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Master Blanket Purchase Order ADCS16-119263

Header Information
Purchase Order Number: ADCS16-119263 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: $1,578.00
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~8.zip Signed HITECH HIPPA Form Signed Offer and Acceptance CindyTatum_Award Letter Cindy Tatum - Amendment 1.docx Cindy Tatum - COI exp. 2-17-17.pdf Cindy Tatum - Professional License Renewals.pdf Contract Amendment 2 Contract Amendment 3~68.zip
Vendor Attachments: 2.4.1 Offer and Acceptance Form.pdf 2.4.2 Attachment 01-ADCS Qualified Contractor Application.pdf 2.4.3 Attachment 02 List of References.pdf 2.4.4 Attachment 03 Licensure-Certification Attestation.pdf 2.4.5 Attachment 4-Copy of Professional License.pdf 2.4.7 Independent Contractor Agreement.pdf 2.4.9 Designation of Confidentiality and Trade Secrets (rev 10-2014).pdf 2.4.10 HITECH Business Associate Agreement.pdf BAFO 2.4.5 Attachment 4-Copy of Professional License.pdf
Agency Attachment Forms:
Vendor Attachment Forms:
Primary Vendor Information & PO Terms
Vendor: 9000010142 - CINDY L TATUM CMSW INC
Cindy Tatum-Shipley
17505 N. 79th. Ave. #G-311
Glendale, AZ 85308
US
Email: cltmsw@outlook.com
Phone: (623)876-2029
FAX: (602)428-7336
Alt. Reference: Z0401
Payment Terms: Shipping Method:
Shipping Terms: Freight Terms:
PO Acknowledgements:
Document Notifications Acknowledged Date/Time
Purchase Order Emailed to cltmsw@outlook.com at 12/30/2015 04:17:16 PM 12/31/2015 10:52:54 AM
Change Order 1 Emailed to cltmsw@outlook.com at 12/23/2016 09:08:27 AM 12/30/2016 08:22:02 AM
Change Order 2 Emailed to cltmsw@outlook.com at 12/29/2017 12:47:22 PM 12/29/2017 04:35:12 PM
Change Order 3 Emailed to cltmsw@outlook.com at 01/05/2018 02:07:05 PM 01/05/2018 03:09:22 PM
Change Order 4 Emailed to cltmsw@outlook.com at 10/04/2018 07:59:52 AM 10/23/2018 03:34:44 PM
Master Blanket/Contract Vendor Distributor List
Vendor ID Alternative ID Vendor Name Preferred Delivery Method Vendor Distributor Status
9000010142
PZ9000010142 CINDY L TATUM CMSW 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 #:  000035862-R1 / 1
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $110.00 HR - Hour 0.00 $0.00 $0.00 $110.00
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 #:  000035862-R1 / 2
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $120.00 HR - Hour 0.00 $0.00 $0.00 $120.00
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 #:  000035862-R1 / 3
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $123.00 HR - Hour 0.00 $0.00 $0.00 $123.00
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 #:  000035862-R1 / 4
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $120.00 EA - Each 0.00 $0.00 $0.00 $120.00
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 #:  000035862-R1 / 5
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $105.00 HR - Hour 0.00 $0.00 $0.00 $105.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
1-5 of 12
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