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Master Blanket Purchase Order ADCS16-119242

Header Information
Purchase Order Number: ADCS16-119242 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: $1,235.00
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 Determination for MultiAgency Contracts for Psychiatric_Psychological_Counseling Services Counseling_Consultation Services RFP rev 10-21-15 Counseling RFP Exhibits and Forms~37.zip Signed HITECH HIPPA Form Signed Offer and Acceptance Mending Hearts_Award Letter Attachment 01_revised 1-7-16.pdf Mending Hearts - Amendment 1.docx Mending Hearts - Facility License Renewal.pdf Mending Hearts - Professional License Renewals.pdf Mending Hearts - Qualified Contractor Application Revised.doc Contract Amendment 2 Contract Amendment 3~76.zip
Vendor Attachments: BAFO Sole Proprietor Waiver.pdf BAFO State of Arizona Substitute W9.pdf BAFO Mending Hearts Family Services Offer and Acceptance~1.pdf BAFO Designation of Confidentiality~1.pdf BAFO Attachment 1 Mending Hearts Family Services~1.pdf.zmcygoz.partial BAFO Attachment 2 Mending Hearts Family Services List ofReferences~2.pdf BAFO Attachment 3 Licensure Attestation~1.pdf Attachment 2 Business Associate Agreement Mending Hearts Family Services ~1.pdf Sharon Carl License~1.pdf Ulises Gonzalez~1.pdf
Agency Attachment Forms:
Vendor Attachment Forms:
Primary Vendor Information & PO Terms
Vendor: 000035466 - Mending Hearts Family Services, Inc.
Sharon Carl
18301 N 79th Ave, Suite F-168
Glendale, AZ 85308
US
Email: scarl@mendingheartsfs.org
Phone: (602)633-2246
FAX: (602)687-7069
Alt. Reference: Z0002
Payment Terms: Shipping Method:
Shipping Terms: Freight Terms:
PO Acknowledgements:
Document Notifications Acknowledged Date/Time
Purchase Order Emailed to scarl@mendingheartsfs.org at 01/07/2016 09:23:37 AM 02/01/2016 02:24:44 PM
Change Order 1 Emailed to scarl@mendingheartsfs.org at 12/28/2016 03:58:09 PM 12/29/2016 01:09:44 PM
Change Order 2 Emailed to scarl@mendingheartsfs.org at 12/28/2017 02:58:06 PM 12/28/2017 05:25:58 PM
Change Order 3 Emailed to scarl@mendingheartsfs.org at 10/11/2018 11:18:31 AM 10/19/2018 03:32:51 PM
Master Blanket/Contract Vendor Distributor List
Vendor ID Alternative ID Vendor Name Preferred Delivery Method Vendor Distributor Status
000035466
PZ000035466 Mending Hearts Family Services, Inc. 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   
1-5 of 12
1 2  3 
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 #:  000035912-R1 / 1
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $85.00 HR - Hour 0.00 $0.00 $0.00 $85.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 2.0, Item # 2:   One (1) Hour Consultation - Rural 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 2 Quote # / Quote Item #:  000035912-R1 / 2
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $90.00 HR - Hour 0.00 $0.00 $0.00 $90.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 3.0, Item # 3:   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 #:  000035912-R1 / 3
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $85.00 HR - Hour 0.00 $0.00 $0.00 $85.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 4.0, Item # 4:   One (1) Hour Unit Consultation - Rural 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 4 Quote # / Quote Item #:  000035912-R1 / 4
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $90.00 EA - Each 0.00 $0.00 $0.00 $90.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 5.0, Item # 5:   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 #:  000035912-R1 / 5
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $85.00 HR - Hour 0.00 $0.00 $0.00 $85.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
1-5 of 12
1 2  3 
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