\(i\) 4^th^ Thursday in November \* Thanksgiving

\(j\) 25 December Christmas

1.6.3. ON CALL DUTY. The contract personnel shall not provide on-call
services, but when required to ensure completion of services that extend
beyond the normal close of business, the ED physician shall remain on
duty in excess of the scheduled shift.

1.6.4. CONTINUITY OF SERVICES/REPLACEMENT STAFF. The Contractor point of
contact shall ensure qualified personnel are available to provide
coverage at all times even during scheduled absences of primary contract
providers.

1.6.5. The Emergency Department Physician services are considered vital
to the Government and must be continued with minimal interruption. In
order to minimize interrupted services, the incumbent contractor shall
exercise its best efforts and cooperation to effect an orderly and
efficient transition to a successor.

1.6.6. PERFORMANCE OF SERVICES DURING CRISIS DECLARED BY THE NATIONAL
COMMAND AUTHORITY OR OVERSEAS COMBATANT COMMANDER. On occasion, services
may be required to support an activation or exercise of contingency
plans outside the normal duty hours. Emergency situations (i.e.,
accident and rescue operations, civil disturbances, natural disasters,
military contingency operations, and exercises) may necessitate the
contractor provide increased or reduced support as determined by the
contracting officer. The Government will negotiate an equitable
adjustment with the contractor for the cost of these emergency
requirements.

**1.7. ORIENTATION**. The Contractor shall ensure that all contract
providers participate in the MTF and Emergency Service Orientation
procedures for newly assigned providers to include regulations specific
to their professional specialty and hospital and Air Force policy and
procedures.

**1.8. RECORDS**. The contractor shall create and maintain
Government-owned/contractor-held records, regardless of media, in
accordance with AFI 33-119, *Electronic Mail (E-mail) Management and
Use,* paragraph 8; AFI 33-202, *Computer Security,* paragraphs 3.5.1 and
3.6.1; AFI 33-322, *Records Management Program,* paragraphs 7,8,9 and 10
and supplements; AFMAN 37-123, *Management of Records,* Chapters 2 -- 6,
paragraphs 7.10 -- 7.29, and Mountain Home supplements (will convert to
AFMAN 33-323); AFI 37-138, *Records Disposition---Procedures and
Responsibilities,* Chapters 2, 3 and 6, and supplements; Mountain Home
AFB Supplement 1 to AFI 33-322, *Records Management Program;* and
Mountain Home AFB Supplement to AFI 37-123*, Management of Records.* The
contractor shall segregate the government-owned records from the
company-owned records. Identify all records required to be created by
the PWS on the RIMS file plans. Upon completion of this contract, all
government-owned/contractor-held records (regardless of media) received,
created, maintained or provided in the performance of the PWS shall be
turned over to the Government. Background electronic data and records
specified for delivery to the contracting agency must be accompanied by
sufficient technical documents to permit the Air Force to use the data.
In the event of default or non-performance, the Government will have
access to all records in order to ensure mission support is not
interrupted.

**1.9. PERSONNEL REQUIREMENTS**

1.9.1. CONTINUING MEDICAL EDUCATION (CME)/ CERTIFIED EDUCATION UNITS
(CEU) REQUIREMENTS. Maintain CME and review pertinent journals, books
and publications. Health care providers registered or certified by
national/medical associations shall continue to meet the minimum
standards for CME to remain current as prescribed in Chapter 4, AFI
41-117, *Medical Service Officer Education.* CME hours shall be reported
to the credentials office for tracking by the Chief of Medical Staff,
annually on the first normal duty day in January for the previous
calendar year. Periodic CME may be conducted at the MTF and will be
available, at no cost, should the health care provider desire to attend.
Attendance will be at the discretion of the Chief of Medical Staff.

1.9.2. LICENSURE/REGISTRATION. In accordance with paragraph 3.1, AFI
44-119, *Clinical Performance Improvement*, 4 Jun 2001, non-personal
services contract personnel providing care in the MTF must be licensed
in the jurisdiction in which the MTF is located. (*NOTE**:
***Dieticians, physician assistants, and substance abuse counselors are
exempt from the requirement for an authorizing document from a US
jurisdiction. For these professional groups, national
registration/certification meets the requirement). Assignment to a
position not involving direct patient care within or outside an MTF does
not eliminate the requirement for license or authorizing document.

1.9.2.1. Non-personal service contract employees must maintain an active
license or authorizing document from the state in which they are
practicing.

1.9.3. CERTIFICATION. The provider must have national and/or state
(required) approved and current board certification in the American
Board of Emergency Medicine, of Internal Medicine, of Family Practice,
of Pediatrics, or of Surgery.

1.9.3.1. Copies of required certification for each Provider shall be
furnished to the Contracting Officer prior to performance on this
contract.

1.9.4. FORMAL EDUCATION. The provider must have a Medical Doctor (MD) or
Doctor of Osteopathic Medicine (DO) degree from an accredited college or
university in the specialty area required to complete the FTE.

1.9.5. EXPERIENCE. The provider must have a minimum of 3 years of
experience within emergency medicine to include fellow and residency
time within the past 36 months prior to provider beginning performance
at MTF.

1.9.6. Maintain certification in Basic Life Support (BLS), Advanced
Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) and
Neonatal Resuscitation Program (NRP).

**1.10. QUALITY CONTROL**: The contractor shall develop and maintain a
quality program to ensure emergency room services are performed in
accordance with commonly accepted commercial practices, manufacturers'
recommendations, this contract, and all federal, state, and local laws
and regulations. As a minimum, the contractor shall develop quality
control procedures addressing the areas identified in the Service
Delivery Summary. The contractor shall develop and implement procedures
to identify, prevent, correct, and ensure nonrecurrence of defective
services. The contractor shall provide a copy of the quality control
plan to the contracting officer no later than the orientation date, and
updated copies as changes occur. Records of all inspections conducted by
the contractor and corrective action taken shall be made available to
the government upon request.

**2. SERVICE DELIVERY SUMMARY. Emergency Services - Physician.**

+------------------------------+---------------+-----------------------+
| **Performance Objective      | #             | # Performance Measure |
| (General)**                  | PWS Paragraph |                       |
+------------------------------+---------------+-----------------------+
| 1\. Practices within         | 1.1.3         | 100% compliance       |
| guidelines established by    |               | required.             |
| MTF and the Medical          |               |                       |
| Director.                    |               |                       |
+------------------------------+---------------+-----------------------+
| 2\. Documents medical        | 1.1.4 and 1.5 | 90% compliance        |
| assessments and              |               | required              |
| observations.                |               |                       |
+------------------------------+---------------+-----------------------+
| 3\. Utilizes the MTF e-mail  | 1.1.13        | 95% compliance        |
| system for communication     |               | required              |
+------------------------------+---------------+-----------------------+
| 4\. Utilizes MTF computer    | 1.1.14        | 90% of orders must be |
| system to enter and sign off |               | signed off at end of  |
| orders                       |               | each shift            |
+------------------------------+---------------+-----------------------+
| 5\. Ensures properly cleaned | 1.1.16        | No more than 3        |
| and stored equipment and     |               | instances per quarter |
| work area.                   |               | of improperly         |
|                              |               | cleaned/stored        |
|                              |               | equipment.            |
+------------------------------+---------------+-----------------------+
| 6\. Complies with safety     | 1.1.17        | Zero violations       |
| policies.                    |               |                       |
+------------------------------+---------------+-----------------------+
| 7\. Consults with other      | 1.1.18        | 100% compliance       |
| specialty practitioners      |               | required              |
+------------------------------+---------------+-----------------------+
| 8\. Maintains patient        | 1.3           | Zero breaches of      |
| privacy/confidentiality.     |               | privacy               |
+------------------------------+---------------+-----------------------+
| 9\. Adheres to work duties   | 1.6           | No more than 2        |
| and schedule for shifts in   |               | unplanned absences    |
| accordance with PWS          |               | per quarter           |
| paragraph.                   |               |                       |
+------------------------------+---------------+-----------------------+
| 10\. Maintains continuing    | 1.9           | 100% compliance       |
| medical education,           |               | required              |
| licensing, registration, and |               |                       |
| certifications               |               |                       |
+------------------------------+---------------+-----------------------+

2.1. The Government shall periodically evaluate the Contractor's
performance by appointing a representative(s) to monitor performance to
ensure services are received. The Government representative(s) shall
evaluate the Contractor's performance through inspections of call
logs/reports and receive and investigate all complaints from base
personnel. The Government may inspect each task as completed or increase
the number of quality assurance inspections if deemed appropriate
because of repeated failures or because of repeated customer complaints.
Likewise, the Government may decrease the number of quality assurance
inspections if performance dictates. The Government Contracting Officer
shall make final determination of the validity of customer complaint(s).

2.2. If any of the services do not conform with contract requirements,
the Government may require the Contractor to perform the services again
in conformity with contract requirements, at no increase in contract
amount. When the defects in services cannot be corrected by
re-performance, the Government may -

> \(a\) Require the Contractor to take necessary action to ensure that
> future performance conforms to contract requirements; and
>
> \(b\) Reduce the contract price to reflect the reduced value of the
> services performed.

**3.** **GOVERNMENT-FURNISHED PROPERTY AND SERVICES.**

**3.1. EQUIPMENT.** Contract providers shall have joint use of all
available equipment for performing services required by this contract:

**3.2. PERSONAL PROTECTIVE EQUIPMENT (PPE).** The Government will
furnish the contract provider(s) with appropriate PPE. The Government
will be responsible for any repair, cleaning and inventory required for
the PPE. This does not include any type of uniform or laboratory coat.

**3.3. IDENTIFICATION CREDENTIALS.** The MTF will provide each contract
provider all required identification media.

**3.4. FORMS.** The MTF will provide required Government forms used in
the performance of services.

**3.5. SUPPLIES.** The MTF will provide medical and non-medical supplies
commonly used in the facility for the care and management of patients
and the performance of the requirements of this contract.

**3.6. UTILITIES.** For the purpose of this contract, the government
will furnish all required utilities (such as water, telephone,
electricity, etc.) at no cost to the contractor. Long distance and
Defense Switched Network (DSN) telephone services will not be provided.
The contractor shall participate in government energy conservation
programs.

**3.7. SERVICES.**

3.7.1. Administrative support. The MTF will provide normal office
administrative support services, to include telephone and utilities.

3.7.2. Patient scheduling. Clinic personnel will assist in patient
scheduling. Complete administrative control of the patient shall remain
with the Government.

3.7.3. The MTF will provide all other ancillary personnel services
required, including personnel to move patients or equipment.

3.7.4. Housekeeping services will be provided by the MTF.

3.7.5 Computers and computer systems repair will be provided by the MTF.

**3.8. CONTRACTOR FURNISHED ITEMS AND SERVICES**

3.8.1. GENERAL. Except for those items or services specifically stated
in Section III to be Government furnished, the Contractor shall furnish
everything required to perform this contract in accordance with all of
its terms.

3.8.2. CONTRACTOR OWNED EQUIPMENT**.**

3.8.2.1. INITIAL INSPECTION**.** Contractor owned equipment will be
inspected and approved by the biomedical equipment maintenance section
prior to use in the facility. This includes personal items such as
coffee makers and radios.

3.8.2.2. RUBBER STAMP**.** The contractor shall provide a rubber stamp
for each physician to include the following information: Physicians
name, DEA number (if writing for controlled substances), professional
degree/status (M.D., D.O.), company's name, and company's address.

**4. GENERAL INFORMATION**

**4.1. PERSONNEL.**

4.1.1. POINT OF CONTACT**.** The Contractor shall provide a point of
contact who shall be responsible for the performance of the work. The
point of contact shall have full authority to act for the Contractor on
all matters relating to the daily operation of this contract. The point
of contact may be a provider providing care in accordance with this PWS.
The Contractor shall designate this individual, in writing, to the
Contracting Officer (CO) before the contract start date. An alternate
may be designated, but the Contractor shall identify those times when
the alternate shall be the primary point of contact.

4.1.2. CRIMINAL BACKGROUND CHECK REQUIREMENT/CHILD CARE NATIONAL AGENCY
CHECK WITH INQUIRIES (CNACI). The Government will conduct at government
expense, a CNACI and state criminal history checks on individuals
providing direct, unsupervised child care services under this contract,
using the procedures set forth in Department of Defense Regulation
5200.1, The DoD Information Security Program and DoD Instruction 1402.5,
*Criminal History Background Checks on Individuals in Child Care
Services,* 19 Jan 93. As a minimum, the Contractor shall contact the
366th Medical Group's security manager for obtaining all necessary forms
(Standard Form 85P, Questionnaire for Public Trust Positions) and
directions for filing background check information in writing and
electronically on personnel hired at the beginning of the contract. This
action shall take place no later than five (5) working days from
contract award date. Contractor shall submit completed personnel
background check applications within twenty (20) working days after
award date to the 366th Medical Group's security manager for processing.
Contractor personnel will be required to be fingerprinted at the 366th
Security Forces Administrative Office on Mountain Home AFB, ID. Requests
for personnel hired subsequent to the contract start date shall be
submitted to the Government not later than five (5) workdays from the
employee's first duty day. Contractor shall provide a list of substitute
contract personnel fulfilling contingency situations (i.e. absences of
certified contract personnel). Names of substitutes and credentials
shall be provided 30 calendar days in advance to accomplish background
checks. Contractor personnel receiving unfavorable CNACIs shall not be
employed. The government will submit requests for investigations on AF
Form 2583, "Request for Personnel Security Action", at no additional
cost to the contractor. The contractor shall comply with the
requirements of DoD 5200.2-R, *Personnel Security Program*, and AFI
33-119, *Electronic Mail (E-Mail) Management and Use*. IAW DODI 1402.5,
"DoD components may employ an individual pending completion of
successful background checks. If an individual is so employed, at all
times while children are in the care of that individual, he or she must
be within sight and under the supervision of an individual whose
background checks have been completed, with no derogatory reports." The
collective forms and fingerprints for individual background checks are
processed through the local security forces administrative office up
through the Office of Personnel Management Investigations in Boyers, PA.
Based on background findings, the 366th Medical Group, Chief of Medical
Staff may be required to conduct a suitability determination and will
provide the contracting office a copy of the determination. If any
conflict, the 366th Medical Group Commander will make final
determination of suitability.

4.1.2.1. Background checks will be based on fingerprints of individuals
obtained by a Government law enforcement officer and inquiries conducted
through the Federal Bureau of Investigation (FBI) and state criminal
history repositories.

4.1.2.2. Individuals shall have the right to obtain a copy of any
background check pertaining to themselves and to challenge the accuracy
and completeness of the information contained in the report. Individuals
requesting access to background investigations pertaining to them should
submit a written request to FOI/P, OPM-FIPC, PO Box 618, Boyers, PA
16018-0618. The request should state that, "the information is being
requested pursuant to the Privacy Act of 1974." The requester is
required to provide full name, hand written signature, other names used,
home address, social security number, date and place of birth. A record
may be disclosed to a representative of the individual to whom the
record pertains after receipt of a notarized written authorization from
the individual who is the subject of the record.

4.1.2.3. Individuals who have previously received a background check
shall provide proof of the check to the Chief of Medical Staff or obtain
a new one.

4.1.3. LOCAL AREA NETWORK ACCESS: Before operating government-furnished
workstations that have access to Air Force automated information
systems, contractor shall have at a minimum a favorable National Agency
Check. This information will be supplied and documented on MHAFB Form 2,
"Request for Interim Local Area Network Account" and processed by the
366th Medical Group security manger through the 366th Communication
Squadron.

4.1.4. CONFLICT OF INTEREST. The Contractor shall not employ any person
who is an employee of the United States Government if the employment of
that person would create a conflict of interest. The Contractor shall
not employ any person who is an employee of the Department of the Air
Force, either military or civilian, unless such person seeks and
receives approval in accordance with DoD Directive 5500.7 and Air Force
policy.

4.1.5. APPEARANCE. Employees are expected to comply with reasonable
dress and grooming standards based on comfort, productivity, health and
type of position occupied. Employee attire will be in good repair, and
should not be considered offensive, disruptive or unsafe.

4.1.5.1. Contract providers shall display legible MTF-provided
identification media on their outer clothing.

4.1.6. PROTECTIVE CLOTHING. When required and supplied by the
Government, the provider shall wear special protective clothing and shoe
covers. When duties will be performed in specified areas, a disposable
protective hood shall be worn to ensure infection control standards are
met. The Government will provide this hood. These items shall remain the
property of the Government and shall not be removed from the MTF. After
use, protective clothing shall be turned in or destroyed as directed by
the Chief of Medical Staff.

**4.2. PRIVILEGING REQUIREMENTS.** The contract providers' credentials
shall be reviewed in accordance with Chapter 4, AFI 44-119, *Clinical
Performance Improvement*, 4 Jun 2001, and approved by the Chief,
Hospital Services and the MTF Credentials Committee. The Contractor is
responsible for ensuring that proposed providers possess the requisite
credentials to enable granting of privileges by the MTF sufficient to
allow for performance of all tasks identified in paragraph 1 of the PWS.

4.2.1. Initial applications for clinical privileges, to include
credentials action history, malpractice history, and certified true
copies of the documents listed below, shall be submitted to the MTF
Credentials Committee, through the Chief of Medical Staff, no later than
5 calendar days after receipt of notice of contract award, or when
requested by the Functional Commander. See Appendix B for a list of
required Air Force application documents.

> a\. Copy of valid, current unrestricted Idaho state license and
> applicable Board Certification. (Submission required with proposal)

b\. Documentation of continuing education and training.

> c\. Current Basic Life Support (BLS), Advanced Cardiac Life Support
> (ACLS), and Pediatric Advanced Life Support (PALS). (Submission
> required with proposal)

d\. A signed consent for release of information.

> e\. Current copy of Drug Enforcement Agency (DEA) certificate, if
> applicable.
>
> f\. A list of all states in which contract provider currently holds or
> has held a license to practice related services.
>
> g\. A copy of the proposed contract provider's professional resume,
> accompanied by that individual's sworn affidavit of the truthfulness
> of same, indicating experience, training, and technical expertise in
> the type of care to be rendered.
>
> h\. Certification of current physical examination. The certification
> shall contain a statement signed by the examining physician stating
> that the employee is free of any contagious diseases. The physical
> examination shall be current as of 12 months prior to application for
> privileges.

4.2.2. Applications for privileges will be screened through the National
Practitioners Data Bank.

4.2.3. Professional staff appointments and clinical privilege actions
will be based on review of documents listed in paragraph 4.2.1 above, in
accordance with AFI 44-119. Re-appointment shall occur not less than
every two years, in accordance with AFI 44-119.

4.2.4. DENIAL/TERMINATION OF PRIVILEGES. Actions to limit, suspend, or
revoke clinical privileges will be in accordance with the procedures
outlined in AFI 44-119. The Chief of Medical Staff, will notify the
Contracting Officer, and provide copies of pertinent documentation, as
soon as possible when the necessity to exercise such authority becomes
apparent. The Contracting Officer will notify the Contractor of the
initiation of the revocation process if such action becomes apparent.

4.2.5 REVIEW OF CREDENTIALS PACKAGES. The Government reserves the right
to limit the number of credentialing packages it will evaluate.

**4.3. HEALTH REQUIREMENTS**.

4.3.1. Contract providers providing services under this contract shall
receive a pre-employment physical examination prior to commencement of
work and annually thereafter. The providers shall report to a Government
physician to receive a pre-employment examination and immunizations
prescribed by the MTF.

4.3.2. Not later than five (5) working days prior to commencement of
work, certification shall be provided to the QAP that the provider has
completed the medical evaluation required above. This certification
shall state the date on which the examination was completed, the name of
the doctor who performed the examination, and a statement concerning the
physical health of the individual. The certification shall also contain
the following statement: "(Name of contract provider) is suffering from
no contagious diseases to include, but not limited to, Tuberculosis,
Hepatitis, and Venereal Disease."

4.3.3. OSHA requires that all contract personnel who will have
occupational exposure to blood or body fluids, or other potentially
infectious materials, shall receive Hepatitis B vaccine (at government
expense in the 366th MDG immunization department), sign a voluntary
declination, or have documented proof of immunity to Hepatitis B
infection. Personnel who sign declinations may change their minds at
anytime and receive the Hepatitis B vaccine without penalty.

4.3.4. The contractor is responsible for reporting to the Chief of
Medical Staff, all information necessary to assure hospital records can
be maintained correctly, and therefore comply with the JCAHO, OSHA, and
CDC health record requirements.

**4.4. EMERGENCY HEALTH CARE**. The MTF will provide emergency health
care for the contract providers for injuries incurred while on duty in
the MTF. These services will be billed to the Contractor at the current
full reimbursement rate.

**4.5 MEDICAL QUALITY IMPROVEMENT/RISK MANAGEMENT (QI/RM).**

4.5.1. The contract provider(s) shall participate in QI/RM activities to
the extent required by Section 2C, AFI 44-119 and the individual MTF
QI/RM plan or regulation.

4.5.2. The Government will evaluate the providers' professional, as
differentiated from administrative, performance under this contract
using Quality Improvement standards specified in paragraphs 2.12 and
2.13, AFI 44-119. Nothing in this paragraph precludes the Government
from also conducting inspections under the Inspection/Acceptance
requirement of FAR clause 52.212-4.

**4.6.** **PERFORMANCE EVALUATION**

4.6.1 The Business Requirements Advisory Group (BRAG) consisting of
contracting officer, QAE, other government personnel as appropriate, and
the contractor will meet at least quarterly or more often if necessary,
to identify opportunities to improve performance. The BRAG will discuss
contract performance, identify initiatives, assess risk associated with
the initiatives, and monitor the success of implementation. The
government will also apprise the contractor of how the government views
the contractor's performance overall.

4.6.2 The government will evaluate the contractor's performance under
this contract. Evaluations will be provided to the contractor, in
writing, on a monthly basis. Contractor performance will also be
recorded annually on AF Form 370 and in the Contractor Performance
Assessment Reporting System (CPARS) database. These evaluations may be
used by other government agencies as a record of contractor performance
history for the purpose of evaluation in other competitive or
noncompetitive acquisitions.

The contractor shall appoint a CPAR point of contact in writing to the
Contracting Officer within 15 calendar days of contract start date.

**4.7. DOD FREEDOM OF INFORMATION ACT (FOIA) PROGRAM.** All FOIA
requests shall be delivered immediately to the Quality Assurance
personnel.

4.7.1. FOR OFFICIAL USE ONLY (FOUO). The contractor shall create and
maintain FOUO material IAW DoD 5400-7R, *DoD Freedom of Information Act
Program,* Chapter 4; AFI 33-129, *Transmission of Information via the
Internet,* paragraphs 7.4, 8.2.3, 16 and 17; and AFI 33-201,
*Communications Security (COMSEC),* Table 1. Mark all documents meeting
the requirements identified in DoD Regulation 5400-7/Air Force
Supplement, paragraphs C3.2.1.2 thru 3.2.1.9 as "For Official Use Only"
IAW instructions identified in paragraph C4.2.1. Safeguard all sensitive
data IAW DoD Regulation 5400.7/Air Force Supplement, paragraph C4.4.
When documents containing FOUO material are authorized for destruction,
shred the records so that the pieces cannot be reconstructed. Degauss or
overwrite magnetic tapes or other magnetic media.

4.7.2. PATIENT LISTS. Patient lists, no matter how developed, shall be
treated as privileged information. Add the following to the bottom of
all patient lists: "*FOR OFFICIAL USE ONLY. This document contains
information exempt from mandatory disclosure under the Freedom of
Information Act (FOIA), Title 5 U.S.C. 552(b)(2) High and (b)(6)
apply."* Lists and/or names of patients shall not be disclosed or
revealed in any way for any use outside the MTF without prior written
permission by the Chief of Medical Staff.

4.7.3. RELEASE OF MEDICAL INFORMATION. The Contractor personnel shall
release medical information obtained during the course of this contract
to MTF staff involved in the care and treatment of that individual
patient only.

**4.8. PRIVACY ACT PROGRAM.** The Contractor shall create and maintain
Privacy Act data IAW AFI 33-129, *Transmission of Information Via the
Internet,* paragraphs 7.4, 8.2.3, 16, and 17, and supplements; AFI
33-201, *Communications Security (COMSEC),* table 1; AFI 33-322, *Air
Force Privacy Act Program,* paragraphs 1.4.7, 1.4.8, 3.3.3, Chapters 7,
9 and 10, and supplements; and, Privacy Act systems of records notice(s)
(<http://www.defenselink.mil/privacy/notices/usaf>). The contractor
shall not create or maintain a Privacy Act system of records prior to
public notice. If the Contractor receives a Privacy Act request, the
contractor shall be responsible for searching for the records and
providing those records to a Government official who, as the authorized
official, will make the decision on releasing the Government records.

**4.9. FUNCTIONAL REQUESTS.** A functional request is a written request
for DoD records that does not cite either the FOIA or Privacy Act
received from any person (including a member of the public), an
organization, or a business. The contractor shall be responsible for
searching for the records and providing those records to a Government
official who, as the authorized official, will make the decision on
releasing the Government records.

**4.10.** **Requirements for Contractor Personnel Requesting Base
Entry.** The contractor shall notify the QAP at Mountain Home AFB,
requesting base entry for providers 15 calendar days prior to provider's
performance start date. The notification shall include:

4.10.1. All Contractors who work on base must submit a typewritten
request with the name, driver's license number, social security number,
date of birth, and employer of each employee to obtain an authorization
letter from the Base Contracting office. This letter is then submitted
to the 366th Security Forces Squadron. When that letter is approved, an
AF Form 75 shall be issued for each employee for the duration of the
contract not to exceed one year. If the option is exercised, the
employees shall be required to renew issued AF Form 75. (NOTE: A
complete background check shall be conducted on all of the employees
submitted. The 366th Security Forces Squadron has the right to refuse
entry of any contractor employee to Mountain Home AFB, based upon the
results of the background check). Contractor passes shall not exceed a
period of more than one year.

4.10.2. When the AF Form 75 is issued; confirmation of Contractor's
employees shall be accomplished by verifying the person's credentials
(driver's license) against the Contractor-supplied employee list. AF
Forms 75 issued in excess of 90 days shall have a photograph attached to
the upper left-hand corner.

4.10.3. A vehicle pass shall be issued upon receipt of proof of
insurance and vehicle registration. Delivery vehicles shall be granted
entry to the base upon presentation of a valid bill of lading and/or
delivery slip. If the driver changes vehicles prior to coming onto the
base, he/she shall stop at the Visitor Center to obtain a vehicle pass
for that particular vehicle.

4.10.4. Contractor shall provide the Contracting Officer a list of its
employees or Subcontractor employees, in advance, who shall need to be
vouched on base for one day.

4.10.5. Contractors operating on base shall be responsible for briefing
and ensuring the employees adhere to the state traffic rules and MHAFBI
31-204, "Motor Vehicle Traffic Supervision". The Foremen, Job Supervisor
and/or other personnel providing workman leadership shall, when
possible, ensure the workers comply with these rules and regulations.
Speed limit on base is 30 miles per hour (MPH) unless otherwise posted.
The speed limit in base housing areas is 15 MPH and the speed limit in
parking lots is 5 MPH. In the school zone, when the warning signal is
flashing, the speed limit is 15 MPH. Individuals are to obey all entry
procedures. When Security Police personnel give instructions, they shall
be complied with immediately. Security Police utilize speed detection
devices and citations shall be issued to violators. Personnel who park
on grass or seeded areas shall be cited.

4.10.6. Contractor personnel shall be given direction by Security Forces
personnel, QAE, or the Contracting Officer, as to what actions are
required, if any, during higher states of readiness requiring changes
Force Protection Conditions, i.e., FPCON Alpha, Bravo, Charlie or Delta
during exercises and real world events.

4.10.6.1. To provide reasonable assurance of the continuation of
essential medical services during real world crisis, military exercises
and higher FPCONS (i.e. FPCON Charlie and Delta); the contractor shall
provide upon request a list of mission essential contractor personnel to
the sponsoring agencies security manager.  This list will be provided to
the Security Forces located at the Visitor Control Center for
identifying/authorizing mission essential personnel prior to entering
base (Ref: DODI 3020.37).

4.10.7. The installation is considered a controlled area. The Contractor
personnel may experience delays or denied entry because of compliance
with entrance/exit requirements as indicated by the readiness state.

4.10.8. The contractor shall return all identification media, including
vehicle decals, to the QAP office upon completion/termination of the
contract, as appropriate.

4.10.9. The contractor personnel shall comply with the requirements of
Volume 1, AFI 71-101, *Criminal Investigations,* and paragraph 1.1 of
Volume 2, *Protective Service* *Matters*. Contractor personnel shall
report any information or circumstances of which they are aware that may
pose a threat to the security of DoD personnel, contractor personnel,
resources, and classified or unclassified defense information to the
Element Chief, Emergency Services. The Contractor employee's immediate
supervisor shall brief him/her upon initial on-base assignment and as
required thereafter.

4.10.10. Physical Security. The contractor shall safeguard all
government property, including controlled forms provided for contractor
use. At the close of each work period, government equipment, facilities,
and other valuable materials shall be secured.

4.10.11. Entry Procedures to Controlled/Restricted Areas. The contractor
shall implement local base procedures for entry to Air Force
controlled/restricted areas where contractor personnel will work.

4.10.12. Traffic Laws. The contractor personnel shall comply with the
installation traffic code as specified in Idaho State Law and MHAFB
Instruction 31-204, Motor Vehicle Traffic Supervision.

4.10.13. Listing of Employees. The contractor personnel shall maintain a
current listing of employees. This list will include the employee's name
and social security number. The list shall be provided to the Program
Manager and sponsoring agency's security manager. An updated listing
shall be provided when an employee's status or information changes.

4.10.14. Security Training. The contractor will ensure all contractor
employees receive initial and recurring security education training from
the sponsoring agency's security manager. Training must be conducted IAW
DOD 5200.1-R, "Information Security Program Regulation", and AFI 31-401,
"Information Security Program Management". Contractor personnel who work
in Air Force controlled/restricted areas must be trained IAW AFI31-101,
"The Air Force Installation Security Program".

4.10.15. Retrieving Identification Media. The contractor shall retrieve
all identification media, including vehicle passes from employees who
depart for any reason before the contract expires; e.g. terminated for
cause, retirement, etc.

4.10.16. Weapons, Firearms, and Ammunition. Contractor employees are
prohibited from possessing weapons, firearms, or ammunition, on
themselves or within their contractor-owned vehicle or privately-owned
vehicle while on Mountain Home AFB, ID

4.10.17. Reporting Requirements. Contractor personnel shall report to an
appropriate authority any information or circumstances of which they are
aware may pose a threat to the security of DOD personnel, contractor
personnel, resources, and classified or unclassified defense
information. Contractor employees shall be briefed by their immediate
supervisor upon initial on-base assignment.

4.10.18. Controlled/Restricted Areas (If Applicable). The contractor
shall implement local base procedures for entry to Air Force
controlled/restricted areas where contractor personnel will work. An AF
Form 2586, Unescorted Entry Authorization Certificate must be completed
and signed by the sponsoring agencies Security Manager before a
Restricted Area Badge will be issued. Contractor employees must have a
completed National Agency Check, Local Agency Check, Credit Check
(NACLC) investigation before receiving a Restricted Area Badge.

4.10.19. Key Control. (If Applicable) The contractor shall establish and
implement methods of making sure all keys to include Medical Officer of
the Day Key issued to the contractor by the government are not lost or
misplaced and are not used by unauthorized persons. The contractor shall
not duplicate any keys issued by the government.

4.10.19.1. The contractor shall immediately report to the Quality
Assurance Evaluator (QAE) or Program Manager any occurrences of lost or
duplicated keys.

4.10.19.2. In the event, other than master keys are lost or duplicated,
the contractor may be required, upon written direction of the
contracting officer, to re-key or replace the affected lock or locks
without cost to the government. The government may, however, at its
option, replace the affected lock or locks or perform re-keying and
deduct the cost of such from the monthly payment due the contractor. In
the event a master key is lost or duplicated, all locks and keys for
that system shall be replaced by the government and the total cost
deducted from the monthly payment due the contractor.

4.10.19.3. The contractor shall prohibit the use of keys, issued by the
government, by any persons other than the contractor's employees and the
opening of locked areas by contractor employees to permit entrance of
persons other than contractor employees engaged in performance of
contract work requirement in those areas.

4.10.20. Lock Combinations. (If Applicable) The contractor shall control
access to all government provided lock combinations to preclude
unauthorized entry. The contractor is not authorized to record lock
combinations without written approval by the Government Program Manager.
Records with written combinations to authorized secure storage
containers, secure storage rooms, or certified vaults, shall be marked
and safeguarded at the highest classification level as the classified
material maintained inside the approved containers.

**APPENDIX A**

**GENERAL DEFINITIONS**

As used throughout this PWS, the following terms shall have the meaning
set forth below:

Composite Health Care System (CHCS). Computer system, which stores
clinical and administrative data. This system provides on-line
communication for users in any supported location.

1\. Contracting Officer (C.O.). A duly appointed person with the
authority to enter into, administer, and/or terminate contracts and make
related determinations and findings on behalf of the Government.

2\. Credentials. Certified documents providing evidence of education,
training, licensure, board certification, experience and expertise of a
health care provider.

3\. Exposure-prone procedure. A certain invasive surgical or dental
procedure that has been implicated in the transmission of the
hepatitis-B virus from an infected health care worker to a patient.
Characteristics of exposure-prone procedures include digital palpation
of a needle tip in a body cavity or the simultaneous presence of the
health care worker's fingers and a needle or other sharp instrument or
object in a poorly visualized or highly confined anatomic site.

4\. Freedom of Information Act (FOIA) Request. A written request for DoD
records made by any person, including a member of the public, an
organization, or a business that either explicitly or implicitly
involves the FOIA, DoD Directive 5400.7.

5\. Full reimbursement rate. A rate, which is set annually by Congress,
for reimbursement by non-eligible personnel who receive medical services
at the MTF. This is a flat rate set for outpatient and inpatient care.

6\. Functional Request. A written request for DoD records made by any
person, including a member of the public, an organization, or a business
that either does not cite the FOIA or Privacy Act. This does not include
requests from Government employees with a need to know to perform
official Government business.

7\. Health care provider. Any contract health care professional who,
under regulations of a Military Department, is granted clinical practice
privileges in a military MTF or Dental Treatment Facility, or who is
licensed or certified to perform health care services by a Governmental
board or Agency, or professional health care society or organization.

8\. Invasive medical procedure. Any procedure that involves a puncture
or incision of the skin, the insertion of an instrument or foreign
material into the body, or breaking of the mucosal lining of the body.

9\. Privacy Act Request. A written request from the subject of the
records or a request with the subject's written consent.

10\. Quality Assurance. A planned and systematic pattern of all actions
necessary to provide confidence that adequate technical requirements are
established, products and services conform to established technical
requirements, and satisfactory performance is achieved. For purposes of
this contract, quality assurance refers to actions by the government.

11\. Quality Improvement/Risk Management (QI/RM) Plan. An organized
document that describes the methods of doing QI reviews within the MTF.
The plan designates the areas of responsibility and accountability for
the QI program and the mechanisms for monitoring and evaluating patient
care. It is consistent with the JCAHO monitoring and evaluation (M&E)
approach and the Air Force Risk Management (RM) efforts.

**APPENDIX A**

GENERAL DEFINITIONS CON'T

12\. Valid license. A grant of permission by an official agency of the
District of Columbia, a state, or territory of the United States, to
provide care independently as a health care professional. Licenses must
be current to be valid. Some jurisdictions issue no-fee licenses to
Federal employees or military personnel. These are acceptable if the
issuing authority will exercise professional regulating control over
individuals with these licenses.

APPENDIX B - APPLICABLE PUBLICATIONS AND FORMS

Publications and forms applicable to the PWS are listed below. The
Contractor is obligated to follow these publications. These publications
are available at http://www.e-publishing.af.mil/ and maintained by AF
publishing. Supplements or amendments to listed publications from any
organizational level may be issued during the life of the contract.

+---------------------------------------------------------------+------+
| PUB NO. TITLE MANDANTORY/ADVISORY (M/A)                       |      |
+---------------------------------------------------------------+------+
|                                                               |      |
+---------------------------------------------------------------+------+
| 1\. **DEPARTMENT OF DEFENSE (DoD) REGULATIONS/MANUALS         |      |
| INSTRUCTIONS/DIRECTIVES**                                     |      |
+---------------------------------------------------------------+------+
|                                                               |      |
+---------------------------------------------------------------+------+
| DoD Instruction 1402.5, Criminal History Background Checks on | M    |
| Individuals in Child Care Services                            |      |
+---------------------------------------------------------------+------+
| DoD Directive 5500.7, Standards of Conduct                    | M    |
+---------------------------------------------------------------+------+
| DoD Instruction 3020.37, "Continuation of Essential DoD       |      |
| Contractor Svcs During Crisis"                                |      |
+---------------------------------------------------------------+------+
|                                                               |      |
+---------------------------------------------------------------+------+
| 2\. **AIR FORCE REGULATIONS/MANUALS**                         |      |
+---------------------------------------------------------------+------+
| AFI 44-119, Medical Service Clinical Quality Management       | M    |
+---------------------------------------------------------------+------+
| AFI 41-117, Program Education for Medical Service Officers    | A    |
+---------------------------------------------------------------+------+
| AFI 44-108, Infection Control Program                         | M    |
|                                                               |      |
| AFI 44-119, Clinical Performance Improvement                  | M    |
+---------------------------------------------------------------+------+
| AFMAN 44-144, Nutritional Medicine Management                 | M    |
+---------------------------------------------------------------+------+
|                                                               |      |
+---------------------------------------------------------------+------+
| 3**. OTHER REFERENCES**                                       |      |
+---------------------------------------------------------------+------+
| MDGI 41-101, Deployment of Medical Records                    |      |
+---------------------------------------------------------------+------+
| MDGI 41-134, Medical Treatment Facility (MTF) Privacy         |      |
| Guidelines                                                    |      |
+---------------------------------------------------------------+------+
| Joint Commission on Accreditation of Healthcare Organizations |      |
| (JCAHO) Accreditation Manual for Hospitals Current Edition    |      |
+---------------------------------------------------------------+------+
| JCAHO Ambulatory Health Care Standards Manual Current Edition |      |
| (www.jcaho.org)                                               |      |
+---------------------------------------------------------------+------+
| MDGI 32-200 1 - Fire Protection, Prevention And Evacuation    |      |
+---------------------------------------------------------------+------+
| MDGI 40-6 - Ethics                                            |      |
+---------------------------------------------------------------+------+
| MDGI 44-172 - Plan for Provision of Patient Care              |      |
+---------------------------------------------------------------+------+
| MDGI 44-125 - Identification and Management of Psychotic,     |      |
| Violent, and Suicidal Patients                                |      |
+---------------------------------------------------------------+------+
| MDGI 44- 135- Informed Consent                                |      |
+---------------------------------------------------------------+------+
| MDGI 44-157 - Use of Patient Restraints                       |      |
+---------------------------------------------------------------+------+
| MDGI 44-163 - Hospital Infection Control Program              |      |
+---------------------------------------------------------------+------+
| MDGI 44-165 - Patient Transfers                               |      |
+---------------------------------------------------------------+------+
| MDGI 44-165, Attachment. I - Patient Transfers, Atch. I       |      |
|                                                               |      |
| MDGI 44-172, Plan for Provision of Patient Care               |      |
|                                                               |      |
| MDGI 91-101, Unit Safety Program                              |      |
+---------------------------------------------------------------+------+
|                                                               |      |
+---------------------------------------------------------------+------+
| 4\. **FORMS**                                                 |      |
+---------------------------------------------------------------+------+
| SF 85P Sep-1995 Questionnaire for Public Trust Positions      |      |
+---------------------------------------------------------------+------+
| SF 502 Jul-1991 Medical Record - Narrative Summary (Clinical  |      |
| Resume)                                                       |      |
+---------------------------------------------------------------+------+
| SF 504 Jul-1991 Medical Records -History Part 1               |      |
+---------------------------------------------------------------+------+
| SF 505 Jul-1991 Medical Record - History Part II and 111      |      |
+---------------------------------------------------------------+------+
| SF 506 Jul-1991 Clinical Record - Physical Examination        |      |
+---------------------------------------------------------------+------+
| SF512 Mar-1994 Plotting Chart                                 |      |
+---------------------------------------------------------------+------+
| SF513 Aug-1992 Medical Record - Consultation Sheet            |      |
+---------------------------------------------------------------+------+
| SF 515 Jul-1991 Medical Record - Tissue Examination (DO Form  |      |
| 2005, Privacy Act Statement serves)                           |      |
+---------------------------------------------------------------+------+
| SF 516 May-1983 Medical Record - Operation Report             |      |
+---------------------------------------------------------------+------+
| SF 519B Aug-1983 Radiological Consultation Request/Report     |      |
| (NOT LRA)                                                     |      |
+---------------------------------------------------------------+------+
| SF 520 Oct-1975 Clinical Record - Electrocardiographic Record |      |
+---------------------------------------------------------------+------+
| SF 526 Feb-1995 Medical Record - Interstitial/Intercavitary   |      |
| Therapy                                                       |      |
+---------------------------------------------------------------+------+
| SF 533 Jul-1975 Medical Record - Prenatal and Pre             |      |
+---------------------------------------------------------------+------+
| SF 534 Dec-1974 Medical Record -- Labor                       |      |
+---------------------------------------------------------------+------+
| SF 535 Oct-1975 Clinical Record -- Newborn                    |      |
+---------------------------------------------------------------+------+
| SF 558 Jun-1982 Medical Record - Emergency Care and Treatment |      |
+---------------------------------------------------------------+------+
| SF 559 Apr-1994 Medical Record - Allergen Extract             |      |
| Prescription, New and Refill                                  |      |
+---------------------------------------------------------------+------+
| SF 600 May-1984 Health Record - Chronological Record of       |      |
| Medical Care                                                  |      |
+---------------------------------------------------------------+------+
| AF 55 Nov-1996 Employee Safety and Health Record              |      |
+---------------------------------------------------------------+------+
| AF 190 Oct-1981 Occupational Illness/Injury Report            |      |
+---------------------------------------------------------------+------+
| AF 560 Jan-1987 Authorization and Treatment Statement         |      |
+---------------------------------------------------------------+------+
| AF 765 Dec1994 Medical Treatment Facility Incident Statement  |      |
+---------------------------------------------------------------+------+
| AF 781 Sun-1988 Multiple Item Prescription (DD Form 2005,     |      |
| Privacy Act Statement serves)                                 |      |
+---------------------------------------------------------------+------+
| AF 1042 Feb-1992 Medical Recommendations for Flying or        |      |
| Special Operational Duty                                      |      |
+---------------------------------------------------------------+------+
| AF 1225 Jan-1996 Informed Consent for Blood Transfusion       |      |
+---------------------------------------------------------------+------+
| AF 1480B JuI-1997 Adult Preventive and Chronic Care Flowsheet |      |
| Continuation Sheet                                            |      |
+---------------------------------------------------------------+------+
| AF 1535 Jan-1982 Physical Therapy Consultation (NOT LRA)      |      |
+---------------------------------------------------------------+------+
| AF 3066 Apr-1987 Doctors Orders                               |      |
+---------------------------------------------------------------+------+
| AF 3078 Nov-1994 Monthly Personnel Time and Salary            |      |
| Distribution Worksheet                                        |      |
+---------------------------------------------------------------+------+
| DD 261 Oct-1995 Report of Investigation Line of Duty and      |      |
| Misconduct Status                                             |      |
+---------------------------------------------------------------+------+
| DD 2005 Feb-1976 Privacy Act Statement - Health Care Records  |      |
+---------------------------------------------------------------+------+
|                                                               |      |
+---------------------------------------------------------------+------+
| As applicable IAW governing regulations.                      |      |
+---------------------------------------------------------------+------+

**APPENDIX C - HISTORICAL DATA**

The following data is provided for information only.

HISTORICAL DATA

The following data is provided for information only.

a\. Present department staff consists of:

> MILITARY CONTRACT CIVILIANS

Providers 1 8

Nurses 4 0

Paraprofessionals 0 0

Medical Technicians 18-22 0

b\. Emergency Services admissions for last 12 months: 13,175

**APPENDIX D**

**366th MEDICAL GROUP CREDENTIALING PROCEDURES**

All required credentialing forms can be obtained from: 366 MDG/SGH
(CREDENTIALS)

> 90 Hope Drive, Building 6000

Mountain Home AFB, ID 83648

**READ INSTRUCTION ON ALL FORMS AND FOLLOW THEM. IF ANY PART OF THE
APPLICATION PACKAGE IS INCOMPLETE OR MISSING THE ENTIRE PACKAGE WILL BE
RETURNED FOR PROPER COMPLETION.**

a\. **Read, complete, and return the following:**

\-\-\--AF Form 1540, Application for Clinical Privileges

\-\-\--AF Form 1541, Credentials Continuing Health Education Training
Record

\-\-\--AF Form 1562, Credentials Evaluation of Health Care Practitioners

\-\-\--AF Form 28XX, Clinical Privileges -- (Specialty)

\-\-\--Release of Liability

\-\-\--Bylaws

\-\-\--Copy of Photo ID

b\. **AF Form 1540, Application for Clinical Privileges.** Complete
Section I through IX and sign. Element Chief and Flight Commander review
and complete the application and sign where indicated.

c\. **Privilege List.** Review and complete the privilege list for your
specialty by placing a \# **1, 2, or 4** in the requested column,
according to the instructions at the top of the form. **DO NOT** use
**"x's" or check marks!!!** Place your signature in the "Provider
Signature" space and obtain your clinical supervisor's recommendation
and signature.

d\. **AF Form 1562**. Sign and date each of the AF Forms 1562. These
will be sent to the individuals you list as references on your
application.

e\. **Provide copies** of the following documents if needed for your
credentials folder (any training certificates, licenses, etc. listed on
your application must be presented before privileges will be awarded):

\- MD, DO, DDS, DMD, CRNA, RN or other professional training
certificates.

\- Internship, residency, fellowship and all other specialty training
certificates.

> \- Copy of Board Certification
>
> **- ALL** current state licenses.

\- Current BLS and, if required for your specialty, ACLS/PALS/NRP/
certification.

\- DEA License

f\. **Return/Deliver** the application for privileges to RM E-131 or
mail to the address above.

# YOU MAY NOT SEE PATIENTS UNTIL CLINICAL PRIVILEGES HAVE BEEN APPROVED

**HELPFUL HINTS:**

(1) **The "service delivery" summary provides measures, but should
    either ask the offeror to describe the method of surveillance, or
    include the information in the PWS.**

(2) **There is no price or fee reduction strategy should the performance
    standards not be met. For this type of service, there may be many
    instances where the performance standard is 100 percent. The
    solicitation should be very clear on what actions the Government
    will take, should the standards not be met.**

(3) **The solicitation should either provide a quality assurance
    surveillance plan (QASP) or state that the Government will complete
    the QASP post-award.**