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					1. General Description of the Vendor
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                        QUESTIONS                                   VENDOR'S RESPONSE
Headquarters location (city and state).
Year established.
Company ownership (public, private, etc.).
Vendor's parent company (if any).
Personnel (in FTEs) in health care information systems for             for              (year)
current and two prior years.                                           for              (year)
                                                                       for              (year)
Number of Implementation Support Personnel
Number of Technical/Customer Support Personnel
Number of new clients in behavioral health information                 for              (year)
systems for the past three years.                                      for              (year)
                                                                       for              (year)
Number of years providing proposed system.
Percent of parent corporation revenues represented by your                    %
division or company.
Percent of revenue allocated to research and development
                                                                              %
(R&D)
Fiscal year gross revenue for current and two prior years (in   $       for             (year)
$1,000).                                                        $       for             (year)
                                                                $       for             (year)
Percentage of gross revenue realized from the proposed                % for             (year)
system for current and two prior years.                               % for             (year)
                                                                      % for             (year)
Fiscal year net income for current and two prior years (in      $       for             (year)
$1,000).                                                        $       for             (year)
                                                                $       for             (year)
Percentage of net income realized from the proposed                   % for             (year)
system for current and two prior years.                               % for             (year)
                                                                      % for             (year)


Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
2. Description of Subcontractor
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                         QUESTIONS                                  SUBCONTRACTOR'S RESPONSE
Name of subcontractor.
Subcontractor's headquarters location (city and state).
Year established.
Company ownership (public, private, etc.).
Subcontractor's parent company (if any).
Personnel (in FTEs) in health care information systems        for   (year)           for   (year)   for        (year)
for current and two prior years.
Number of years providing proposed
system(s)/service(s).
Fiscal year gross revenue for current and two prior       $                    for                        (year)
years (in $1,000).                                        $                    for                        (year)
                                                          $                    for                        (year)
Percentage of gross revenue realized from the                                % for                        (year)
proposed system for current and two prior years.                             % for                        (year)
                                                                             % for                        (year)
Fiscal year net income for current year and two prior     $                    for                        (year)
years (in $1,000).                                        $                    for                        (year)
                                                          $                    for                        (year)
Percentage of net income realized from the proposed                          % for                        (year)
system for current and two prior years.                                      % for                        (year)
                                                                             % for                        (year)
Primary systems and services offered (name of
product(s) and function(s) and date developed).
Specific tasks to be assigned to subcontractor.
Sites where subcontractor has previously performed
these tasks for primary vendor.


Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
3. Product Information

Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                        PRODUCT DESCRIPTION                                                   VENDOR RESPONSE
 Product name or applications family*
 Product status (e.g., Fully Operational , Planned, in Testing,
 Beta)
 How is the product included in the bid (included, not included,
 included as an option)?
 Product sold with perpetual license (yes/no)
 Year product first introduced
 Number of major new versions/releases to date
 Number and date of current version/release
 Projected date of next major version/release
 Number of fully operational (i.e., Live) sites (all releases)
 Number of fully operational sites (current release)
 Subset of fully operational sites that are county providers of
 Mental Health and/or Alcohol & Drug Services
 Other names under which the product(s) (or previous versions)
 have been sold

 * Indicate the name(s) of the overall product line(s). Complete one form for each product.




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
4. Applications Bid
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                                       CORRESPONDING VENDOR NAME OF
                REQUIRED APPLICATION
                                                            APPLICATION/MODULE
 PATIENT/CLIENT MANAGEMENT
 Preadmission
 Registration
 Admission, Discharge, Transfer Medical Records
 Index
 Census Reporting
 Medical Records
 Eligibility

 PATIENT ACCOUNTING
 Grants Management
 Financial Analysis / Entitlement / PFI
 Patient Accounting / Billing / Remittance
 Clinic Patient Accounting
 Payer Contract Management
 Cost Accounting

 MANAGED CARE OPERATIONS
 Member enrollment / eligibility
 Service Authorizations / Benefits / Referrals
 Claims Processing / Adjudication
 Contract Management / Negotiation Support
 Provider Relations
 Call Logs / Client Contacts




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
4. Applications Bid

                                               CORRESPONDING VENDOR NAME OF
                REQUIRED APPLICATION
                                                    APPLICATION/MODULE
 CLINICAL OPERATIONS

 Behavioral Health Assessment
 Multidisciplinary Documentation
 Behavioral Health Treatment Plans and Notes
 Order Entry
 Results Reporting
 Electronic Medical Record
 Clinical Decision Support
 Inpatient/Outpatient & Resource Scheduling
 Controlled Substance/Pharmacy
 Quality Assurance – Followup
 Ambulatory Clinical Support
 Clinician Access
 Outcome Measurement/Reporting

 GENERAL SYSTEM FUNCTIONS
 Security mechanisms and services
 Interface engine
 Screen Builder
 Intranet / Extranet / Internet Enabled




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
5. Applications Not Bid
Hospital Santa Clara Valley Health & Hospital System
Vendor
Product
Date


                                                                          STATUS
         VENDOR                                  FULLY OPERATIONAL                        NOT FULLY OPERATIONAL
    APPLICATION NAME                   YEAR         NUMBER OF        NUMBER OF     STATUS (CHECK ONE ())   ANTICIPATED
                                    INTRODUCED   IMPLEMENTATIONS      RELEASES     PLANNED     IN TESTING  RELEASE DATE




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
6. System Architectural Design
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                                                          INCLUDED                   NOTES
                                                              AVAILABLE
                             FEATURES                                       IN BID   (e.g., list products where feature
                                                                (Y/N)
                                                                             (Y/N)                is available)
 Able to supports HIPAA security services and
 mechanisms
 Customizable online help screens
 Dedicated training environment
 Dedicated testing environment
 User modifiable profile/parameter application control to
 implement SCVHHS business rules. That is, no custom
 coding required to implement clinical and financial rules.
 Bar code readers
 Bar code generation
 Hand held terminals/input devices
 Wireless technology
 Voice recognition
 Palm pilot integration or Windows CE-based computing
 Microsoft Word integration (e.g., to compose progress
 notes)
 User ability to add new data elements to the application
 data dictionary and screens
 User ability to modify screens and screen flow
 Open relational DBMS standard, please specify
 ODBC compliant with ODBC driver included
 Interface engine architecture
 Microsoft Excel and Access native data export building
 CCOW clinical context compliant
 HL7 data messaging compliant




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
7. Hardware Upgrade Path
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                                        TRANSACTION VOLUME GROWTH FROM CURRENT VOLUMES
                                            0 - 125 PERCENT      125 - 150 PERCENT   150 - 200 PERCENT   200 - 250 PERCENT
 Specify CPU or number of
 CPUs Required to                          (Proposed
 Accommodate Transaction                   Processor)
 Volume Growth
 Specify Disk Upgrade
 (megabytes) to Accommodate                (Proposed Disk
 Volume Growth                             Storage)




                                                            CONCURRENT USER GROWTH FROM CURRENT VOLUMES
                                            0 – 125 PERCENT      125 - 150 PERCENT   150 - 200 PERCENT   200 - 250 PERCENT
 Specify CPU or number of
 CPUs Required to                          (Proposed
 Accommodate Concurrent                    Processor)
 User Growth
 Specify Applicable
 Communications Equipment                  (Proposed
 (e.g., ports, modems,                     Communications
 controllers) Required to                  Equipment)
 Accommodate Device Growth




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
8. Systems Software
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                                                                      FROM WHOM DOES THE
                                                                LEVEL OF NEED ()
  SYSTEMS SOFTWARE                   PRODUCT NAME   RELEASE                           CUSTOMER PURCHASE
                                                              MANDATORY    OPTIONAL     THE SOFTWARE?
 Operating System
 Application Programming
 Language
 Network Software
 Communications
 Software
 Report Writer
 Screen Builder
 Database Management
 System
 Other (Specify)



 Other (Specify)




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
9. Interface Experience
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                                                                                             SITE WITH THE
                                                                                              HL-7          BEST EXAMPLE OF
  YOUR APPLICATION                    OTHER VENDOR'S     DIRECTION1   MODE2   METHOD3    COMPLIANT          THIS INTERFACE/
                                       APPLICATION                                       (yes/no/partial)      SIMILAR TO
                                                                                                                SCVHHS?




1. 1 = ONE-WAY INTERFACE                   2 = TWO-WAY INTERFACE
2. R = ONLINE REALTIME                     B = ONLINE BATCH        T = TAPE/DISKETTE   O = OTHER (DESCRIBE)       N = NONE
3. P = POINT-TO-POINT                      IE = INTERFACE ENGINE




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
10. Implementation Support Proposed*
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                              SUPPORT FEATURES                                   SUPPORT FEATURES DESCRIPTION
                                              SOFTWARE IMPLEMENTATION SUPPORT
  1. Location of implementation team (city, state).
  2. Does the vendor have different implementation support
     packages? If so, what are they and how do they differ from one
     another? Which package is being proposed here?
  3. Number of Entity’s person-hours required for implementation with
     the proposed option.
  4. Does the vendor utilize a "train-the-trainer" or "train-the-user"
     approach for the application software.
  5. Aggregate percentage of core trainer training for the application    a. % Onsite          b. % Offsite
     software held onsite and offsite?
  6. List offsite training locations for the application software.
  7. Indicate the maximum number of people that can be trained in a
     vendor-sponsored class for the application software.
  8. Regarding technical training that addresses the issues below,
     state how and when the training for each is received and whether
     the training is conducted on- or offsite.
           Classes for system programmers and database managers.
            Classes on system utilities such as report writers, screen
             builders, database design, and query functions.
            Classes in system operations and job processing.


  *    Use the last page of this form to answer questions fully.


Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
10. Implementation Support Proposed*
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                               SUPPORT FEATURES                              SUPPORT FEATURES DESCRIPTION
                                               HARDWARE INSTALLATION SUPPORT

 1. Whose responsibility is it to transport the hardware, upon delivery at
    the Entity, from the loading dock to the Entity's storage or staging
    site? The hardware vendor? The software vendor? The shipping
    company? The Entity?


 2. Does the software or hardware vendor uncrate the hardware?


 3. Does the software or hardware vendor install the hardware?


 4. Does the software or hardware vendor install the operating system?


 5. Number of vendor's person-hours dedicated to hardware training.


   *    Use the last page of this form to answer questions fully.




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
10. Implementation Support Proposed*


 To provide more complete responses to any of the questions on Form 10, this page may be utilized. Please number each
 question being answered below.




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
11. Recommended SCVHHS Staffing Requirements
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                           ESTIMATED TIME COMMITMENT REQUIRED   ESTIMATED TIME COMMITMENT REQUIRED
        STAFF CATEGORY
                                              FOR IMPLEMENTATION ACTIVITIES            FOR ONGOING ACTIVITIES
 Systems Office Department
 Systems Office Manager
 Project Manager
 Applications
 Programmer/Analyst
 User Analyst
 Systems Programmer
 Microcomputer Analyst
 Database Administrator
 Operations Manager
 Security Officer
 Job Scheduler
 Operator
 Data Entry Clerk
 Trainer/Documenter
 Clerical Staff
 Forms Distributor
 Interface Specialist
 Network Manager
 Other (Specify)

 User Departments
 Administrative Management
 System Trainers
 Clinical Management
 Clinical Staff

Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
11. Recommended SCVHHS Staffing Requirements

                                           ESTIMATED TIME COMMITMENT REQUIRED   ESTIMATED TIME COMMITMENT REQUIRED
        STAFF CATEGORY
                                              FOR IMPLEMENTATION ACTIVITIES            FOR ONGOING ACTIVITIES
 Report/Results Processing
 Other (Specify)




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
12. Implementation Support Description
Entity     Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                                                                                                                  IMPLEMENTATION
                                   PROJECT MANAGEMENT*                                      TRAINING**
                                                                                                                                     SUPPORT***
     APPLICATION                   OFFSITE                                         OFFSITE                                      OFFSITE
      TRAINING                      DAYS                ONSITE DAYS                 DAYS              ONSITE DAYS                DAYS     ONSITE DAYS




 OPERATIONS/TECHNICAL TRAINING




 HARDWARE TRAINING




  * Indicate the time allotted for project management activities.
 ** Indicate the time allotted for user training, including training for such activities as file building, report generation, and software function.
 *** Indicate the time allotted to support the implementation other than training or project management.




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
13. Ongoing Support Description
Entity     Santa Clara Valley Health & Hospitals System
Vendor
Product
Date                                               Ongoing Support Description: Basic

                                                           DOES THE VENDOR      IS THE COST FOR     INDICATE WHETHER
                                                             PROVIDE THIS         THIS FEATURE    THE SUPPORT IS TO BE
                                                          SUPPORT FEATURE?      INCLUDED IN THE      PROVIDED BY THE
                 SUPPORT FEATURES
                                                               (YES/NO)            PROPOSED        PRIMARY VENDOR OR
                                                                                SUPPORT COSTS?    BY A SUBCONTRACTOR
                                                                                    (YES/NO)
Conformance to Federal Regulations
Conformance to California Regulations
Conformance to Santa Clara County Regulations
 Conformance to JCAHO Requirements
 Conformance to HIPAA Requirements
Hard Copy and Soft Copy Documentation Updates
Training on System Software Upgrades
Training on New Releases
Customized Workshop/Educational Programs
Operational Audit/System Performance Evaluation
User Group Membership
Hardware Maintenance
 Time and Materials
     8:00 - 5:00 PCT, Monday through Friday
     24 Hours/Day, 7 Days/Week
Software Support
 8:00 - 5:00 PCT, Monday through Friday
     24 Hours/Day, 7 Days/Week
 Remote Support Available
Entity  Santa Clara Valley Health & Hospitals System

Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
13. Ongoing Support Description
Vendor
Product
Date                                            Ongoing Support Description: Premium

                                                      DOES THE VENDOR         IS THE COST FOR     INDICATE WHETHER
                                                        PROVIDE THIS            THIS FEATURE    THE SUPPORT IS TO BE
                                                     SUPPORT FEATURE?         INCLUDED IN THE      PROVIDED BY THE
                 SUPPORT FEATURES
                                                          (YES/NO)               PROPOSED        PRIMARY VENDOR OR
                                                                              SUPPORT COSTS?    BY A SUBCONTRACTOR
                                                                                  (YES/NO)
Conformance to Federal Regulations
Conformance to California Regulations
Conformance to Santa Clara County Regulations
 Conformance to JCAHO Requirements
 Conformance to HIPAA Requirements
Hard Copy and Soft Copy Documentation Updates
Training on System Software Upgrades
Training on New Releases
Customized Workshop/Educational Programs
Operational Audit/System Performance Evaluation
User Group Membership
Hardware Maintenance
 Time and Materials
     8:00 - 5:00 PCT, Monday through Friday
     24 Hours/Day, 7 Days/Week
Software Support
 8:00 - 5:00 PCT, Monday through Friday
     24 Hours/Day, 7 Days/Week
Remote Support Available



Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
14. Software Change Policy
Entity     Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                                                               SOFTWARE MODIFICATION CATEGORY
                                                                                     (e.g., Version, Release)

                 MODIFICATION NAME/FEATURE                         (specify)       (specify)    (specify)   (specify)
1. Are customers charged (in addition to support fees) for this
   category of modification (yes/no)?
2. What is the estimated cost for purchase of this modification?
3. How often are modifications issued (e.g., monthly, quarterly,
   yearly)?
4. Are modifications vendor-installed or customer-installed? If
   the answer varies by level of support purchased, explain.
5. What is the estimated cost of installation for these
   modifications?
6. Does vendor provide user education? If so, does education
   occur onsite or at vendor location?
7. Will vendor guarantee that these modifications are
   compatible with existing customer-specific code? If so, is
   there an additional charge to upgrade the custom code?
8. How many of this category of modifications have been
   issued within each of the last two calendar years?
9. What is the number and date issued of the most current
   modification?
10. Does the customer control the date and time of modification
    implementation?
11. Does the vendor provide user documentation for software
    modifications?




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
15. Client Base Overview
Entity     Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                           NUMBER OF       NUMBER OF SITES                       NUMBER OF        IS MODULE
                                                                              NUMBER OF
    CLIENT BASE DESCRIPTION                  SIGNED       IN IMPLEMENTATION                   SYSTEM/PRODUCT     INCLUDED IN
                                                                              "LIVE" SITES
                                           CONTRACTS             PHASE                       DEIMPLEMENTATIONS       BASE
                                                                                                                   SYSTEM?


 Total Client Base
 (Proposed Product)



 Base System



 [SPECIFY] Module



 [SPECIFY] Module


 Clients in California



 [SPECIFY] Module

 Other Module

 __________________




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
16. Client References*
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

    CLIENT NAME:
    Total yearly Mental Health client visits: ____________        Total yearly Alcohol & Drug client visits: ____________
    Client Contact (name, title, phone):


                                                             APPLICATION HISTORY

                           APPLICATIONS                                 RELEASE NUMBER                             DATE INSTALLED




                                                             HARDWARE PLATFORM
    CPU/Memory/Disk:
    Number of Workstations:
    Has This Hardware Been Upgraded? Is Upgrade Planned?


                                 CLIENT PROFILE                                              IMPLEMENTATION HISTORY
    Multientity Site (Yes/No):                                           Previous System(s) Replaced:
    Public provider organization (Yes/No):                               Other Systems Installed at this Site:
    Uses contract providers (Yes/No):                                    Duration of Implementation                        to
                                                                                                                   Start        End
    Operates in California (Yes/No):
    Unique Aspects Regarding This Site:



*     Complete one form for each client reference.



Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
   16(2). Client References*
   INTERFACE HISTORY


       ENTITY:
       FROM SYSTEM                            TO SYSTEM              APPLICATION(S)        NATURE OF INTERFACE ()              STATUS ()
                                                                      INTERFACED
Vendor Name      Product Name       Vendor Name       Product Name                    One-Way   Two-Way   Batch      Online   Live    Planned




       ENTITY:
       FROM SYSTEM                            TO SYSTEM              APPLICATION(S)        NATURE OF INTERFACE ()              STATUS ()
                                                                      INTERFACED
Vendor Name      Product Name       Vendor Name       Product Name                    One-Way   Two-Way   Batch      Online   Live    Planned




       ENTITY:
       FROM SYSTEM                            TO SYSTEM              APPLICATION(S)        NATURE OF INTERFACE ()              STATUS ()
                                                                      INTERFACED
Vendor Name      Product Name       Vendor Name       Product Name                    One-Way   Two-Way   Batch      Online   Live    Planned




   *   Complete one form for each client reference.




   Santa Clara Valley Health & Hospital System
   f0087f51-c357-48fb-a085-49af2a5179ca.doc
        17. Hardware Costs
        Entity  Santa Clara Valley Health & Hospitals System
        Vendor
        Product
        Date

                               SUGGESTED                                   TOTAL PURCHASE      UNIT ANNUAL   TOTAL ANNUAL     EXTENDED
ITEM DESCRIPTION                                       UNIT COST
                                QUANTITY                                        PRICE         MAINTENANCE*   MAINTENANCE    MAINTENANCE**




Total
Discounts
Net Total


        *     Cost for 24-hour support.
        **    A one time payment for multiple years (e.g., five years) of hardware support.




        Santa Clara Valley Health & Hospital System
        f0087f51-c357-48fb-a085-49af2a5179ca.doc
        18. Application Software Costs
        Entity  Santa Clara Valley Health & Hospitals System
        Vendor
        Product
        Date

                                                      ONE-TIME                                IMPLEMENTATION                     EXTENDED
 APPLICATION             LICENSE TERM*                                       ANNUAL COST                       TRAINING COST
                                                    LICENSE COST                                   COST                        MAINTENANCE**




Total
Discounts
Net Total


        *     Indicate number of years of license term, or "P" for perpetual license.
        **    A one-time payment for multiple years (e.g., five years) of software support.




        Santa Clara Valley Health & Hospital System
        f0087f51-c357-48fb-a085-49af2a5179ca.doc
     19. Other Software Costs
     Entity  Santa Clara Valley Health & Hospitals System
     Vendor
     Product
     Date

                                                                  LICENSE         LICENSE     ONE-TIME     ANNUAL    EXTENDED
               ITEM                      PRODUCT NAME
                                                                   TERM1           TYPE2    LICENSE COST    COSTS   MAINTENANCE3
Operating System
Application Programming
Language
Report Writer
Screen Builder
Forms Builder
Data Dictionary
Database Management System
Network Software
Communications Software
Other
(Specify)
Other
(Specify)
Total
Discounts
Net Total


     1.     Indicate number of years of license term, or "P" for perpetual license.
     2.     Indicate license type: "S" = Site    "U" = Single User License
     3.     A one-time payment for multiple years (e.g., five years) of software support.




     Santa Clara Valley Health & Hospital System
     f0087f51-c357-48fb-a085-49af2a5179ca.doc
 20. Interface Costs
 Entity  Santa Clara Valley Health & Hospitals System
 Vendor
 Product
 Date

   INTERFACE(S) BID
                                                                                     ONE-TIME   IMPLEMENTATION
  VENDOR     TARGET                              1      2         3            4                                      ANNUAL
                                     DIRECTION       MODE   FORMAT    MEDIUM       LICENSE COST      COST
  SYSTEM    SYSTEM                                                                                                     COST
[SPECIFY]        [SPECIFY]




Additional Software, Utilities, Tools, etc. Required (specify):




Total

    1.    DIRECTION:        1 = ONE-WAY INTERFACE                     2 = TWO-WAY INTERFACE
    2.    MODE:             R = ONLINE REALTIME    B = ONLINE BATCH
    3.    FORMAT:           FLATFILE           X12                HL7               UB92                  Other (Specify)
    4.    MEDIUM:           F = FTP            T=Tape             D=Diskette/CD     E= Interface Engine   Other (Specify)




 Santa Clara Valley Health & Hospital System
 f0087f51-c357-48fb-a085-49af2a5179ca.doc
21. Conversion Costs
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                                                                        ASSUMPTIONS
               CONVERSION FILE                         ONE-TIME COST
                                                                       (e.g., file must be in vendor-specified format)
 [SPECIFY]




 Total
 Discounts
 Net Total




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
22. Additional Costs
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

                                   ITEM                                           ONE-TIME COST         ANNUAL COST

    Additional Application Software Training
    System Operations Training
    Software Customization
    Travel and Living Expenses
    File Building Assistance
    Software Escrow Fee
    Project Manager*
    Manuals and Documentation
    Other (specify)
    Other (specify)
Total
Discounts
Net Total


   * Specify time commitment included in basic implementation and what this additional cost includes.




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
23. Cost Notes and Assumptions
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date

   Use this form to specify notes and assumptions to Forms 15 through 20.




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc
24. Cost Summary
Entity  Santa Clara Valley Health & Hospitals System
Vendor
Product
Date



           COST CATEGORY                           ONE-TIME COST   ANNUAL ONGOING COST

HARDWARE COSTS

SOFTWARE COSTS

    Application Costs

    Other Software

    Implementation

    Conversions

SOFTWARE COSTS SUBTOTAL

INTERFACES

    Interface Costs

    Implementation

INTERFACE COSTS SUBTOTAL

ADDITIONAL COSTS

TOTAL COSTS




Santa Clara Valley Health & Hospital System
f0087f51-c357-48fb-a085-49af2a5179ca.doc

				
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