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Master Blanket Purchase Order ADCS16-119257

Header Information
Purchase Order Number: ADCS16-119257 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: $730.00
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~36.zip Signed HITECH HIPPA Form Signed Offer and Acceptance Our Family Services_Award Letter Our Family Services - Amendment 1.docx Our Family Services COI (GL) exp. 7-01-17.pdf Our Family Services - Professional License Renewal.pdf Our Family Services - Qualified Contractor Application Revised.doc Contract Amendment 2~35.zip Contract Amendment 3~80.zip
Vendor Attachments: Offer and Acceptance Attachment 01 ADCS Qualified Contractor Application Attachment 02 List of References Attachment 03 Licensure.Certification Attestation Attachment 04 Professional License Sole Proprietor Waiver Independent Contractor Agreement Arizona Substitute W-9 Designation of Confidential, Trade Secret and Proprietary Information HITECH Business Associate Agreement BAFO Attachment 04 Copy of Professional License.pdf
Agency Attachment Forms:
Vendor Attachment Forms:
Primary Vendor Information & PO Terms
Vendor: 9000005564 - OUR FAMILY SERVICES INC
Lana Baldwin
2590 n Alvernon Way
Tucson, AZ 85712
US
Email: bmorrison@ourfamilyservices.org
Phone: (520)323-1708 Ext. 413
FAX: (520)323-9077
Alt. Reference: Z0001
Payment Terms: Net 30 Shipping Method:
Shipping Terms: N/A Freight Terms:
PO Acknowledgements:
Document Notifications Acknowledged Date/Time
Purchase Order Emailed to pcaldwell@ourfamilyservices.org at 01/07/2016 08:45:30 AM 01/07/2016 12:38:49 PM
Change Order 1 Emailed to bmorrison@ourfamilyservices.org at 12/21/2016 03:35:15 PM 12/21/2016 04:09:12 PM
Change Order 2 Emailed to bmorrison@ourfamilyservices.org at 12/18/2017 03:55:31 PM 04/25/2018 11:26:06 AM
Change Order 3 Emailed to bmorrison@ourfamilyservices.org at 10/12/2018 03:58:32 PM
Master Blanket/Contract Vendor Distributor List
Vendor ID Alternative ID Vendor Name Preferred Delivery Method Vendor Distributor Status
9000005564
PZ9000005564 OUR 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   
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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 #:  000035884-R1 / 1
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $125.00 HR - Hour 0.00 $0.00 $0.00 $125.00
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 #:  000035884-R1 / 3
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $125.00 HR - Hour 0.00 $0.00 $0.00 $125.00
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 #:  000035884-R1 / 5
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 # 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 #:  000035884-R1 / 7
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $140.00 HR - Hour 0.00 $0.00 $0.00 $140.00
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 #:  000035884-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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