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Master Blanket Purchase Order ADCS16-119236

Header Information
Purchase Order Number: ADCS16-119236 Release Number: 0 Short Description: Counseling & Consultation Services
Status: 3PS - Sent Purchaser: Delilah Gonzalez Receipt Method: Quantity
Fiscal Year: 2016 PO Type: Blanket Minor Status:
Organization: Arizona Department of Child Safety
Department: OP - Office of Procurement Location: OP - Contracts Type Code:
Alternate ID: Entered Date: 12/24/2015 09:22:07 AM Control Code:
Days ARO: 0 Retainage %: 0.00% Discount %: 0.00%
Print Dest Detail: If Different
Catalog ID: Release Type: Direct Release Pcard Enabled: No
Contact Instructions: Delilah Gonzalez at 602-255-2887 or Delilah.Gonzalez@azdcs.gov Tax Rate: Actual Cost: $811.09
Master Blanket/Contract End Date (Maximum): 12/31/2020 11:59:59 PM
Project No.:
Special Purchase Types:
PIJ NUMBER:
Commodity Reference Id:
PO External Doc Type:
Agency Attachments: 01 Pre-solicitation Documents.zip 02 Solicitation Documents.zip Counseling_Consultation Services RFP rev 10-21-15.pdf Exhibit 1 Limited English Proficiency Policy~29.pdf Exhibit A J.K. Principles~4.pdf Exhibit B Progress Report CSO-1139A~2.doc Exhibit C DCS Unit Consult Log and Verification of Client Services-Clinical-Cnslg~2.doc Exhibit D DCS Counseling Consultation Services Invoice~2.xlsx Exhibit E ADJC Verification of Juvenile Services-Clinical-Counseling~3.doc Exhibit F ADJC Service Providers Unusual-Significant Incident Report Protocol rev 10-23-15~2.pdf Exhibit G DCS Significant Incident Report CSO-1151A~2.doc Exhibit H Clinical Family Assessment rev 10-23-15~2.doc Exhibit I Quarterly Data Report~2.xlsx Exhibit M ADJC Program Evaluation~2.pdf Signed HITECH Business Associate Agreement~5.pdf Family Service Agency_Award Letter Signed Offer and Acceptance Family Service Agency COI Exp 8122016.pdf Family Service Agency - Amendment 1.docx Family Service Agency - Professional License Renewals.pdf Family Service Agency - COI exp. 1-01-17.pdf Family Service Agency - Qualified Contractor Application (Revised).pdf Contract Amendment 2~36.zip Contract Amendment 3~59.zip
Vendor Attachments: Attachment 01 - ADCS Qualified Contractor Application.pdf Attachment 02 - List of References.pdf Attachment 03 - Licensure-Certification Attestation.pdf Attachment 04 - Copy of Professional License.PDF Sole Proprietor Waiver.pdf Independent Contractor Agreement.pdf Designation of Confidential Trade Secret and Proprietary Information.pdf Offeror Licenses.pdf
Agency Attachment Forms:
Vendor Attachment Forms:
Primary Vendor Information & PO Terms
Vendor: 000006163 - FAMILY SERVICE AGENCY
Clarice Parham
2400 N. Central Avenue
Suite 101
Phoenix, AZ 85004
US
Email: clarice.parham@fsaphoenix.org
Phone: (602)264-9891
FAX: (602)234-2639
Alt. Reference: Z0002
Payment Terms: Shipping Method:
Shipping Terms: Freight Terms:
PO Acknowledgements:
Document Notifications Acknowledged Date/Time
Purchase Order Emailed to van.braswell@fsaphoenix.org at 12/25/2015 07:25:54 AM 01/21/2016 12:16:56 PM
Change Order 1 Emailed to van.braswell@fsaphoenix.org at 08/08/2016 07:47:09 AM 08/08/2016 10:41:46 AM
Change Order 2 Emailed to van.braswell@fsaphoenix.org at 12/23/2016 03:57:27 PM 12/27/2016 09:39:46 AM
Change Order 3 Emailed to cparham@fsaphoenix.org at 12/19/2017 09:55:54 AM 12/20/2017 11:08:01 AM
Change Order 4 Emailed to clarice.parham@fsaphoenix.org at 09/26/2018 03:21:56 PM 09/26/2018 03:59:25 PM
Master Blanket/Contract Vendor Distributor List
Vendor ID Alternative ID Vendor Name Preferred Delivery Method Vendor Distributor Status
000006163
PZ000006163 FAMILY SERVICE AGENCY Email Active
Master Blanket/Contract Controls
Master Blanket/Contract Begin Date: 01/01/2016 Master Blanket/Contract End Date: 12/31/2019
Cooperative Purchasing Allowed: Yes
Organization Department Dollar Limit Dollars Spent to Date Minimum Order Amount
ADCS - Arizona Department of Child Safety AGY - Agency Umbrella Master Control $0.00 $0.00 $0.00
ADES - Arizona Department of Economic Security AGY - Agency Umbrella Master Control $0.00 $0.00 $0.00
ADJC - Arizona Department of Juvenile Corrections AGY - Agency Umbrella Master Control $0.00 $0.00 $0.00
Item Information   
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Print Sequence # 1.0, Item # 1:   One (1) Hour Consultation - Urban 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 1 Quote # / Quote Item #:  000035872-R1 / 1
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $123.63 HR - Hour 0.00 $0.00 $0.00 $123.63
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 3.0, Item # 2:   One (1) Hour Unit Consultation - Urban 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 3 Quote # / Quote Item #:  000035872-R1 / 3
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $108.09 HR - Hour 0.00 $0.00 $0.00 $108.09
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 5.0, Item # 3:   One (1) Therapy Hour of Individual and/or Family Counseling: Office Setting - Urban 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 5 Quote # / Quote Item #:  000035872-R1 / 5
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $75.46 HR - Hour 0.00 $0.00 $0.00 $75.46
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 7.0, Item # 4:   One (1) Therapy Hour of Individual and/or Family Counseling: Home Based - Urban 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 7 Quote # / Quote Item #:  000035872-R1 / 7
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $88.68 HR - Hour 0.00 $0.00 $0.00 $88.68
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 9.0, Item # 5:   One (1) Group Counseling Session - Urban 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 9 Quote # / Quote Item #:  000035872-R1 / 9
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $93.21 EA - Each 0.00 $0.00 $0.00 $93.21
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
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