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Master Blanket Purchase Order ADCS16-119248

Header Information
Purchase Order Number: ADCS16-119248 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: $625.00
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~25.zip Signed HITECH HIPPA Form Signed Offer and Acceptance Florence Crittenton Svc of AZ_Award Letter Florence Crittenton Svc of AZ_Award Letter Flo Crit COI Exp 7012017.pdf Florence Crittenton - Amendment 1.docx Florence Crittenton - COI exp. 7-01-17.pdf Florence Crittenton - Professional License Renewal.pdf Florence Crittenton - Qualified Contractor Application (Revised).pdf Contract Amendment 2~39.zip Contract Amendment 3~72.zip
Vendor Attachments: ADCS16-00005689 Florence Crittenton Servcies of Arizona Program Narrative.pdf Attachment 01 ADCS Qualified Contractor Application.pdf Attachment 02 List of References.pdf Attachment 03 Licensure Certification Attestation.pdf Attachment 04 Professional License.pdf Designation of Confidential Trade Secret-Propriety Information.pdf HITECH Business Associate Agreement.pdf Independent Contractor Agreement.pdf Offer and Acceptance.pdf Sole Proprietor Waiver.pdf Therapist Licenses.pdf Arizona Substitute W-9 - Updated
Agency Attachment Forms:
Vendor Attachment Forms:
Primary Vendor Information & PO Terms
Vendor: 9000000519 - FLORENCE CRITTENTON SERVICES OF ARIZONA INC
Kellie Warren
715 W. Mariposa St.
Phoenix, AZ 85013
US
Email: kwarren@flocrit.org
Phone: (602)288-4543
FAX: (602)274-7549
Alt. Reference: Z0001
Payment Terms: Net 60 Shipping Method: Best Way
Shipping Terms: As Specified Freight Terms: Freight Prepaid
PO Acknowledgements:
Document Notifications Acknowledged Date/Time
Purchase Order Emailed to kwarren@flocrit.org at 01/05/2016 10:48:27 AM 01/05/2016 10:59:04 AM
Change Order 1 Emailed to kwarren@flocrit.org at 09/01/2016 09:41:38 AM 09/26/2016 04:36:50 PM
Change Order 2 Emailed to kwarren@flocrit.org at 12/28/2016 03:55:49 PM 01/31/2017 11:14:27 AM
Change Order 3 Emailed to kwarren@flocrit.org at 12/21/2017 09:50:31 AM 12/28/2017 01:40:02 PM
Change Order 4 Emailed to kwarren@flocrit.org at 10/11/2018 01:55:46 PM 11/27/2018 03:51:07 PM
Master Blanket/Contract Vendor Distributor List
Vendor ID Alternative ID Vendor Name Preferred Delivery Method Vendor Distributor Status
9000000519
PZ9000000519 FLORENCE CRITTENTON SERVICES OF ARIZONA 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   
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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 #:  000035885-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 # 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 #:  000035885-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 # 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 #:  000035885-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:
 
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 #:  000035885-R1 / 7
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $135.00 HR - Hour 0.00 $0.00 $0.00 $135.00
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 #:  000035885-R1 / 9
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $40.00 EA - Each 0.00 $0.00 $0.00 $40.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
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