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Master Blanket Purchase Order ADCS16-119269

Header Information
Purchase Order Number: ADCS16-119269 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: $1,207.00
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~18.zip Signed HITECH HIPPA Form Signed Offer and Acceptance. Derek Todd Lofgreen_Award Letter Derek Lofgreen COI Exp 3092017.pdf Lofgreen Derek T License Exp 12312017.pdf Lofgreen Extension~2.docx Contract Amendment 2~33.zip Contract Amendment 3~56.zip
Vendor Attachments: Offer and Acceptance Attachment 01 DCS 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 & Proprietary Information HITECH Business Associate Agreement
Agency Attachment Forms:
Vendor Attachment Forms:
Primary Vendor Information & PO Terms
Vendor: 9000016674 - DEREK TODD LOFGREEN
Derek T. Lofgreen
207 N. Gilbert Rd. #005
Gilbert, AZ 85234
US
Email: dereklofgreen@gmail.com
Phone: (602)779-4325
FAX: (480)545-7320
Alt. Reference: Z0002
Payment Terms: Shipping Method:
Shipping Terms: Freight Terms:
PO Acknowledgements:
Document Notifications Acknowledged Date/Time
Purchase Order Emailed to dereklofgreen@gmail.com at 01/04/2016 01:29:25 PM 01/11/2016 07:33:19 AM
Change Order 1 Emailed to dereklofgreen@gmail.com at 09/01/2016 08:51:01 AM 09/02/2016 04:16:32 PM
Change Order 2 Emailed to dereklofgreen@gmail.com at 09/13/2016 12:04:49 PM 10/03/2016 09:16:31 AM
Change Order 3 Emailed to dereklofgreen@gmail.com at 12/20/2016 07:09:19 AM 01/09/2017 08:37:07 AM
Change Order 4 Emailed to dereklofgreen@gmail.com at 12/18/2017 02:15:19 PM 12/18/2017 02:57:31 PM
Change Order 5 Emailed to dereklofgreen@gmail.com at 09/24/2018 03:47:24 PM 10/01/2018 10:04:25 AM
Master Blanket/Contract Vendor Distributor List
Vendor ID Alternative ID Vendor Name Preferred Delivery Method Vendor Distributor Status
9000016674
PZ9000016674 DEREK TODD LOFGREEN 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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1 2 
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 #:  000035824-R1 / 1
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $100.00 HR - Hour 0.00 $0.00 $0.00 $100.00
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 #:  000035824-R1 / 2
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $100.00 HR - Hour 0.00 $0.00 $0.00 $100.00
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 #:  000035824-R1 / 3
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:
 
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 #:  000035824-R1 / 4
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $96.00 EA - Each 0.00 $0.00 $0.00 $96.00
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 #:  000035824-R1 / 5
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:
 
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