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Master Blanket Purchase Order ADCS16-119265

Header Information
Purchase Order Number: ADCS16-119265 Release Number: 0 Short Description: Counseling & Consultation Services
Status: 3PS - Sent Purchaser: Francine Whittington 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: $1,410.00
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~4.zip Signed HITECH HIPPA Form Signed Offer and Acceptance Intermountain Centers for Human Development_Award Letter Detemination_Mistakes_After_Award_Intermountain.pdf Intermountain COI Exp 9152016.pdf Intermountain - Amendment 1.docx Intermountain - Facility License Renewal.pdf Intermountain - Professional License Renewals.pdf Intermountain - Qualified Contractor Application (Revised).doc Intermountain COI exp. 1-01-17.pdf Contract Amendment 2 Contract Amendment 3~69.zip
Vendor Attachments: Attachment 01 ADCS Qualified Contractor Application Attachment 02 List of References Attachment 03 Licensure Certification Attestation Attachment 04 Professional License Offer and Acceptance Form Sole Proprietor Waiver Independent Contractor Agreement Designation of Confidential Trade Secret and Proprietary Information HITECH Business Associate Agreement
Agency Attachment Forms:
Vendor Attachment Forms:
Primary Vendor Information & PO Terms
Vendor: 9000011535 - INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT, INC.
David K. Giles
P.O. Box 17749
Tucson, AZ 85731-7749
US
Email: RLopez@ichd.net
Phone: (520)721-1887
FAX: (520)721-0069
Alt. Reference: Z0001
Payment Terms: Shipping Method:
Shipping Terms: Freight Terms:
PO Acknowledgements:
Document Notifications Acknowledged Date/Time
Purchase Order Emailed to davidg@ichd.net at 12/30/2015 12:07:04 PM 12/30/2015 12:55:45 PM
Change Order 1 Emailed to davidg@ichd.net at 01/08/2016 10:14:07 AM 02/25/2016 09:25:37 AM
Change Order 2 Emailed to RLopez@ichd.net at 08/08/2016 08:33:44 AM 08/08/2016 02:01:55 PM
Change Order 3 Emailed to RLopez@ichd.net at 12/21/2016 02:40:26 PM 12/27/2016 02:37:28 PM
Change Order 4 Emailed to RLopez@ichd.net at 12/28/2017 01:28:25 PM 12/29/2017 07:28:43 AM
Change Order 5 Emailed to RLopez@ichd.net at 10/04/2018 02:05:11 PM
Master Blanket/Contract Vendor Distributor List
Vendor ID Alternative ID Vendor Name Preferred Delivery Method Vendor Distributor Status
9000011535
PZ9000011535 INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT, 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 #:  000035856-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 #:  000035856-R1 / 2
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $95.00 HR - Hour 0.00 $0.00 $0.00 $95.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 3.0, Item # 9:   One (1) Hour Unit Consultation - Urban 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
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 # 10:   One (1) Hour Unit Consultation - Rural 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $95.00 HR - Hour 0.00 $0.00 $0.00 $95.00
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 #:  000035856-R1 / 5
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $80.00 HR - Hour 0.00 $0.00 $0.00 $80.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
1-5 of 12
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