HARRIS COUNTY JOB NO.: 02/0288
BID COVER SHEET
Date Due: AUGUST 6, 2002
DUE NO LATER THAN 1:00 P.M.
Bids received later than the date and time
above will not be considered.
BID FOR: TERM CONTRACT TO PROVIDE PROSTHETIC, ORTHOTIC AND PEDORTHOTIC
DEVICES TO HARRIS COUNTY HOSPITAL DISTRICT (Beginning October 1, 2002 and ending
September 30, 2003)
OFFERORS NOTE!!
Carefully read all instructions, requirements and Please return bid in the envelope provided or in a
specifications. Fill out all forms properly and completely. comparable size envelope. ENVELOPE MUST SHOW
Submit your bid with all appropriate supplements and/or THE JOB NUMBER, DESCRIPTION AND BE
samples. MARKED “SEALED BID.”
RETURN BID TO:
HARRIS COUNTY PURCHASING AGENT
1001 PRESTON AVENUE, SUITE 670
HOUSTON, TEXAS 77002
For additional information, contact Laurie Wainwright @ 713-755-6597
You must sign below in INK; failure to sign WILL disqualify the offer. All prices must be typewritten or written in
ink.
Total Amount of Bid: $____________________________
Company Name: _________________________________________________________________________
Company Address: _________________________________________________________________________
City, State, Zip Code: _________________________________________________________________________
Taxpayer Identification Number (T.I.N.): __________________________________________________________
Telephone No. ___________________ FAX No.____________________ e-mail___________________________
Print Name: _________________________________________________________________________________
Signature: ___________________________________________________________________________________
[Your signature attests to your offer to provide the goods and/or services in this bid according to the published provisions of this Job.
When an award letter is issued, it becomes a part of this contract. Contract is not valid until Purchase Order is issued.]
Revised 03/02
Page 1 of 51
TABLE OF CONTENTS
Items checked below represent components which comprise this bid/proposal package. If the item IS NOT checked, it is NOT
APPLICABLE to this bid/proposal. Offerors are asked to review the package to be sure that all applicable parts are included. If any
portion of the package is missing, notify the Purchasing Department immediately.
It is the Offeror's responsibility to be thoroughly familiar with all Requirements and Specifications. Be sure you understand the
following before you return your bid packet.
__X__ 1. Cover Sheet
Your company name, address, the total amount of the bid/proposal, and your signature (IN INK) should appear on
this page.
__X__ 2. Table of Contents
This page is the Table of Contents.
__X__ 3. General Requirements
You should be familiar with all of the General Requirements.
__X__ 4. Special Requirements/Instructions
This section provides information you must know in order to make an offer properly.
__X__ 5. Specifications
This section contains the detailed description of the product/service sought by the County.
__X__ 6. Pricing/Delivery Information
This form is used to solicit exact pricing of goods/services and delivery costs.
__X__ 7. Attachments
__X__ a. Residence Certification
Be sure to complete this form and return with packet.
_____ b. Bid Guaranty & Performance Bond Information & Requirements
This form applies only to certain bids/proposals. Please read carefully and fill out completely.
_____ c. Bid Check Return Authorization Form
This form applies only to certain forms. Please read carefully and fill out completely.
_____ d. Vehicle Delivery Instructions
Included only when purchasing vehicles.
__X__ e. Minimum Insurance Requirements
Included when applicable (does not supersede "Hold Harmless" section of General
Requirements).
__X__ f. Workers' Compensation Insurance Coverage Rule 110.110
This requirement is applicable for a building or construction contract.
_____ g. Financial Statement
When this information is required, you must use this form.
_____ h. Reference Sheet
_____ i. Other
From time to time other attachments may be included.
Revised 09/00
Page 2 of 51
GENERAL REQUIREMENTS
FOR BIDS
READ THIS ENTIRE DOCUMENT CAREFULLY. FOLLOW ALL INSTRUCTIONS. YOU ARE RESPONSIBLE FOR
FULFILLING ALL REQUIREMENTS AND SPECIFICATIONS. BE SURE YOU UNDERSTAND THEM.
General Requirements apply to all advertised bids; however, these may be superseded, whole or in part, by the SPECIAL
REQUIREMENTS/INSTRUCTIONS OR OTHER DATA CONTAINED HEREIN. Review the Table of Contents. Be sure your bid
package is complete.
GOVERNING LAW
This invitation to bid is governed by the competitive bidding requirements of the County Purchasing Act, Texas Local Government Code,
§262.021 et seq., as amended. Offerors shall comply with all applicable federal, state and local laws and regulations. Offeror is further advised
that these requirements shall be fully governed by the laws of the State of Texas and that Harris County may request and rely on advice,
decisions and opinions of the Attorney General of Texas and the County Attorney concerning any portion of these requirements.
POTENTIAL CONFLICTS OF INTEREST
An outside consultant or contractor is prohibited from submitting a bid or proposal for services on a Harris County project of which the
consultant or contractor was a designer or other previous contributor, or was an affiliate, subsidiary, joint venturer or was in any other
manner associated by ownership to any party that was a designer or other previous contributor. If such a consultant or contractor submits a
prohibited bid or proposal, that bid or proposal shall be disqualified on the basis of conflict of interest, no matter when the conflict is
discovered by Harris County.
BID FORM COMPLETION
Fill out and return to the Harris County Purchasing Department ONE (1) complete bid form, using the envelope provided or in a
comparable size envelope. ENVELOPE MUST SHOW THE JOB NUMBER, DESCRIPTION AND BE MARKED “SEALED
BID.” An authorized representative of the offeror should sign the Cover Sheet. The contract will be binding only when signed by Harris
County, funds are certified by the County Auditor and or the Hospital District, as applicable, and a Purchase Order issued.
BID RETURNS
Offerors must return all completed bids to the Harris County Purchasing Department reception desk at 1001 Preston Avenue, Suite 670,
Houston, Texas before 1:00 P.M. on the date specified. Late bids will not be accepted.
GOVERNING FORMS
In the event of any conflict between the terms and provisions of these requirements and the specifications, the specifications shall govern.
In the event of any conflict of interpretation of any part of this overall document, Harris County's interpretation shall govern.
ADDENDA
When specifications are revised, the Harris County Purchasing Department will issue an addendum addressing the nature of the change.
Offerors must sign and include it in the returned bid package.
HOLD HARMLESS AGREEMENT
Contractor, the successful offeror, shall indemnify and hold Harris County harmless from all claims for personal injury, death and/or
property damage resulting directly or indirectly from contractor's performance. Contractor shall procure and maintain, with respect to the
subject matter of this bid, appropriate insurance coverage including, as a minimum, public liability and property damage with adequate
limits to cover contractor's liability as may arise directly or indirectly from work performed under terms of this bid. Certification of such
coverage must be provided to the County upon request.
WAIVER OF SUBROGATION
Offeror and offeror's insurance carrier waive any and all rights whatsoever with regard to subrogation against Harris County as an indirect
party to any suit arising out of personal or property damages resulting from offeror's performance under this agreement.
SEVERABILITY
If any section, subsection, paragraph, sentence, clause, phrase or word of these requirements or the specifications shall be held invalid,
such holding shall not affect the remaining portions of these requirements and the specifications and it is hereby declared that such
remaining portions would have been included in these requirements and the specifications as though the invalid portion had been omitted.
BONDS
If this bid requires submission of bid guarantee and performance bond, there will be a separate page explaining those requirements. Bids
submitted without the required bid bond or cashier's check are not acceptable.
TAXES
Harris County is exempt from all federal excise, state and local taxes unless otherwise stated in this document. Harris County claims
exemption from all sales and/or use taxes under Texas Tax Code §151.309, as amended. Texas Limited Sales Tax Exemption Certificates
will be furnished upon written request to the Harris County Purchasing Agent.
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FISCAL FUNDING
A multi-year lease or lease/purchase arrangement (if requested by the Special Requirements/Instructions), or any contract continuing as a
result of an extension option, must include fiscal funding out. If, for any reason, funds are not appropriated to continue the lease or
contract, said lease or contract shall become null and void on the last day of the current appropriation of funds. After expiration of the
lease, leased equipment shall be removed by the offeror from the using department without penalty of any kind or form to Harris County.
All charges and physical activity related to delivery, installation, removal and redelivery shall be the responsibility of the offeror.
PRICING
Prices for all goods and/or services shall be firm for the duration of this contract and shall be stated on the Pricing/Delivery Information
form. Prices shall be all inclusive: No price changes, additions, or subsequent qualifications will be honored during the course of
the contract. All prices must be written in ink or typewritten. Pricing on all transportation, freight, drayage and other charges are to be
prepaid by the contractor and included in the bid prices. If there are any additional charges of any kind, other than those mentioned above,
specified or unspecified, offeror MUST indicate the items required and attendant costs or forfeit the right to payment for such items. Where
unit pricing and extended pricing differ, unit pricing prevails.
SILENCE OF SPECIFICATIONS
The apparent silence of specifications as to any detail, or the apparent omission from it of a detailed description concerning any point, shall
be regarded as meaning that only the best commercial practice is to prevail and that only material and workmanship of the finest quality are
to be used. All interpretations of specifications shall be made on the basis of this statement. The items furnished under this contract shall
be new, unused of the latest product in production to commercial trade and shall be of the highest quality as to materials used and
workmanship. Manufacturer furnishing these items shall be experienced in design and construction of such items and shall be an
established supplier of the item bid.
SUPPLEMENTAL MATERIALS
Offerors are responsible for including all pertinent product data in the returned bid package. Literature, brochures, data sheets,
specification information, completed forms requested as part of the bid package and any other facts which may affect the evaluation and
subsequent contract award should be included. Materials such as legal documents and contractual agreements, which the offeror wishes to
include as a condition of the bid, must also be in the returned bid package. Failure to include all necessary and proper supplemental
materials may be cause to reject the entire bid.
MATERIAL SAFETY DATA SHEETS
Under the "Hazardous Communication Act", commonly known as the "Texas Right To Know Act", an offeror must provide to the County
with each delivery, material safety data sheets which are applicable to hazardous substances defined in the Act. Failure of the offeror to
furnish this documentation will be cause to reject any bid applying thereto.
NAME BRANDS
Specifications may reference name brands and model numbers. It is not the intent of Harris County to restrict these bids in such cases, but
to establish a desired quality level of merchandise or to meet a pre-established standard due to like existing items. Offerors may offer items
of equal stature and the burden of proof of such stature rests with offerors. Harris County shall act as sole judge in determining equality
and acceptability of products offered.
COLOR SELECTION
Determination of colors of materials is a right reserved by the using department unless otherwise specified in the bid. Unspecified colors
shall be quoted as standard colors, NOT colors which require upcharges or special handling. Unspecified fabrics or vinyls should be
construed as medium grade. If offeror fails to get color/material approvals prior to delivery of merchandise, the using department may
refuse to accept the items and demand correct shipment without penalty, subject to other legal remedies.
EVALUATION
Evaluation shall be used as a determinant as to which bid items or services are the most efficient and/or most economical for the County. It
shall be based on all factors which have a bearing on price and performance of the items in the user environment. All bids are subject to
tabulation by the Harris County Purchasing Department and recommendation to Harris County Commissioners Court. Compliance with all
bid requirements, delivery and needs of the using department are considerations in evaluating bids. Pricing is NOT the only criteria for
making a recommendation. The Harris County Purchasing Department reserves the right to contact any offeror, at any time, to clarify,
verify or request information with regard to any bid.
INSPECTIONS
Harris County reserves the right to inspect any item(s) or service location for compliance with specifications and requirements and needs of
the using department. If an offeror cannot furnish a sample of a bid item, where applicable, for review, or fails to satisfactorily show an
ability to perform, the County can reject the bid as inadequate.
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TESTING
Harris County reserves the right to test equipment, supplies, material and goods bid for quality, compliance with specifications and ability
to meet the needs of the user. Demonstration units must be available for review. Should the goods or services fail to meet requirements
and/or be unavailable for evaluation, the bid is subject to rejection.
DISQUALIFICATION OF OFFEROR
Upon signing this bid document, an offeror offering to sell supplies, materials, services, or equipment to Harris County certifies that the
offeror has not violated the antitrust laws of this state codified in Texas Business and Commerce Code §15.01, et seq., as amended, or the
federal antitrust laws, and has not communicated directly or indirectly the bid made to any competitor or any other person engaged in such
line of business. Any or all bids may be rejected if the County believes that collusion exists among the offerors. Bids in which the prices
are obviously unbalanced may be rejected. If multiple bids are submitted by a offeror and after the bids are opened, one of the bids is
withdrawn, the result will be that all of the bids submitted by that offeror will be withdrawn; however, nothing herein prohibits a vendor
from submitting multiple bids for different products or services.
AWARD
Harris County reserves the right to award this contract on the basis of LOWEST AND BEST BID in accordance with the laws of the State
of Texas, to waive any formality or irregularity, to make awards to more than one offeror, to reject any or all bids. In the event the lowest
dollar offeror meeting specifications is not awarded a contract, the offeror may appear before the Commissioners Court or Hospital District
Board of Managers, as applicable, and present evidence concerning his responsibility after officially notifying the Office of the Purchasing
Agent of his intent to appear.
ASSIGNMENT
The successful offeror may not assign, sell or otherwise transfer this contract without written permission of Harris County Commissioners
Court.
TERM CONTRACTS
If the contract is intended to cover a specific time period, the term will be given in the specifications under SCOPE.
MAINTENANCE
Maintenance required for equipment bid should be available in Harris County by a manufacturer-authorized maintenance facility. Costs
for this service shall be shown on the Pricing/Delivery Information form. If Harris County opts to include maintenance, it shall be so stated
in the purchase order and said cost will be included. Service will commence only upon expiration of applicable warranties and should be
priced accordingly.
CONTRACT OBLIGATION
Harris County Commissioners Court must award the contract and the County Judge or other person authorized by the Harris County
Commissioners Court must sign the contract before it becomes binding on Harris County or the offerors. Department heads are NOT
authorized to sign agreements for Harris County. Binding agreements shall remain in effect until all products and/or services covered by
this purchase have been satisfactorily delivered and accepted.
TITLE TRANSFER
Title and Risk of Loss of goods shall not pass to Harris County until Harris County actually receives and takes possession of the goods at
the point or points of delivery. Receiving times may vary with the using department. Generally, deliveries may be made between 8:30 a.m.
and 4:00 p.m., Monday through Friday. Offerors are advised to consult the using department for instructions. The place of delivery shall
be shown under the "Special Requirements/Instructions" section of this bid package and/or on the Purchase Order as a "Deliver To:"
address.
WARRANTIES
Offerors shall furnish all data pertinent to warranties or guarantees which may apply to items in the bid. Offerors may not limit or exclude
any implied warranties. Offeror warrants that product sold to the County shall conform to the standards established by the U.S.
Department of Labor under the Occupational Safety and Health Act of 1970. In the event product does not conform to OSHA Standards,
where applicable, Harris County may return the product for correction or replacement at the offeror's expense. If offeror fails to make the
appropriate correction within a reasonable time, Harris County may correct at the offeror's expense.
PURCHASE ORDER AND DELIVERY
The successful offeror shall not deliver products or provide services without a Harris County Purchase Order, signed by an authorized
agent of the Harris County Purchasing Department. The fastest, most reasonable delivery time shall be indicated by the offeror in the
proper place on the Pricing/Delivery Information form. Any special information concerning delivery should also be included, on a separate
sheet, if necessary. All items shall be shipped F.O.B. INSIDE DELIVERY unless otherwise stated in the specifications. This
Page 5 of 51
shall be understood to include bringing merchandise to the appropriate room or place designated by the using department. Every tender or
delivery of goods must fully comply with all provisions of these requirements and the specifications including time, delivery and quality.
Nonconformance shall constitute a breach which must be rectified prior to expiration of the time for performance. Failure to rectify within
the performance period will be considered cause to reject future deliveries and cancellation of the contract by Harris County without
prejudice to other remedies provided by law. Where delivery times are critical, Harris County reserves the right to award
accordingly.
CONTRACT RENEWALS
Renewals may be made ONLY by written agreement between Harris County and the offeror. Any price escalations are limited to those
stated by the offeror in the original bid.
INVOICES AND PAYMENTS
Offerors shall submit an original invoice on each purchase order or purchase release after each delivery, indicating the purchase order
number. Invoices must be itemized. Any invoice which cannot be verified by the contract price and/or is otherwise incorrect, will be
returned to the offeror for correction. Under term contracts, when multiple deliveries and/or services are required, the offeror may invoice
following each delivery and the County will pay on invoice. Contracts providing for a monthly charge will be billed and paid on a monthly
basis only. Prior to any and all payments made for good and/or services provided under this contract, the offeror should provide his
Taxpayer Identification Number or social security number as applicable. This information must be on file with the Harris County Auditor’s
office. Failure to provide this information may result in a delay in payment and/or back-up withholding as required by the Internal Revenue
Service.
TERMINATION
Harris County reserves the right to terminate the contract for default if offeror breaches any of the terms therein, including warranties of
offeror or if the offeror becomes insolvent or commits acts of bankruptcy. Such right of termination is in addition to and not in lieu of any
other remedies which Harris County may have in law or equity. Default may be construed as, but not limited to, failure to deliver the
proper goods and/or services within the proper amount of time, and/or to properly perform any and all services required to Harris County's
satisfaction and/or to meet all other obligations and requirements. Harris County may terminate the contract without cause upon thirty (30)
days written notice.
RECYCLED MATERIALS
Harris County encourages the use of products made of recycled materials and shall give preference in purchasing to products made of
recycled materials if the products meet applicable specifications as to quantity and quality. Harris County will be the sole judge in
determining product preference application.
SCANNED OR RE-TYPED RESPONSE
If in its bid response, offeror either electronically scans, re-types, or in some way reproduces the County's published bid package, then in
event of any conflict between the terms and provisions of the County's published bid specifications, or any portion thereof, and the terms
and provisions of the bid response made by offeror, the County's bid specifications as published shall control. Furthermore, if an alteration
of any kind to the County's published bid specifications is only discovered after the contract is executed and is or is not being performed,
the contract is subject to immediate cancellation.
FLOPPY DISK
If offeror obtained the bid specifications on a floppy disk in order to prepare a response, the bid must be submitted in hard copy according
to the instructions contained in this bid package. If, in its bid response, offeror makes any changes whatsoever to the County's published
bid specifications, the County's bid specifications as published shall control. Furthermore, if an alteration of any kind to the County's
published bid specifications is only discovered after the contract is executed and is or is not being performed, the contract is subject to
immediate cancellation.
E-MAIL ADDRESSES CONSENT
Vendor affirmatively consents to the disclosure of its e-mail addresses that are provided to Harris County, the Harris County Flood
Control District, the Harris County Hospital District including its HMO, the Harris County Appraisal District, or any agency of Harris
County. This consent is intended to comply with the requirements of the Texas Public Information Act, Tex. Gov’t Code Ann. §522.137,
as amended, and shall survive termination of this agreement. This consent shall apply to e-mail addresses provided by Vendor, its
employees, officers, and agents acting on Vendor’s behalf and shall apply to any e-mail address provided in any form for any reason
whether related to this bid/proposal or otherwise.
Revised 03/20/02
Page 6 of 51
SPECIAL REQUIREMENTS/INSTRUCTIONS
Where these specific requirements differ from the preceding General Requirements, these specific
requirements shall control. The term "Harris County" is understood to include the Harris County Hospital
District.
BID RETURN
A bid may be considered incomplete and unacceptable unless it contains all the following:
1. a completed residency certification;
2. appropriate bid sheet/pricing data including, but not limited to, description, unit price, packaging,
renewal verification;
3. detailed specification data for goods supplies and/or detailed performance data for services to be
rendered.
4. copies of certification for the contractor, Prothetist, Orthotist and Pedorthotist
EVALUATION AND AWARD
All offers must be firm for a minimum of ninety (90) days after bid opening date. Bids will be evaluated
to determine the best, most efficient offer for the District. Vendors with warehousing and/or distribution
facilities in Houston, Harris County, Texas will be preferred. Evaluation will include, but not be limited
to, bidder capability to perform, bidder qualifications, costs, references, stability, location, personnel,
servicing of like entities and health care facilities and response time. Any and all exceptions to this
package must be noted in the bid return.
Award will be made to the lowest and best bid as determined by the bid document and subsequent
evaluation. The District anticipates awarding on an "All or None Basis" or as in its best interest. "Best
bid" shall be interpreted as that which best supports the overall needs of the project and end users in
consideration of all appropriate factors which impact cost and performance.
All requirements, standards, terms and conditions contained in this package will be incorporated into the
body of contracts issued pursuant to this request.
BIDDER QUALIFICATIONS
In an effort to ensure vendor reliability, the following qualifications must be met by the bidder receiving
award of any part or all of this contract. Contractor must:
1) be, and have been, in business for no less than one full year, under its current form (i.e.
corporation, proprietorship, etc.);
2) be able to met all federal, state and local requirements as may be appropriate for this type product
and/or services.
3) be certified by the American Board for Certification in orthotics and prosthetics. The prosthetist,
orthotist and pedorthotist must be certified and have appropriate credentials. Awarded vendor
must maintain appropriate licensing and certifications throughout the term of the contract.
4) comply with Hospital District's proof of delivery and invoicing policies;
5) provide proof of financial stability if requested;
6) provide references on request.
Page 7 of 51
SPECIAL REQUIREMENTS/INSTRUCTIONS - (Continued)
NONPERFORMANCE BY CONTRACTOR
Contractor may be placed on probation, canceled or terminated, by the District, for either or both of the
following:
1) failure to meet and maintain minimum quality or performance standards set forth in this document
and/or any subsequent documents related to this contract;
2) failure to cure any deficiencies found as a result of tests or other analysis or performance of
product or services.
Probation shall be for a one (1) month period during which complete remedy is required. Failure to
rectify within that time will result in cancellation or termination. Under conditions of probation,
cancellation or termination, vendor will not be entitled to damages or compensation beyond payment for
goods and/or services already rendered through the end of the probation period and the District shall not
suffer any penalties or liquidated damages as a result of this action.
ESTIMATES
Estimates of dollar amounts are based on current information available. The District reserves the right to
purchase more or less of any product at the bid price.
DELIVERY
Delivery shall be made on an as needed basis, by request only, and only when person(s) authorized to
make such requests on behalf of the District place the order. Order placement must be accompanied by
the purchase order number.
In the event contractor fails to deliver articles within the time specified by the contractor in their bid, the
purchasing agent reserves the right to authorize purchases of these products and/or services on the open
market. In such event, contractor agrees to reimburse the District for the extra cost incurred by it or
provide a credit memorandum to cover the costs so that said amount may be deducted from invoices
extant.
PRICING, INVOICING AND PAYMENTS
Bids containing unknown or estimated cost components cannot be evaluated and may be rejected without
further consideration. In case of handwritten bids, the right is reserved to interpret the amount bid, as
written, or reject any item or portion of the bid as illegible.
Correct purchase order numbers must be noted on each invoice for goods and/or services. All goods
and/or services shall be F.O.B. inside delivery and be all-inclusive. "All-inclusive" shall be construed as
costs incorporating all charges for personnel, travel and any other cost incurred to product the desired
results. No separate line item charges for these will be accepted.
Each invoice should be adequately detailed to identify which types and styles of products were delivered,
delivery location, cost of each item and purchase order. Send invoices to Harris County Hospital
District, Accounts Payable Department, P.O. Box 66769, Houston, Texas 77266.
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SPECIFICATIONS
PROVIDE PROSTHETIC, ORTHOTIC AND PEDORTHOTIC DEVICES TO HARRIS
COUNTY HOSPITAL DISTRICT
SCOPE
It is the intent of this specification to secure pricing and availability of Prosthetic, Orthotic and
Pedorthotic Devices for Harris County Hospital District. The contract will be for a twelve (12) month
period beginning approximately October 1, 2002 and ending on September 30, 2003 or until all goods
and/or services ordered prior to the expiration date have been satisfactorily delivered and accepted by the
using department. If you need technical information contact Carol Oddo at (713) 873-3840, for any
additional information contact Laurie Wainwright at (713) 755-6597.
RENEWAL OPTION
The District wishes to consider renewal options for two (2) additional years, renewed one year at a time,
under the same terms, conditions and pricing as the original year. The District may consider justified cost
increases which do not exceed the Medical Consumers Price Index. Once renewals are exhausted, the
contract must be re-bid. If bidder does not wish to renew, mark "N/A" in the space provided on the bid
sheet. The County retains the option to re-bid at any time as is in its best interest and is not
automatically bound to renewal.
HIPAA REQUIREMENTS
Offerors will adhere to any Health Insurance Portability Accountability Act (HIPAA) requirements in the
curse of working with detailed District information.
SPECIFICATIONS
The vendor will furnish the devices listed herein in accordance with these specifications and on an as
needed basis. The following services must be provided and costs for them are to be included in the
pricing for the devices.
Group I - Prosthetic Devices
1. All hardware must be guaranteed against mechanical defects for a period of at least six
months following delivery except in cases of inappropriate use or abuse.
2. Fitting problems occurring within a period of thirty days after delivery will be resolved
without charge provided the patients physical condition and limb measurements remain
essentially unchanged.
3. A Certified Prosthetist must be available on a bi-weekly basis for clinic consultation and
on an as needed basis for in-patients.
4. Vendor must accept Medicare assignments on new devices as well as repairs.
Groups II and III - Orthotic Devices
1. All hardware must be guaranteed against mechanical defects for a period of at least six
months following delivery except in cases of inappropriate use or abuse.
2. Fitting problems occurring within a period of thirty days after delivery will be resolved
without charge provided the patients physical condition and limb measurements remain
essentially unchanged.
Page 9 of 51
SPECIFICATIONS-Continued
3. A Certified Orthotist must be available on a bi-weekly basis for clinic consultation and on
an as needed basis for in-patients.
4. Vendor must accept Medicare assignments on new devices as well as repairs.
Group IV - Pedorthotic Devices
1. Fitting problems occurring within a period of thirty days after delivery will be resolved
without charge provided the patients physical condition and limb measurements remain
essentially unchanged.
2. A Pedorthotist must be available on a bi-weekly basis for clinic consultation and on an as
needed basis for in-patients.
Page 10 of 51
PRICING/DELIVERY INFORMATION
RENEWAL OPTION
Vendor agrees to renew this contract for additional time under the same terms, conditions and pricing as
the original year. (See Renewal Option, page 11)
Renewal Year 2003-2004: _________
Renewal Year 2004-2005: _________
Page 11 of 51
PRICING/DELIVERY INFORMATION – (Continued)
GROUP I
PROSTHETIC PROCEDURES
TAKEN FROM HCFA COMMON PROCEDURE CODING SYSTEM
LOWER LIMB - L5
The procedures in this section are considered as "base" or "basic" procedures, and may be modified by listing
items/procedures or special materials from the "additions" section, and adding them to the base procedure.
PROCEDURE DESCRIPTION PRICE
CODE
LOWER LIMB - PARTIAL FOOT - L5000 - L5049
1. L5000 PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL
ARCH, TOE FILLER $_________________
2. L5010 PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT,
WITH TOE FILLER $_________________
3. L5020 PARTIAL FOOT, MOLDED SOCKET, TIBIAL
TUBERCLE HEIGHT, WITH TOE FILLER $_________________
LOWER LIMB ANKLE - L5050 L5099
4. L5050 ANKLE, SYMES, MOLDED SOCKET, SACH FOOT $_________________
5. L5060 ANKLE, SYMES, METAL FRAME, MOLDED
LEATHER SOCKET, ARTICULATED ANKLE/FOOT $_________________
LOWER LIMB BELOW KNEE - L5100 - L5149
6. L5100 BELOW KNEE, MOLDED SOCKET, SHIN,
SACH FOOT $_________________
Page 12 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
LOWER LIMB KNEE DISARTICULATION - L5150 L5199
7. L5150 KNEE DISARTICULATION (OR THROUGH KNEE),
MOLDED SOCKET, EXTERNAL KNEE JOINTS,
SHIN, SACH FOOT $_________________
8. L5160 KNEE DISARTICULATION (OR THROUGH KNEE),
MOLDED SOCKET, BENT KNEE CONFIGURATION,
EXTERNAL KNEE JOINTS, SHIN, SACH FOOT $_________________
LOWER LIMB ABOVE KNEE - L5200 - L5249
9. L5200 ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS
CONSTANT FRICTION KNEE, SHIN, SACH FOOT $_________________
10. L5210 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE
JOINT ("STUBBIES"), WITH FOOT BLOCKS, NO
ANKLE JOINTS, EACH $_________________
11. L5220 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE
JOINT ("STUBBIES"), WITH ARTICULATED
ANKLE/FOOT, DYNAMICALLY ALIGNED, EACH $_________________
12. L5230 ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL
DEFICIENCY, CONSTANT FRICTION KNEE SHIN
SACH FOOT $_________________
LOWER LIMB HIP DISARTICULATION L5250 L5279
13. L5250 HIP DISARTICULATION, CANADIAN TYPE,
MOLDED SOCKET, HIP JOINT, SINGLE AXIS
CONSTANT FRICTION KNEE, SHIN, SACH FOOT $_________________
14. L5270 HIP DISARTICULATION, TILT TABLE TYPE,
MOLDED SOCKET, LOCKING HIP JOINT, SINGLE
AXIS CONSTANT FRICTION KNEE, SHIN, SACH
FOOT $_________________
Page 13 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
LOWER LIMB HEMIPELVECTOMY L5280 L5299
15. L5280 HEMIPELVECTOMY, CANADIAN TYPE, MOLDED
SOCKET, HIP JOINT, SINGLE AXIS CONSTANT
FRICTION KNEE, SHIN, SACH FOOT $_________________
LOWER LIMB ENDOSKELETAL BELOW KNEE L5300 L5309
16. L5300 BELOW KNEE, MOLDED SOCKET, SACH FOOT,
ENDOSKELETAL SYSTEM, INCLUDING SOFT
COVER AND FINISHING $_________________
LOWER LIMB ENDOSKELETAL KNEE DISARTICULATION - L5310 L5319
17. L5310 KNEE DISARTICULATION (OR THROUGH KNEE),
MOLDED SOCKET, SACH FOOT, ENDOSKELETAL
SYSTEM, INCLUDING SOFT COVER & FINISHING $_________________
LOWER LIMB ENDOSKELETAL ABOVE KNEE - L5320 L5329
18. L5320 ABOVE KNEE, MOLDED SOCKET, OPEN END,
SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE
AXIS KNEE, INCLUDING SOFT COVER & FINISHING $_________________
LOWER LIMB ENDOSKELETAL HIP DISARTICULATION -
L5330 L5339
19. L5330 HIP DISARTICULATION, CANADIAN TYPE,
MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP
JOINT SINGLE AXIS KNEE, SACH FOOT, INCLUDING
SOFT COVER AND FINISHING $_________________
Page 14 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
LOWER LIMB - ENDOSKELETAL HEMIPELVECTOMY -
L5340 L5349
20. L5340 HEMIPELVECTOMY, CANADIAN TYPE, MOLDED
SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT,
SINGLE AXIS KNEE, SACH FOOT, INCLUDING SOFT
COVER AND FINISHING $_________________
IMMEDIATE EARLY - INITIAL - PREPARATORY PROCEDURES -
L5400 L5999
IMMEDIATE POST SURGICAL OR EARLY FITTING
PROCEDURES - L5400 L5499
21. L5400 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF INITIAL RIGID DRESSING,
INCLUDING FITTING, ALIGNMENT, SUSPENSION
AND ONE CAST CHANGE, BELOW KNEE $_________________
22. L5410 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF INITIAL RIGID DRESSING,
INCLUDING FITTING, ALIGNMENT AND SUSPEN-
SION, BELOW KNEE, EACH ADDITIONAL CAST
CHANGE AND REALIGNMENT $_________________
23. L5420 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF INITIAL RIGID DRESSING,
INCLUDING FITTING, ALIGNMENT AND SUSPEN-
SION AND ONE CAST CHANGE, "AK" OR KNEE
DISARTICULATION $_________________
24. L5430 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF INITIAL RIGID DRESSING,
INCLUDING FITTING, ALIGNMENT AND SUSPEN-
SION, "AK" OR KNEE DISARTICULATION, EACH
ADDITIONAL CAST CHANGE AND REALIGNMENT $_________________
Page 15 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
25. L5450 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF NON WEIGHT BEARING RIGID
DRESSING, BELOW KNEE $_________________
26. L5460 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF NON WEIGHT BEARING RIGID
DRESSING, ABOVE KNEE $_________________
INITIAL PROSTHESIS - L5500 - 5509
27. L5500 INITIAL, BELOW KNEE "PTB" TYPE SOCKET,
"USMC" OR EQUAL PYLON, NO COVER, SACH
FOOT, PLASTER SOCKET, DIRECT FORMED $_________________
28. L5505 INITIAL, ABOVE KNEE KNEE DISARTICULATION,
ISCHIAL LEVEL SOCKET, "USMC" OR EQUAL
PYLON, NO COVER, SACH FOOT, PLASTER SOCKET,
DIRECT FORMED $_________________
PREPARATORY PROSTHESIS L5510 L5599
29. L5510 PREPARATORY, BELOW KNEE "PTB" TYPE SOCKET,
"USMC" OR EQUAL PYLON, NO COVER, SACH FOOT
PLASTER SOCKET, MOLDED TO MODEL $_________________
30. L5520 PREPARATORY, BELOW KNEE "PTB" TYPE SOCKET,
"USMC" OR EQUAL PYLON, NO COVER, SACH FOOT
THERMOPLASTIC OR EQUAL, DIRECT FORMED $_________________
31. L5530 PREPARATORY, BELOW KNEE "PTB" TYPE SOCKET,
"USMC" OR EQUAL PYLON, NO COVER, SACH FOOT
THERMOPLASTIC OR EQUAL, MOLDED TO
MODEL $_________________
32. L5540 PREPARATORY, BELOW KNEE "PTB" TYPE SOCKET,
"USMC" OR EQUAL PYLON, NO COVER, SACH FOOT
LAMINATED SOCKET, MOLDED TO MODEL $_________________
Page 16 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
33. L5560 PREPARATORY, ABOVE KNEE-KNEE DISARTICU-
LATION, ISCHIAL LEVEL SOCKET, "USMC" OR
EQUAL PYLON, NO COVER, SACH FOOT, PLASTER
SOCKET, MOLDED TO MODEL $_________________
34. L5570 PREPARATORY, ABOVE KNEE-KNEE DISARTICU-
LATION, ISCHIAL LEVEL SOCKET, "USMC" OR
EQUAL PYLON, NO COVER, SACH FOOT, THERMO-
PLASTIC OR EQUAL, DIRECT FORMED $_________________
35. L5580 PREPARATORY, ABOVE KNEE-KNEE DISARTICU-
LATION, ISCHIAL LEVEL SOCKET, "USMC" OR
EQUAL PYLON, NO COVER, SACH FOOT, THERMO-
PLASTIC OR EQUAL, MOLDED TO MODEL $_________________
36. L5585 PREPARATORY, ABOVE KNEE-KNEE DISARTICU-
LATION, ISCHIAL LEVEL SOCKET, "USMC" OR
EQUAL PYLON, NO COVER, SACH FOOT, PREFABRI-
CATED ADJUSTABLE OPEN END SOCKET $_________________
37. L5590 PREPARATORY, ABOVE KNEE-KNEE DISARTICU-
LATION, ISCHIAL LEVEL SOCKET, "USMC" OR
EQUAL PYLON, NO COVER, SACH FOOT,
LAMINATED SOCKET, MOLDED TO MODEL $_________________
ADDITIONS TO LOWER EXTREMITY
38. L5600 PREPARATORY, HIP DISARTICULATION HEMI-
PELVECTOMY, PYLON, NO COVER, SACH FOOT, $_________________
LAMINATED SOCKET, MOLDED TO PATIEN MODEL $_________________
39. L5610 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
HYDRACADENCE SYSTEM $_________________
40. L5611 ADDITION TO LOWER EXTREMITY, ABOVE KNEE-
KNEE DISARTICULATION, OHC 4 BAR LINKAGE,
WITH FRICTION SWING PHASE CONTROL $_________________
Page 17 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
41. L5613 ADDITION TO LOWER EXTREMITY, ABOVE KNEE-
KNEE DISARTICULATION, OHC 4 BAR LINKAGE,
WITH HYDRAULIC SWING PHASE CONTROL $_________________
42. L5616 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
UNIVERSAL MULTIPLEX SYSTEM, FRICTION SWING
PHASE CONTROL $_________________
ADDITIONS - TEST SOCKETS
43. L5618 ADDITION TO LOWER EXTREMITY, TEST SOCKET
SYMES $_________________
44. L5620 ADDITION TO LOWER EXTREMITY, TEST SOCKET,
BELOW KNEE $_________________
45. L5622 ADDITION TO LOWER EXTREMITY, TEST SOCKET,
KNEE DISARTICULATION $_________________
46. L5624 ADDITION TO LOWER EXTREMITY, TEST SOCKET,
ABOVE KNEE $_________________
47. L5626 ADDITION TO LOWER EXTREMITY, TEST SOCKET,
HIP DISARTICULATION $_________________
48. L5628 ADDITION TO LOWER EXTREMITY, TEST SOCKET,
HEMIPELVECTOMY $_________________
49. L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
ACRYLIC SOCKET $_________________
ADDITIONS - SOCKET VARIATIONS
50. L5630 ADDITION TO LOWER EXTREMITY, SYMES TYPE,
EXPANDABLE WALL SOCKET $_________________
Page 18 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
51. L5631 ADDITION TO LOWER EXTREMITY, ABOVE KNEE
OR KNEE DISARTICULATION, ACRYLIC SOCKET $_________________
52. L5632 ADDITION TO LOWER EXTREMITY, SYMES TYPE,
"PTB" BRIM DESIGN SOCKET $_________________
53. L5634 ADDITION TO LOWER EXTREMITY, SYMES
TYPE, POSTER OPENING (CANADIAN) SOCKET $_________________
54. L5636 ADDITION TO LOWER EXTREMITY, SYMES TYPE,
MEDIAL OPENING SOCKET $_________________
55. L5637 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
TOTAL CONTACT $_________________
56. L5638 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
LEATHER SOCKET $_________________
57. L5639 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
WOOD SOCKET $_________________
58. L5640 ADDITION TO LOWER EXTREMITY, KNEE
DISARTICULATION, LEATHER SOCKET $_________________
59. L5642 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
LEATHER SOCKET $_________________
60. L5643 ADDITION TO LOWER EXTREMITY, HIP
DISARTICULATION, FLEXIBLE INNER SOCKET,
EXTERNAL FRAME $_________________
61. L5644 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
WOOD SOCKET $_________________
62. L5645 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
FLEXIBLE INNER SOCKET, EXTERNAL FRAME $_________________
63. L5646 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
AIR CUSHION SOCKET $_________________
Page 19 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
64. L5647 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
SUCTION SOCKET $_________________
65. L5648 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
AIR CUSHION SOCKET $_________________
66. L5649 ADDITION TO LOWER EXTREMITY, ISCHIAL
CONTAINMENT/NARROW M L SOCKET $_________________
67. L5650 ADDITIONS TO LOWER EXTREMITY, TOTAL CON-
TACT, ABOVE KNEE OR KNEE DISARTICULATION
SOCKET $_________________
68. L5651 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
FLEXIBLE INNER SOCKET, EXTERNAL FRAME $_________________
69. L5652 ADDITION TO LOWER EXTREMITY, SUCTION
SUSPENSION, ABOVE KNEE OR KNEE
DISARTICULATION SOCKET $_________________
70. L5653 ADDITION TO LOWER EXTREMITY, KNEE DISAR-
TICULATION, EXPANDABLE WALL SOCKET $_________________
ADDITIONS - SOCKET INSERT AND SUSPENSION
71. L5654 ADDITION TO LOWER EXTREMITY, SOCKET INSERT,
SYMES, (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE
OR EQUAL) $_________________
72. L5655 ADDITION TO LOWER EXTREMITY, SOCKET INSERT,
BELOW KNEE (KEMBLO, PELITE, ALIPLAST,
PLASTAZOTE OR EQUAL $_________________
73. L5656 ADDITION TO LOWER EXTREMITY, SOCKET INSERT,
KNEE DISARTICULATION, (KEMBLO, PELITE,
ALIPLAST, PLASTAZOTE OR EQUAL) $_________________
Page 20 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
74. L5658 ADDITION TO LOWER EXTREMITY, SOCKET INSERT,
ABOVE KNEE (KEMBLO, PELITE, ALIPLAST,
PLASTAZOTE OR EQUAL $_________________
75. L5660 ADDITION TO LOWER EXTREMITY, SOCKET INSERT,
SYME, SILICONE GEL OR EQUAL $_________________
76. L5661 ADDITION TO LOWER EXTREMITY, SOCKET INSERT,
SOCKET INSERT, MULTI DUROMETER SYMES $_________________
77. L5662 ADDITION TO LOWER EXTREMITY, SOCKET INSERT,
BELOW KNEE, SILICONE GEL OR EQUAL $_________________
78. L5663 ADDITION TO LOWER EXTREMITY, SOCKET INSERT,
KNEE DISARTICULATION, SILICONE GEL OR EQUAL $_________________
79. L5664 ADDITION TO LOWER EXTREMITY, SOCKET INSERT,
ABOVE KNEE, SILICONE GEL OR EQUAL $_________________
80. L5665 ADDITION TO LOWER EXTREMITY, SOCKET INSERTS,
MULTI DUROMETER, BELOW KNEE $_________________
81. L5666 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
CUFF SUSPENSION $_________________
82. L5668 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
MOLDED DISTAL CUSHION $_________________
83. L5670 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
MOLDED SUPRACONDULAR SUSPENSION ("PTS"
OR SIMILAR) $_________________
84. L5672 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
REMOVABLE MEDIAL BRIM SUSPENSION $_________________
85. L5674 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
LATEX SLEEVE SUSPENSION OR EQUAL, EACH $_________________
Page 21 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
86. L5675 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
LATEX SLEEVE SUSPENSION OR EQUAL, HEAVY
DUTY, EACH $_________________
87. L5676 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
KNEE JOINTS, SINGLE $_________________
88. L5677 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE,
KNEE JOINTS, POLYCENTRIC, PAIR $_________________
89. L5678 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
JOINT COVERS, PAIR $_________________
90. L5680 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
THIGH LACER, NON MOLDED $_________________
91. L5682 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
THIGH LACER, GLUTEAL/ISCHIAL, MOLDED $_________________
92. L5684 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
FORK STRAP $_________________
93. L5686 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
BACK CHECK $_________________
94. L5688 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
WAIST BELT, WEBBING $_________________
95. L5690 ADDITION TO LOWER EXTREMITY, BELOW KNEE,
WAIST BELT, PADDED AND LINED $_________________
96. L5692 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
PELVIC CONTROL BELT, LIGHT $_________________
97. L5694 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
PELVIC CONTROL BELT, PADDED AND LINED $_________________
98. L5695 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
PELVIC CONTROL, SLEEVE SUSPENSION, NEOPRENE
OR EQUAL, EACH $_________________
Page 22 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
99. L5696 ADDITION TO LOWER EXTREMITY, ABOVE KNEE
OR KNEE DISARTICULATION, PELVIC JOINT $_________________
100. L5697 ADDITION TO LOWER EXTREMITY, ABOVE KNEE
OR KNEE DISARTICULATION, PELVIC BAND $_________________
101. L5698 ADDITION TO LOWER EXTREMITY, ABOVE KNEE
OR KNEE DISARTICULATION, SILESIAN BANDAGE $_________________
102. L5699 ALL LOWER EXTREMITY PROTHESES,
SHOULDER HARNESS $_________________
ADDITIONS - KNEE SHIN SYSTEM
Exoskeletal
103. L5710 ADDITION, EXOSKELETAL KNEE SHIN $_________________
104. L5711 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, MANUAL LOCK, ULTRA LIGHT
MATERIAL $_________________
105. L5712 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, FRICTION SWING AND STANCE
PHASE CONTROL (SAFETY KNEE) $_________________
106. L5714 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, VARIABLE FRICTION SWING PHASE
CONTROL $_________________
107. L5716 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
POLYCENTRIC, MECHANICAL STANCE PHASE LOCK
108. L5718 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
POLYCENTRIC, FRICTION SWING AND STANCE
PHASE CONTROL $_________________
109. L5722 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, PNEUMATIC SWING, FRICTION
STANCE PHASE CONTROL $_________________
Page 23 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
110. L5724 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, FLUID SWING PHASE CONTROL $_________________
111. L5726 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, EXTERNAL JOINTS, SWING PHASE
CONTROL $_________________
112. L5728 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, FLUID SWING AND STANCE PHASE
CONTROL $_________________
113. L5780 ADDITION, EXOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATIC
SWING PHASE CONTROL $_________________
COMPONENT MODIFICATION
114. L5785 ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE,
ULTRA LIGHT MATERIAL (TITANIUM, CARBON
FIBER OR EQUAL) $_________________
115. L5790 ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE,
ULTRA LIGHT MATERIAL (TITANIUM, CARBON
FIBER OR EQUAL) $_________________
116. L5795 ADDITION, EXOSKELETAL SYSTEM, HIP
DISARTICULATION, ULTRA-LIGHT MATERIAL
(TITANIUM, CARBON FIBER OR EQUAL) $________________
ENDOSKELETAL
117. L5810 ADDITION, ENDOSKELETAL KNEE SHIN SYSTEM
SINGLE AXIS, MANUAL LOCK $_________________
118. L5811 ADDITION, ENDOSKELETAL KNEE SHIN SYSTEM
SINGLE AXIS, MANUAL LOCK, ULTRA LIGHT
MATERIAL $_________________
Page 24 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
119. L5812 ADDITION, ENDOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, FRICTION SWING AND STANCE
PHASE CONTROL (SAFETY KNEE) $_________________
120. L5816 ADDITION, ENDOSKELETAL KNEE SHIN SYSTEM,
POLYCENTRIC, MECHANICAL STANCE PHASE LOCK $_________________
121. L5818 ADDITION, ENDOSKELETAL KNEE SHIN SYSTEM,
POLYCENTRIC, FRICTION SWING, AND STANCE
PHASE CONTROL $_________________
122. L5822 ADDITION, ENDOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, PNEUMATIC SWING, FRICTION
STANCE PHASE CONTROL $_________________
123. L5824 ADDITION, ENDOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, FLUID SWING PHASE CONTROL $_________________
124. L5828 ADDITION, ENDOSKELETAL KNEE SHIN SYSTEM,
SINGLE AXIS, FLUID SWING AND STANCE
PHASE CONTROL $_________________
125. L5830 ADDITION, ENDOSKELETAL, KNEE SHIN SYSTEM,
SINGLE AXIS, PNEUMATIC SWING PHASE CONTROL $_________________
126. L5850 ADDITION, ENDOSKELETAL SYSTEM, ABOVE
KNEE OR HIP DISARTICULATION, KNEE
EXTENSION ASSIST $_________________
127. L5910 ADDITION, ENDOSKELETAL SYSTEM, BELOW
KNEE, ALIGNABLE SYSTEM $_________________
128. L5920 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE
OR HIP DISARTICULATION, ALIGNABLE SYSTEM $_________________
129. L5940 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE,
ULTRA LIGHT MATERIAL (TITANIUM, CARBON
FIBER OR EQUAL) $_________________
Page 25 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
130. L5950 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE,
ULTRA LIGHT MATERIAL (TITANIUM, CARBON
FIBER OR EQUAL) $_________________
131. L5960 ADDITION, ENDOSKELETAL SYSTEM, HIP
DISARTICULATION, ULTRA LIGHT MATERIAL
(TITANIUM, CARBON FIBER OR EQUAL) $_________________
132. L5970 ALL LOWER EXTREMITY PROSTHESES, FOOT,
EXTERNAL KEEL, SACH FOOT $_________________
133. L5974 ALL LOWER EXTREMITY PROSTHESES, FOOT,
SINGLE AXIS ANKLE/FOOT $_________________
134. L5978 ALL LOWER EXTREMITY PROSTHESES, FOOT,
MULTIAXIAL ANKLE/FOOT (GREISSINGER OR EQUAL) $_________________
135. L5982 ALL EXOSKELETAL LOWER EXTREMITY
PROSTHESES, AXIAL ROTATION UNIT $_________________
136. L5984 ALL ENDOSKELETAL LOWER EXTREMITY
PROSTHESES, AXIAL ROTA ON UNIT $_________________
137. L5986 ALL LOWER EXTREMITY PROSTHESES, MULTI
AXIAL ROTATION UNIT ("MCP" OR EQUAL) $_________________
UPPER LIMB L6000 L7499
Note: The procedures in L6000 L6599 are considered as "base" or "basic" procedures and may
be modified by listing procedures from the "additions" section. The base procedures include
only standard friction wrist and control cable system unless otherwise specified.
UPPER LIMB - PARTIAL HAND - L6000 - L6049
138. L6000 PARTIAL HAND, ROBIN AIDS, THUMB REMAINING
(OR EQUAL) $_________________
Page 26 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
139. L6010 PARTIAL HAND, ROBIN AIDS, LITTLE AND/OR
RING FINGER REMAINING (OR EQUAL) $_________________
140. L6020 PARTIAL HAND, ROBIN AIDS, NO FINGER
REMAINING (OR EQUAL) $_________________
WRIST DISARTICULATION - L6050 L6099
141. L6050 WRIST DISARTICULATION, MOLDED SOCKET,
FLEXIBLE ELBOW HINGES, TRICEPS PAD $_________________
142. L6055 WRIST DISARTICULATION, MOLDED SOCKET WITH
EXPANDABLE INTERFACE, FLEXIBLE ELBOW
HINGES, TRICEPS PAD $_________________
UPPER LIMB - BELOW ELBOW - L6100 L6199
143. L6100 BELOW ELBOW, MOLDED SOCKET, FLEXIBLE
ELBOW HINGE, TRICEPS PAD $_________________
144. L6110 BELOW ELBOW, MOLDED SOCKET (MUENSTER
OR NORTHWESTERN SUSPENSION TYPES) $_________________
145. L6120 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT
SOCKET, STEP UP HINGES, HALF CUFF $_________________
146. L6130 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT
SOCKET, STUMP ACTIVATED LOCKING HINGE,
HALF CUFF $_________________
UPPER LIMB ELBOW DISARTICULATION - L6200 - L6249
147. L6200 ELBOW DISARTICULATION, MOLDED SOCKET,
OUTSIDE LOCKING HINGE, FOREARM $_________________
148. L6205 ELBOW DISARTICULATION, MOLDED SOCKET
WITH EXPANDABLE INTERFACE, OUTSIDE
LOCKING HINGES, FOREARM $_________________
Page 27 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
UPPER LIMB ABOVE ELBOW - L6250 - L6299
149. L6250 ABOVE ELBOW, MOLDED DOUBLE WALL SOCKET,
INTERNAL LOCKING ELBOW, FOREARM $_________________
UPPER LIMB SHOULDER DISARTICULATION - L6300 - L6349
150. L6300 SHOULDER DISARTICULATION, MOLDED SOCKET,
SHOULDER BULKHEAD, NUMERAL SECTION,
INTERNAL LOCKING ELBOW, FOREARM $_________________
151. L6310 SHOULDER DISARTICULATION, PASSIVE
RESTORATION (COMPLETE PROSTHESIS) $
152. L6320 SHOULDER DISARTICULATION, PASSIVE
RESTORATION (SHOULDER CAP ONLY) $_________________
UPPER LIMB - INTERSCAPULAR THORACIC - L6350 - L6379
153. L6350 INTERSCAPULAR THORACIC, MOLDED SOCKET,
SHOULDER BULKHEAD, NUMERAL SECTION,
INTERNAL LOCKING ELBOW, FOREARM $_________________
154. L6360 INTERSCAPULAR THORACIC, PASSIVE
RESTORATION (COMPLETE PROSTHESIS) $_________________
155. L6370 INTERSCAPULAR THORACIC, PASSIVE
RESTORATION (SHOULDER CAP ONLY) $_________________
UPPER LIMB - IMMEDIATE AND EARLY POST SURGICAL
PROCEDURES - L6480-L6399
156. L6380 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF INITIAL RIGID DRESSING,
INCLUDING FITTING ALIGNMENT AND SUSPENSION
OF COMPONENTS, AND ONE CAST CHANGE, WRIST
DISARTICULATION OR BELOW ELBOW $_________________
Page 28 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
157. L6382 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF INITIAL RIGID DRESSING,
INCLUDING FITTING ALIGNMENT AND SUSPENSION
OF COMPONENTS, AND ONE CAST CHANGE, ELBOW
DISARTICULATION OR ABOVE ELBOW $_________________
158. L6384 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF INITIAL RIGID DRESSING,
INCLUDING FITTING ALIGN MENT AND SUSPENSION
OF COMPONENTS, AND ONE CAST CHANGE,
SHOULDER DISARTICULATION OR
INTERSCAPULAR THORACIC $_________________
159. L6386 IMMEDIATE POST SURGICAL OR EARLY FITTING,
EACH ADDITIONAL CAST CHANGE AND
REALIGNMENT $_________________
160. L6388 IMMEDIATE POST SURGICAL OR EARLY FITTING,
APPLICATION OF RIGID DRESSING ONLY $_________________
UPPER LIMB - ENDOSKELETAL - BELOW ELBOW - L6400 L6449
161. L6400 BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL
SYSTEM, INCLUDING SOFT PROSTHETIC
TISSUE SHAPING $_________________
UPPER LIMP - ENDOSKELETAL - ELBOW DISARTICULATION -
L6450-L6499
162. L6450 ELBOW DISARTICULATION, MOLDED SOCKET,
ENDOSKELETAL SYSTEM, INCLUDING SOFT
PROSTHETIC TISSUE SHAPING $_________________
UPPER LIMB - ENDOSKELETAL - ABOVE ELBOW - L6500 - L6549
163. L6500 ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL
SYSTEM, INCLUDING SOFT PROSTHETIC
TISSUE SHAPING $_________________
Page 29 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
UPPER LIMB - ENDOSKELETAL - SHOULDER DISARTICULATION -
L6550 - L6569
164. L6550 SHOULDER DISARTICULATION, MOLDED SOCKET,
ENDOSKELETAL SYSTEM, INCLUDING SOFT
PROSTHETIC TISSUE SHAPING $_________________
UPPER LIMB - ENDOSKELETAL - INTERSCAPULAR THORACIC -
L6570 L6579
165. L6570 INTERSCAPULAR THORACIC, MOLDED SOCKET,
ENDOSKELETAL SYSTEM, INCLUDING SOFT
PROSTHETIC TISSUE SHAPING $_________________
UPPER LIMB - PREPARATORY PROCEDURES - L6580 - L6599
166. L6580 PREPARATORY, WRIST DISARTICULA TION OR
BELOW ELBOW, SINGLE WALL PLASTIC SOCKET,
FRICTION WRIST, FLEXIBLE ELBOW HINGES,
FIGURE OF EIGHT HARNESS, NUMERAL CUFF,
BOWDEN CABLE CONTROL, USMC OR EQUAL
PYLON, NO COVER, MOLDED TO PATIENT MODEL $_________________
167. L6582 PREPARATORY, WRIST DISARTICULATION OR
BELOW ELBOW, SINGLE WALL SOCKET, FRICTION
WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT
HARNESS, NUMERAL CUFF, BOWDEN CABLE
CONTROL, USMC OR EQUAL PYLON, NO COVER
DIRECT FORMED $_________________
168. L6584 PREPARATORY, ELBOW DISARTICULATION OR
ABOVE ELBOW, SINGLE WALL PLASTIC SOCKET,
FRICTION WRIST, LOCKING ELBOW, FIGURE OF
EIGHT HARNESS, FAIR LEAD CABLE CONTROL,
USMC OR EQUAL PYLON, NO COVER, MOLDED
TO PATIENT MODEL $_________________
Page 30 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
169. L6586 PREPARATORY, ELBOW DISARTICULATION OR
ABOVE ELBOW, SINGLE WALL SOCKET, FRICTION
WRIST, LOCKING ELBOW, FIGURE OF EIGHT
HARNESS, FAIR LEAD CABLE CONTROL, USMC
OR EQUAL PYLON, NO COVER, DIRECT FORMED $_________________
170. L6588 PREPARATORY, SHOULDER DISARTICULATION OR
INTERSCAPULAR THORACIC, SINGLE WALL
PLASTIC SOCKET, SHOULDER JOINT, LOCKING
ELBOW, FRICTION WRIST, CHEST STRAP, FAIR
LEAD CABLE CONTROL, USMC OR EQUAL PYLON,
NO COVER, MOLDED TO PATIENT MODEL $_________________
171. L6590 PREPARATORY, SHOULDER DISARTICULATION OR
INTERSCAPULAR THORACIC, SINGLE WALL
SOCKET, SHOULDER JOINT, LOCKING ELBOW,
FRICTION WRIST, CHEST STRAP, FAIR LEAD.CABLE
CONTROL, USMC OR EQUAL PYLON, NO
COVER, DIRECT FORMED $_________________
ADDITIONS - UPPER LIMB - L6600 - L6999
Note: The following procedures/modifications/components may be added to other base procedures. The items
in this section should reflect the additional complexity of each modification procedure, in addition to base
procedure, at the time of the original order.
172. L6600 UPPER EXTREMITY ADDITIONS, POLYCENTRIC
HINGE, PAIR $_________________
173. L6605 UPPER EXTREMITY ADDITIONS, SINGLE PIVOT
HINGE, PAIR $_________________
174. L6610 UPPER EXTREMITY ADDITIONS, FLEXIBLE METAL
HINGE, PAIR $_________________
175. L6615 UPPER EXTREMITY ADDITION, DISCONNECT
LOCKING WRIST UNIT $_________________
Page 31 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
176. L6620 UPPER EXTREMITY ADDITION, FLEXION
FRICTION WRIST UNIT $_________________
177. L6623 UPPER EXTREMITY ADDITION, SPRING ASSISTED
ROTATIONAL WRIST UNIT WITH LATCH RELEASE $_________________
178. L6625 UPPER EXTREMITY ADDITION, ROTATION
WRIST UNIT WITH CABLE LOCK $_________________
179. L6628 UPPER EXTREMITY ADDITION, QUICK DISCONNECT
HOOK ADAPTER, OTTO BOCK OR EQUAL $_________________
180. L6629 UPPER EXTREMITY ADDITION, QUICK
DISCONNECT LAMINATION COLLAR WITH
COUPLING PIECE, OTTO BOCK OR EQUAL $_________________
181. L6630 UPPER EXTREMITY ADDITION, STAINLESS
STEEL, ANY WRIST $_________________
182. L6632 UPPER EXTREMITY ADDITION, LATEX
SUSPENSION SLEEVE, EACH $_________________
183. L6635 UPPER EXTREMITY ADDITION, LIFT
ASSIST FOR ELBOW $_________________
184. L6637 UPPER EXTREMITY ADDITION, NUDGE
CONTROL ELBOW LOCK $_________________
185. L6640 UPPER EXTREMITY ADDITIONS, SHOULDER
ABDUCTION JOINT, PAIR $_________________
186. L6641 UPPER EXTREMITY ADDITION, EXCURSION
AMPLIFIER, PULLEY TYPE $_________________
187. L6642 UPPER EXTREMITY ADDITION, EXCURSION
AMPLIFIER, LEVER TYPE $_________________
188. L6645 UPPER EXTREMITY ADDITION, SHOULDER
FLEXION ABDUCTION JOINT, EACH $_________________
Page 32 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
189. L6650 UPPER EXTREMITY ADDITION, SHOULDER
UNIVERSAL JOINT, EACH $_________________
190. L6655 UPPER EXTREMITY ADDITION, STANDARD
CONTROL CABLE, EXTRA $_________________
191. L6660 UPPER EXTREMITY ADDITION, HEAVY DUTY
CONTROL CABLE $_________________
192. L6665 UPPER EXTREMITY ADDITION, TEFLON,
OR EQUAL, CABLE LINING $_________________
193. L6670 UPPER EXTREMITY ADDITION, HOOK TO HAND,
CABLE ADAPTER $_________________
194. L6672 UPPER EXTREMITY ADDITION, HARNESS,
CHEST OR SHOULDER, SADDLE TYPE $_________________
195. L6675 UPPER EXTREMITY ADDITION, HARNESS, FIGURE
OF ("8") EIGHT TYPE, FOR SINGLE CONTROL $_________________
196. L6680 UPPER EXTREMITY ADDITION, TEST SOCKET,
WRIST DISARTICULATION OR BELOW ELBOW $_________________
197. L6682 UPPER EXTREMITY ADDITION, TEST SOCKET,
ELBOW DISARTICULATION OR ABOVE ELBOW $_________________
198. L6684 UPPER EXTREMITY ADDITION TEST SOCKET,
SHOULDER DISARTICULATION OR INTERSCAPULAR
THORACIC $_________________
199. L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET $_________________
200. L6687 UPPER EXTREMITY ADDITION, FRAME
TYPE SOCKET, BELOW ELBOW $_________________
201. L6688 UPPER EXTREMITY ADDITION, FRAME
TYPE SOCKET, ABOVE ELBOW $_________________
Page 33 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
202. L6689 UPPER EXTREMITY ADDITION, FRAME TYPE
SOCKET, SHOULDER DISARTICULATION $_________________
203. L6690 UPPER EXTREMITY ADDITION, FRAME TYPE
SOCKET, INTERSCAPULAR THORACIC $_________________
204. L6691 UPPER EXTREMITY ADDITIONAL
REMOVABLE INSERT, EACH $_________________
TERMINAL DEVICES L6700 L6899
Hooks
205. L6700 TERMINAL DEVICE, HOOK, DORRANCE, OR
EQUAL, MODEL #3 $_________________
206. L6705 TERMINAL DEVICE, HOOK, DORRANCE, OR
EQUAL, MODEL #5 $_________________
207. L6710 TERMINAL DEVICE, HOOK, DORRANCE, OR
EQUAL, MODEL #5X $_________________
208. L6715 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #5XA $_________________
209. L6720 TERMINAL DEVICE, HOOK, DORRANCE, OR
EQUAL, MODEL #6 $_________________
210. L6725 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #7 $_________________
211. L6730 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #7LO $_________________
212. L6735 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #8 $_________________
Page 34 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
213. L6740 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #8X $_________________
214. L6745 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #88X $_________________
215. L6750 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #10P $_________________
216. L6755 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #10X $_________________
217. L6765 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #12P $_________________
218. L6770 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #99X $_________________
219. L6775 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #555 $_________________
220. L6780 TERMINAL DEVICE, HOOK, DORRANCE,
OR EQUAL, MODEL #SS555 $_________________
221. L6790 TERMINAL DEVICE, HOOK, ACCU HOOK,
OR EQUAL $_________________
222. L6795 TERMINAL DEVICE, HOOK, 2 LOAD,
OR EQUAL $_________________
223. L6800 TERMINAL DEVICE, HOOK APRL VC,
OR EQUAL $_________________
224. L6805 TERMINAL DEVICE, MODIFIER WRIST
FLEXION UNIT $_________________
225. L6806 TERMINAL DEVICE, HOOK, TRS, GRIP, VC $_________________
226. L6807 TERMINAL DEVICE, HOOK, TRS, ADEPT,
CHILD, VC $_________________
227. L6810 TERMINAL DEVICE, PINCHER TOOL,
OTTO BOCK OR EQUAL $_________________
Page 35 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
Hands
228. L6825 TERMINAL DEVICE, HAND, DORRANCE, VC $_________________
229. L6830 TERMINAL DEVICE, HAND, APRL, VC $_________________
230. L6835 TERMINAL DEVICE, HAND, SIERRA, VO $_________________
231. L6840 TERMINAL DEVICE, HAND, BECKER IMPERIAL $_________________
232. L6845 TERMINAL DEVICE, HAND, BECKER LOCK GRIP $_________________
233. L6850 TERMINAL DEVICE, HAND, BECKER PLYLITE $_________________
234. L6855 TERMINAL DEVICE, HAND, ROBIN AIDS, VO $_________________
235. L6860 TERMINAL DEVICE, HAND, ROBIN AIDS, VO SOFT $_________________
236. L6865 TERMINAL DEVICE, HAND, PASSIVE HAND $_________________
237. L6870 TERMINAL DEVICE, HAND, CHILD MITT $_________________
238. L6872 TERMINAL DEVICE, HAND, NYU CHILD HAND $_________________
239. L6875 TERMINAL DEVICE, HAND, BOCK, VC $_________________
240. L6880 TERMINAL DEVICE, HAND, BOCK, VO $_________________
Gloves For Above Hands
241. L6890 TERMINAL DEVICE, GLOVE FOR ABOVE
HANDS, PRODUCTION GLOVE $_________________
242. L6895 TERMINAL DEVICE, GLOVE FOR ABOVE
HANDS, PRODUCTION GLOVE $_________________
HAND RESTORATION - L6900 - L6919
243. L6900 HAND RESTORATION (CASTS, SHADING AND
MEASUREMENTS INCLUDED), PARTIAL HAND,
WITH GLOVE, THUMB OR ONE FINGER REMAINING $_________________
Page 36 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
244. L6905 HAND RESTORATION (CASTS, SHADING AND
MEASUREMENTS INCLUDED), PARTIAL HAND,
WITH GLOVE, MULTIPLE FINGERS REMAINING $_________________
245. L6910 HAND RESTORATION (CASTS, SHADING AND
MEASUREMENTS INCLUDED), PARTIAL HAND,
WITH GLOVE, NO FINGERS REMAINING $_________________
246. L6915 HAND RESTORATION (SHADING, AND
MEASUREMENTS INCLUDED),
REPLACEMENT GLOVE FOR ABOVE $_________________
GENERAL BREAST PROTHESES - L8000-L8299
247. L8000 BREAST PROSTHESIS, MASTECTOMY BRA $_________________
248. L8010 BREAST PROSTHESIS, MASTECTOMY SLEEVE $_________________
249. L8020 BREAST PROSTHESIS, MASTECTOMY FORM $_________________
GENERAL - TRUSSES - L8300-L8399
250. L8300 TRUSS, SINGLE WITH STANDARD PAD $_________________
251. L8310 TRUSS, DOUBLE WITH STANDARD PADS $_________________
252. L8320 TRUSS, ADDITION TO STANDARD PAD,
WATER PAD $_________________
253. L8330 TRUSS, ADDITION TO STANDARD PAD,
SCROTAL PAD $_________________
PROSTHETIC SOCKS - L8400 - L8489
254. L8400 PROSTHETIC SHEATH, BELOW KNEE, EACH $_________________
255. L8410 PROSTHETIC SHEATH, ABOVE KNEE, EACH $_________________
256. L8415 PROSTHETIC SHEATH, UPPER LIMB, EACH $_________________
Page 37 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
257. L8420 PROSTHETIC SOCK, WOOL, BELOW KNEE, EACH $_________________
258. L8430 PROSTHETIC SOCK, WOOL ABOVE KNEE, EACH $_________________
259. L8435 PROSTHETIC SOCK, WOOL, UPPER LIMB, EACH $_________________
260. L8440 PROSTHETIC SHRINKER, BELOW KNEE, EACH $_________________
261. L8460 PROSTHETIC SHRINKER, ABOVE KNEE, EACH $_________________
262. L8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH $_________________
263. L8470 STUMP SOCK, SINGLE PLY, FITTING, BELOW
KNEE, EACH $_________________
264. L8480 STUMP SOCK, SINGLE PLY, FITTING, ABOVE KNEE,
EACH $_________________
ADDITIONAL - PROSTHETIC FEET
265. SAFE FOOT $_________________
266. SAFE FOOT II $_________________
267. SEATTLE FOOT $_________________
268. CARBON COPY II FOOT $_________________
269. BOCK DYNAMIC FOOT $_________________
270. KINGSLEY STEN FOOT $_________________
271. FLEX-WALK FOOT $_________________
Page 38 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
GROUP II
ORTHOTIC DEVICES
(FOR ORTHOPEDICS DEPARTMENT)
272. JEWELT HYPEREXTENSION ORTHOSIS,
A SINGLE THREE POINT BRACE SYSTEM THAT
RESTRICTS FORWARD IN THE THORACOLUMBAR
AREA AND ENCOURAGE A HYPEREXTENSION
POSTURE.
CONSISTS OF ANTERIOR AND LATERAL TORSO
FRAME TO WHICH ARE ATTACHED A STERNAL
PAD, A SUPRAPUBIC PAD, A THORACOLUMBAR
PAD AND TWO LATERAL PADS. WITH THE
PATIENT SEATED AND ORTHOSIS PROPERLY
ADJUSTED, THE STERNAL PAD SHOULD
BE JUST INFERIOR TO THE STERNAL
NOTCH AND THE SUPRAPUBIC PAD
SHOULD BE SUPERIOR TO THE SYMPHYSIS. $_________________
273. PLASTIC BODY JACKET,
THIS IS A PLASTIC RIGID BODY JACKET MADE FROM
A PLASTER PARIS MOLD OF THE PATIENT, WITH
SOFT LINING MATERIAL TO SUPPORT AND
RESTRICT MOTION OF THE SPINE. USUALLY THE
ORTHOSIS IS BI-VALVED WITH SIDE OPENINGS BUT
IT MAY ALSO HAVE A SINGLE FRONT OF BACK
OPENING. IT MAY ALSO HAVE AN ABDOMINAL
WINDOW.
**MATERIALS: THERMOPLASTIC MATERIAL
(E.G. POLYPROPYLENE OR POLYETHYLENE AND
PELITE) HEAT BONDED AND MOLDED TO CAST.
BI-VALVE JACKET - SIX TOW INCH VELCRO
STRAPS REINFORCED WITH LEATHER. $_________________
ONE PIECE JACKET - FIVE TO SIX ONE INCH
VELCRO STRAPS REINFORCED WITH LEATHER.
PELITE PLASTIC TONGUE, STAINLESS STEEL RIVETS $_________________
Page 39 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
274. SPINAL SOMI-STERNAL OCCIPITAL
MANDIBULAR IMMOBILIZER CERVICAL,
MULTIPLE POST COLLAR OCCIPITAL/
MANDIBULAR SUPPORTS, ADJUSTABLE CERVICAL
BARS, MOLDED TO PATIENT. A UNIQUE SUPPORT
FOR THE CERVICAL SPINE THAT CAN BE EASILY
FITTED TO PATIENT IN THE BED FOR AFTER
SURGERY OR CERVICAL FRACTURES. ITS TWO
POSTERIOR SUPPORTS ARISE FROM A STERNAL
PLATE, EXTEND UPWARD AND BACKWARD AND
ATTACH TO AN OCCIPITAL SUPPORT. ITS SINGLE
ANTERIOR UPRIGHTS WITH MANDIBULAR
SUPPORT CAN BE REMOVED FROM THE
STERNAL PLATE. $_________________
275. MINERVA - ANTERIOR POSTERIOR
LATERAL CONTROL ORTHOSIS,
A RIGID ORTHOSIS MADE OF PLASTIC WITH A
SOFT LINING MATERIAL, MOLDED TO THE
PATIENT THAT RESTRICTS MOTION OF THE
ENTIRE SPINE AND PROVIDES MAXIMUM SUPPORT.
IT ENCLOSES THE ENTIRE POSTERIOR SKULL AND
TO BELOW THE SCAPULA. THE ANTERIOR PORTION
EXTENDS FROM THE CHIN TO BELOW THE STERNUM.
FUNCTION: CUSTOM MOLDED ORTHOSIS TO
POSITION THE HEAD AND APPLY STABILIZING
FORCEPS UNDER AND AROUND THE CHIN AND
OCCIPITAL TO RESTRICT FLEXION AND EXTENSION,
LATERAL MOTION, AND ROTATION OF THE HEAD
AND CERVICAL SPINE. $_________________
Page 40 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
276. SPINAL CERVICAL THORACIC HALO
PROCEDURE HALO, A RIGID ORTHOSIS USED IN THE
CONTROL OF THE CERVICAL PORTION OF THE SPINE
WHICH IS INCORPORATED INTO A JACKET
THORACIC SUPPORT. THE HALO PROVIDES THE
GREATEST CONTROL OF ALL CERVICAL ORTHOSES.
COMPONENTS: HALO RING, DISTRACTION RODS,
SHOULDERS BARS AND CUSTOM FITTED BI-VALVE
POLYETHYLENE VEST LINED WITH NATURAL LAMBS
WOOL AND FASTENED WITH TWO INCH VELCRO
STRAPS. THE ANTERIOR AND POSTERIOR
SHOULDER BARS ARE FASTENED WITH
HORIZONTAL BARS WITH A THIRD VERTICAL BAR
EXTENDING FROM THE POSTERIOR ASPECT
FASTENING TO THE HALO RING.
FUNCTION: THE HALO CERVICAL ORTHOSIS
IMMOBILIZES THE HEAD AND CERVICAL SPINE.
IT CAN PROVIDE DISTRACTING FORCES THAT AID
IN SPINAL STABILIZATION. $_________________
277. SPINAL DORSOLUMBAR CORSET, THORACIC
LUMBOSACRAL ORTHOSIS (TLSO), FLEXIBLE,
CUSTOM-FITTED TO PATIENT. A FLEXIBLE
ORTHOSIS THAT PROVIDES SUPPORT FOR THE
ENTIRE TORSO WITH PARASPINAL STAYS
MOLDED TO THE SPINE. $_________________
278. SPINAL LUMBOSACRAL CORSET, A CLOTH
GARMENT THAT ENCOMPASSES THE TORSO AND
PELVIS AND IS ADJUSTABLE CIRCUMFERENTIALLY
BY MEANS OF SIDE, FRONT OF BACK LACES OR
HOOKS. ANTERIORLY IT EXTENDS BELOW THE
XIPHOID PROCESS TO ABOVE THE PUBIC
SYMPHYSIS.
POSTERIORLY ITS SUPERIOR BORDER IS BELOW
THE INFERIOR ANGLE OF THE SCAPULA AND ITS
INFERIOR BORDER IS BELOW THE GLUTEAL BULGE. $_________________
Page 41 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
279. LONG TAYLOR-KNIGHT SPINAL ORTHOSIS,
SPINAL THORACIC LUMBOSACRAL,
ANTERIOR-POSTERIOR-ROTARY CONTROL WITH
APRON FRONT. A RIGID SPINAL ORTHOSIS
PROVIDING ANTERIOR-POSTERIOR AND MEDIAL-
LATERAL CONTROL OF THE SPINE. THIS ORTHOSIS
IS SIMILAR TO THE SHORT TAYLOR KNIGHT WITH
THE EXCEPTION OF PARASPINAL BARS EXTENDING
TO BETWEEN THE SCAPULAS. THE AXILLARY
STRAPS EXTEND ANTERIORLY OVER THE
SHOULDERS AND PASS UNDER THE AXILLAR
ATTACHING TO THE THORACIC BAND.
MATERIALS: ALUMINUM FRAME COVERED IN
LEATHER WITH FELT PADDING. CORSET FRONT
FASTENED TO THE FRAME WITH LACES
AND ATTACHED IN FRONT WITH STRAPS. $_________________
280. SHORT TAYLOR-KNIGHT SPINAL ORTHOSIS,
A CUSTOM MEASURED AND MANUFACTURED
RIGID ORTHOSIS CONSISTING OF TWO POSTERIOR
UPRIGHTS ATTACHED TO A PELVIC BAND AND A
THORACIC BAND AS WELL AS TWO LATERAL
UPRIGHTS. A FULL CORSET FRONT IS FASTENED
TO THE FRAME BY LACES AND ATTACHED IN
FRONT WITH STRAPS. THE ALUMINUM FRAME IS
COVERED IN LEATHER AND PADDED WITH FELT.
THE THORACIC BAND SHOULD FIT INFERIOR TO THE
SCAPULA AND THE PELVIC BAND AT THE SACRAL
COXAGIAL JUNCTION. THE PARASPINAL BARS
SHOULD BE CONTOURED TO THE PATIENTS SPINE. $_________________
Page 42 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
GROUP III
ORTHOTIC DEVICES
(FOR USE IN PHYSICAL MEDICINE)
281. METAL SHORT LEG BRACE, (AFO) - CUSTOM, A
DOUBLE OR SINGLE BAR ORTHOSIS WITH FREE
OR LIMITED ANKLE MOTION JOINTS AND SOLID
STIRRUP FOR CONTROL OF THE ANKLE, WHICH
PROVIDES SUPPORT AND CONTROL. A LEATHER
CALF BAND IS ATTACHED AND HAS VELCRO
CLOSURES. A SHOE IS ATTACHED TO THIS ORTHOSIS. $_________________
282. METAL SHORT LEG BRACE WITH T-STRAP,
(AFO) - SAME AS ABOVE WITH A T-STRAP. $_________________
283. METAL LONG LEG BRACE, (KAFO) - CUSTOM, A
SINGLE OR DOUBLE BAR OTHOSIS TO PROVIDE
VARIOUS TYPES OF CONTROL FOR THE KNEE
AND ANKLE JOINTS. THE KNEE AND ANKLE
JOINTS PERMIT UNRESTRICTED OR LIMITED
MOTION. THE LOWER PART OF THE ANKLE
JOINT IS FASTENED RIGIDLY TO THE SHOE AND
THE DOUBLE OR SINGLE VERTICAL UPRIGHT IS
HELD IN PLACE BY LEATHER BANDS ABOUT
THE THIGH (2 BANDS) AND CALF (1 BAND). $_________________
284. METAL LONG LEG BRACE, (HKAFO) -
SAME AS ABOVE INCLUDING THE HIP JOINT. $_________________
285. PREFABRICATED ANKLE FOOT ORTHOSIS,
(AFO) - A ONE PIECE PLASTIC ORTHOSIS,
CUSTOM FITTED, TRIMMED PROXIMAL TO
THE METATARSAL HEADS. $_________________
286. ENGEN TYPE ANKLE FOOT ORTHOSIS, (AFO) -
"DROP-FOOT", A PLASTIC ANKLE FOOT ORTHOSIS
CUSTOM MOLDED. CONTROLS PLANTARFLEXION. $_________________
Page 43 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
287. TOTAL CONTACT ANKLE FOOT ORTHOSIS,
(AFO) - CUSTOM, A SOLID PLASTIC ORTHOSIS
CUSTOM MOLDED FROM A CAST OF THE
PATIENTS LOWER LEG AND FOOT. THIS ORTHOSIS
CONTROL MEDIAL AND LATERAL INSTABILITY AS
WELL AS PLANTAR AND DORSIFLEXION. $_________________
288. ELASTIC LUMBAR BINDER, (LSO) -
CUSTOM, A FLEXIBLE ELASTIC MATERIAL
GARMENT FOR SUPPORT OF THE LOWER SPINE. $_________________
289. NDT FOOT PLATE $_________________
290. PTB SHORT LEG ORTHOSIS, (AFO) -
CUSTOM PATELLA TENDON BEARING ORTHOSIS
FRACTURE ORTHOSIS, MOLDED TO PATIENT
MODEL. CONSTRUCTED OF LIGHTWEIGHT PLATIC
WITH A UNIQUE TWO-PIECE CONTRUCTION
DESIGNED WITH OR WITHOUT HINGES DEPENDING
ON ORTHOTIC RECOMMENDATIONS. $_________________
291. ELASTIC KNEE SLEEVE, (KO) - CUSTOM,
AN ELASTIC SLEEVE TO PROVIDE GENERAL
SUPPORT ABOUT THE KNEE JOINT. $_________________
292. PAVLIK HARNESS, (HO) - CUSTOM,
ABDUCTION/FLEXION CONTROL OF HIP
JOINTS, FLEXIBLE PERMITS OTHER MOTION
IN INFANTS PRIOR TO THE SITTING PHASE. $_________________
293. ABDOMINAL BINDER - A FLEXIBLE, MULTI-
PANELED ADJUSTABLE GARMENT USED
TO CONTROL A PENDULOUS ABDOMEN OR
SURGICAL INCISION SITE. $_________________
294. BLEDSOE TYPE ARM ORTHOSIS, (EO) - CUSTOM,
A DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS,
ADJUSTABLE EXTENSION/FLEXION CONTROL. $_________________
Page 44 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
295. BLEDSOE TYPE KNEE ORTHOSIS, (KO) - CUSTOM,
ADJUSTABLE KNEE JOINTS, FLEXION/EXTENSION
ADJUSTABILITY USED AFTER INJURY OR SURGERY
TO SUPPORT AND PROTECT KNEE JOINT. $_________________
296. COCK-UP WRIST SPLINT, (WO) - CUSTOM, AN
ORTHOSIS TO PROVIDE SUPPORT FOR A WEAK
WRIST AND LIMIT MOTION. MADE OF CANVAS
OR LEATHER. $_________________
297. SI BELT $_________________
298. LUMBAR ROLL - LENGTH 14", "D" SHAPED,
REGULAR DENSITY, WITH STABILIZATION
STRAPS AND BUCKLE. $_________________
299. FLOOR REACTION, (AFO) $_________________
GROUP IV
PEDORTHOTIC DEVICES
ORTHOPEDIC OXFORD SHOES
300. MEN SIZE 2-5 $_________________
301. MEN SIZE 5-9 $_________________
302. MEN SIZE 9-12 $_________________
303. MEN SIZE 12 AND OVER $_________________
304. WOMEN SIZE $_________________
Page 45 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
EXTRA DEPTH ORTHOPEDIC OXFORD SHOES
305. MEN $_________________
306. WOMEN CREPE SOLE $_________________
307. WOMEN LEA SOLE $_________________
CUSTOM MOLDED SHOES
308. BASIC SHOE TO SEE 12 $_________________
309. FOR HIGH TOP, WEDGING AND OVERSIZE $_________________
310. DERMAPLAST SHOES $_________________
HEEL LIFT
311. TRANSFERRABLE INSIDE HEEL LIFTS TO 3/4 $_________________
312. OUTSIDE HEEL AND SOLE RAWES PER $_________________
ARCH SUPPORT
313. LONGITUDINAL ARCH OR MET FIXED IN SHOE $_________________
CUSTOM MOLDED ORTHOTIC WITH MET BLOCK
314. 3/4 LENGTH TRANSFERRABLE $_________________
315. FULL LENGTH TRANSFERRABLE $_________________
Page 46 of 51
PRICING/DELIVERY INFORMATION – (Continued)
PROCEDURE DESCRIPTION PRICE
CODE
SURGICAL SHOES
316. WOMEN SIZE 4 - 10 $_________________
317. MEN SIZE 2 1/2 - 6 $_________________
318. MEN SIZE 6 1/2 - 12 $_________________
319. MEN SIZE 12 AND OVER $_________________
320. CUSTOM MOLDED INSERTS $_________________
321. PRICE PER HOUR FOR CUSTOM WORK
WHEN A SET PRICE IS NOT AVAILABLE. $_________________
Page 47 of 51
Attachment a
RESIDENCE CERTIFICATION
Pursuant to Texas Government Code §2252.001 et seq., as amended, Harris County requests Residence
Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of
governmental contracts; pertinent provisions of §2252.001 are stated below:
(3) "Nonresident bidder" refers to a person who is not a resident.
(4) "Resident bidder" refers to a person whose principal place of business is in this state, including a
contractor whose ultimate parent company or majority owner has its principal place of business in
this state.
I certify that ______________________________________ is a Resident Bidder of Texas as defined in
[Company Name]
Government Code §2252.001.
I certify that ______________________________________ is a Nonresident Bidder as defined in
Government [Company Name]
Code §2252.001 and our principal place of business is __________________________________.
[City and State]
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Attachment e.
Minimum Insurance Requirements
• The contractor shall, at all times during the term of this contract, maintain insurance coverage with
not less than the type and requirements shown below. Such insurance is to be provided at the sole
cost of the contractor. These requirements do not establish limits of the contractor's liability.
• All policies of insurance shall waive all rights of subrogation against the County, its officers,
employees and agents.
• Upon request, certified copies of original insurance policies shall be furnished to Harris County.
• The County reserves the right to require additional insurance should it be deemed necessary.
A. Workers' Compensation (with Waiver of subrogation to Harris County) Employer's Liability,
including all states, U.S. Longshoremen, Harbor Workers and other endorsements, if applicable to
the Project.
Statutory, and Bodily Injury by Accident: $100,000 each employee. Bodily Injury by Disease:
$500,000 policy limit $100,000 each employee.
B. Commercial General Liability Occurrence Form including, but not limited to, Premises and
Operations, Products Liability Broad Form Property Damage, Contractual Liability, Personal and
Advertising Injury Liability and where the exposure exists, coverage for watercraft, blasting
collapse, and explosions, blowout, cratering and underground damage.
$300,000 each occurrence Limit Bodily Injury and Property Damage Combined $300,000 Products-
Completed Operations Aggregate Limit $500,000 Per Job Aggregate $300,000 Personal and
Advertising Injury Limit. Harris County shall be named as "additional insured" on commercial
general liability policy.
C. Automobile Liability Coverage:
$300,000 Combined Liability Limits. Bodily Injury and Property Damage Combined. Harris
County shall be named as "additional insured" on automobile policy.
Revised 12/00
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Attachment f.
Page 1 of 2
TWCC RULE 110.110 WORKERS' COMPENSATION INSURANCE COVERAGE
If this bid/proposal package is for a building or construction contract, all of the provisions of this rule as shown below apply.
Since this is a mandatory requirement, cost increases should not be experienced because of the need to comply with the Texas
Workers' Compensation Law. For additional information contact the Texas Workers' Compensation Commission, Southfield
Building, 400 S. IH-35, Austin, Texas 78704-7491, (512) 440-3618.
A. Definitions:
Certificate of coverage ("Certificate") - A copy of a certificate of insurance, a certificate of authority to self-
insure issued by the commission, or a coverage agreement, TWCC-81, TWCC-82, TWCC-83, or TWCC-84
showing statutory workers' compensation insurance coverage for the person's or entity's employees providing
services on a project, for the duration of the project.
Duration of the project - Includes the time from the beginning of the work on the project until the
contractor's/person's work on the project has been completed and accepted by the governmental entity.
Persons providing services on the project ("subcontractor" in §406.096) - Includes all persons or entities
performing all or part of the services the contractor has undertaken to perform on the project, regardless of
whether that person contracted directly with the contractor and regardless of whether that person has
employees. This includes, without limitation, independent contractors, subcontractors, leasing companies,
motor carriers, owner-operators, employees of any such entity, or employees of any entity which furnishes
persons to provide services on the project. "Services" include, without limitation, providing, hauling or
delivering equipment or materials, or providing labor, transportation, or other service related to a project.
"Services" does not include activities unrelated to the project, such as food/beverage vendors, office supply
deliveries, and delivery of portable toilets.
B. The Contractor shall provide coverage, based on proper reporting of classification codes and payroll amounts and filing
of any coverage agreements, which meets the statutory requirements of Texas Labor Code, Section 401.011(44) for all
employees of the contractor providing services on the project, for the duration of the project.
C. The Contractor must provide a certificate of coverage to the governmental entity prior to being awarded the contract.
D. If the coverage period shown on the Contractor's current certificate of coverage ends during the duration of the project,
the Contractor must, prior to the end of the coverage period, file a new certificate of coverage with the governmental
entity showing that coverage has been extended.
E. The Contractor shall obtain from each person providing services on a project, and provide to the
governmental entity:
(1) A certificate of coverage, prior to that person beginning work on the project, so the governmental entity will
have on file certificates of coverage showing coverage for all persons providing services on the project; and
(2) No later than seven (7) days after receipt by the Contractor, a new certificate of coverage showing extension of
coverage, if the coverage period shown on the current certificate of coverage ends during the duration of the
project.
F. The Contractor shall retain all required certificates of coverage for the duration of the project and for one (1) year
thereafter.
G. The Contractor shall notify the governmental entity in writing by certified mail or personal delivery, within ten (10)
days after the contractor knew or should have known, of any change that materially affects the provision of coverage of
any person providing services on the project.
Page 50 of 51
Attachment f.
Page 2 of 2
H. The Contractor shall post on each project site a notice, in the text, form and manner prescribed by the Texas Workers'
Compensation Commission, informing all persons providing services on the project that they are required to be covered,
and stating how a person may verify coverage and report lack of coverage.
I. The Contractor shall contractually require each person with whom it contracts to provide services on a project to:
(1) Provide coverage, based on reporting of classification codes and payroll amounts and filing of any coverage
agreements, which meets the statutory requirements of Texas Labor Code, Section 401.011(44) for all its
employees providing services on the project, for the duration of the project.
(2) Provide to the Contractor, prior to that person beginning work on the project a certificate of coverage showing
that coverage is being provided for all employees of the person providing services on the project, for the
duration of the project.
(3) Provide the Contractor, prior to the end of coverage period, a new certificate of coverage showing extension of
coverage, if the coverage period shown on the current certificate of coverage ends during the duration of the
project.
(4) Obtain from each other person with whom it contracts, and provide to the Contractor:
(a) A certificate of coverage, prior to the other person beginning work on the project, and
(b) a new certificate of coverage showing extension of coverage, prior to the end of the coverage period,
if the coverage period shown on the current certificate of coverage ends during the duration of the
project;
(5) Retain all required certificates of coverage on file for the duration of the project and for one (1) year thereafter.
(6) Notify the government entity in writing by certified mail or personal delivery, within ten (10) days after the
person knew or should have known, of any change that materially affects the provision of coverage of any
person providing services on the project; and
(7) Contractually require each person with whom it contracts, to perform as required by paragraphs (1) - (7), with
the certificates of coverage to be provided to the person for whom they are providing services.
J. By signing this contract or providing or causing to be provided a certificate of coverage, the Contractor is representing
to the governmental entity that all employees of the contractor who will provide services on the project will be covered
by workers' compensation coverage for the duration of the project, that the coverage will be based on proper reporting of
classification codes and payroll amounts, and that all coverage agreements will be filed with the appropriate insurance
carrier or, in the case of a self-insured, with the commission's Division of Self-Insurance Regulation. Providing false or
misleading information may subject the contractor to administrative penalties, criminal penalties, civil penalties, or other
civil actions.
K. The Contractor's failure to comply with any of these provisions is a breach of contract by the contractor which entitles
the governmental entity to declare the contract void if the Contractor does not remedy the breach within ten (10) days
after receipt of notice of breach from the governmental entity.
Revised 4/02
Page 51 of 51