Lic Proposal Form 340

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 REQUEST FOR PROPOSAL                                                 JOB NO.: 05/0057
       Cover Sheet                                              Date Due: MARCH 7, 2005
                                                                    DUE NO LATER THAN 2:00 P.M.
                                                                   LOCAL TIME IN HOUSTON, TEXAS
                                                                Proposals received later than the date
                                                                and time above will not be considered.

 PROPOSAL FOR: Waste, Fraud and Abuse Prevention Services for Community Health Choice, Inc.

                                         OFFERORS NOTE!!
Carefully read all instructions, requirements and          Please return proposal in an appropriately sized
specifications.  Fill out all forms properly and           envelope or box. PACKAGE MUST SHOW THE JOB
completely. Submit your proposal with all appropriate      NUMBER, DESCRIPTION AND BE MARKED
supplements and/or samples.                                "SEALED PROPOSAL".

                                     RETURN PROPOSAL TO:
                             HARRIS COUNTY PURCHASING AGENT
                               1001 PRESTON AVENUE, SUITE 670
                                     HOUSTON, TEXAS 77002

For additional information, contact Vivian Groce at 713-755-2606 or

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 Proposal $____________________________

Company Name:         ________________________________________________________________

Company Address:      ________________________________________________________________

City, State, Zip Code: ________________________________________________________________

Taxpayer Identification Number (T.I.N.): _________________________________________________

Telephone No. __________________FAX No. _____________________e-mail__________________

Print Name: ________________________________________________________________________

Signature: __________________________________________________________________________

Revised 05/04

                                                                                                    Page 1 of 22
                                                     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

__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/Tax Form
                                     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. All public work contracts over $25,000 require a
                                     Payment Bond and over $100,000 must also have a Performance Bond, in a form approved by the
                                     County. Please read carefully and fill out completely.

                  _____    c.        Bid Check Return Authorization Form
                                     This form applies only to certain bids/proposals. Please read carefully and fill out completely.

                  _____    d.        Vehicle Delivery Instructions
                                     Included only when purchasing vehicles.

                  __X__ e.           Minimum Insurance Requirements
                                     (Included in specific requirements when applicable (does not supersede ―Hold Harmless‖ section of
                                     General Requirements).

                  _____    f.        Worker’s 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.

                  __X__ h.           Reference Sheet
                                     When this information is required, you must use this sheet.

                  ___X__ i.          Other
                                     From time to time other attachments may be included.
Revised 03/04

                                                                                                                           Page 2 of 22
                                                 GENERAL REQUIREMENTS FOR PROPOSALS


General Requirements apply to all advertised requests for proposals; however, these may be superseded, whole or in part, by the SPECIAL
REQUIREMENTS/INSTRUCTIONS OTHER DATA CONTAINED HEREIN. Review the Table of Contents. Be sure your proposal package is

When specifications are revised, the Harris County Purchasing Agent will issue an addendum addressing the nature of the change. Offerors must sign it
and include it in the returned proposal package.

The successful offeror may not assign, sell or otherwise transfer this contract without written permission of Harris County Commissioners Court.

Harris County reserves the right to award this contract on the basis of LOWEST AND BEST OFFER 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 proposals. In the event the lowest dollar offeror meeting
specifications is not awarded a contract, the offeror may appear before the Commissioners Court, Hospital District Board of Managers, Community
Supervision & Corrections Department Board, the Juvenile Board or other applicable governing body and present evidence concerning his responsibility
after officially notifying the Office of the Purchasing Agent of his intent to appear.

If this proposal requires submission of proposal guarantee and performance bond, there will be a separate page explaining those requirements. Offers
submitted without the required proposal bond or Cashier's Check are not acceptable.

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 offeror. 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

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 proposal.

Upon signing this proposal 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 §15.01, et seq., Business & Commerce Code, or the federal antitrust laws, and has not
communicated directly or indirectly the offer made to any competitor or any other person engaged in such line of business. Any or all proposals may
be rejected if the County believes that collusion exists among the offerors. Proposals in which the prices are obviously unbalanced may be rejected. If
multiple proposals are submitted by an offeror and after the proposals are opened, one of the proposals is withdrawn, the result will be that all of the
proposals submitted by that offeror will be withdrawn; however, nothing herein prohibits a vendor from submitting multiple offers for different
products or services.

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.

Evaluation shall be used as a determinant as to which proposed 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 proposals are subject to negotiations by the
Purchasing Agent and other appropriate departments, with recommendation to the appropriate governing body. Compliance with all requirements, delivery
and needs of the using department are considerations in evaluating proposals. Pricing is NOT the only criteria for making a recommendation. A
preliminary evaluation by Harris County will be held and appropriate proposals will be subjected to the negotiating process. Upon completion of the
negotiations, Harris County will make an award. All proposals that have been submitted shall be available and open for public inspection after the contract
is awarded except for trade secrets or confidential information contained in the proposals and identified as such.

Revised 03/03

                                                                                                                                        Page 3 of 22
A multi-year lease or lease/purchase arrangement (if requested by the specifications), 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 contractor 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.

If offeror obtained the specifications on a floppy disk in order to prepare a response, the proposal must be submitted in hard copy according to the
instructions contained in this Request for Proposal package. If, in its response, offeror makes any changes whatsoever to the County's published
specifications, the County's specifications as published shall control. Furthermore, if an alteration of any kind to the County's published specifications is
only discovered after the contract is executed and is or is not being performed, the contract is subject to immediate cancellation.

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.

This request for proposals 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.

Any contract entered into by the County that is to be paid from grant funds shall be limited to payment from the grant funding and the vendor/provider
understands that the County has not set aside any County funds for the payment of obligations under a grant contract. If grant funding should become
unavailable at any time for the continuation of services paid for by the grant, and further funding cannot be obtained for the contract, then the sole
recourse of the provider shall be to terminate any further services under the contract and the contract shall be null and void.

Offeror agrees to comply with the Standards for Privacy of Individually Identifiable Health Information of the Health Insurance Portability and
Accountability Act of 1996, PL 104-191, 45 CFR Parts 160-164, as amended, and the Texas Medical Records Privacy Act, Texas Health and Safety
Code Chapter 181, as amended, collectively referred to as "HIPAA", to the extent that the Offeror uses, discloses or has access to protected health
information as defined by HIPAA. Offeror may be required to enter a Business Associate Agreement pursuant to HIPAA.

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 proposal,
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 proposal. Certification of such coverage must be provided to the County upon request.

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.

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 goods 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.

Maintenance required for equipment proposed should be available in Harris County by a manufacturer-authorized maintenance facility. Costs for this
service shall be shown on the Pricing/Delivery Information. 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.

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.
Revised 03/03

                                                                                                                                           Page 4 of 22
All products and/or services furnished as part of this contract must be compliant for the present year and forward. This applies to all computers
including hardware and software as well as all other commodities with date sensitive embedded chips.

An outside consultant or contractor is prohibited from submitting a 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 proposal, that
proposal shall be disqualified on the basis of conflict of interest, no matter when the conflict is discovered by Harris County.

Prices for all goods and/or services shall be negotiated to a firm amount for the duration of this contract or as agreed to in terms of time frame. All prices
must be written in ink or typewritten. Where unit pricing and extended pricing differ, unit pricing prevails.

Fill out and return to Purchasing, ONE (1) complete proposal form in an appropriately sized envelope or box. PACKAGE MUST SHOW THE JOB
NUMBER, DESCRIPTION AND BE MARKED “SEALED PROPOSAL.” An authorized company representative should sign the Proposal Cover
Sheet. Completion of these forms is intended to verify that the offeror has submitted the proposal, is familiar with its contents and has submitted the
material in accordance with all requirements.

Offerors must return all completed proposals to the office of the Harris County Purchasing Agent reception desk at 1001 Preston Avenue, Suite 670,
Houston, Texas before 2:00 P.M. LOCAL TIME IN HOUSTON, TEXAS on the date specified. Late proposals will not be accepted.

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 Agent. The fastest, most reasonable delivery time shall be indicated by the offeror in the proper place on the proposal document. 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 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.

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.

If in its response, offeror either electronically scans, re-types, or in some way reproduces the County's published proposal package, then in the event of any
conflict between the terms and provisions of the County's published proposal package, or any portion thereof, and the terms and provisions of the response
made by offeror, the County's proposal package as published shall control. Furthermore, if an alteration of any kind to the County's published proposal
package is only discovered after the contract is executed and is or is not being performed, the contract is subject to immediate cancellation.

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.

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 proposed.

Offerors are responsible for including all pertinent product data in the returned proposal package. Literature, brochures, data sheets, specification
information, completed forms requested as part of the proposal 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 proposal, must
also be in the returned proposal package. Failure to include all necessary and proper supplemental materials may be cause to reject the entire proposal.
Revised 04/04

                                                                                                                                          Page 5 of 22
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.

If the contract is intended to cover a specific time period, the term will be given in the specifications under SCOPE.

Harris County reserves the right to terminate the contract for default if Seller 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.

Harris County reserves the right to test equipment, supplies, material and goods proposed 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 offer is subject to rejection.

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 proposal and/or on the Purchase Order as a "Deliver To:" address.

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.

Offerors shall furnish all data pertinent to warranties or guarantees which may apply to items in the proposal. 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.

                                                             VENDORS OWING TAXES
Pursuant to TX Local Government Code 262.0276, the Hospital District Board of Managers has adopted a policy which requires that vendors’ taxes be
current as of the date bids/proposals are due. Bidders/proposers with delinquent taxes on the due date will not be eligible for award. Whether or not a
vendor’s taxes are delinquent will be determined by an independent review of the Tax Office records. Vendors who believe a delinquency is reflected
in error must contact the Tax Office to correct any errors or discrepancies prior to submitting their bid in order to ensure that their bid will be
considered. Tax records are available online at the Tax Office website— Prior to submitting a bid, vendors are encouraged to visit the
Tax Office website, set up a portfolio of their accounts and make their own initial determination of the status of their tax accounts. This policy is
effective for all bids due on or after July 1, 2004.

Revised 06/04

                                                                                                                                          Page 6 of 22
                                  SPECIAL REQUIREMENTS/INSTRUCTIONS

The following requirements and specifications supersede General Requirements where applicable. The term
"Harris County" is understood to include Community Health Choice, Inc. (CHC).

Responses to this Request for Proposal (RFP) shall be formatted as follows:
All proposals must be typed on standard 8-1/2" X 11" paper, indexed and placed in a 2 or 3-ring binder. Proposal
should be organized in the following order for consistency and easy screening:

Section I:      RFP Cover Sheet, Transmittal Letter, and Residence Certification - The transmittal letter should include
company name and address; name, title, telephone and fax number of person(s) to be contacted for clarifications or additional
information regarding proposal; name, title, telephone and fax number of person authorized to contractually obligate your
company with proposal and any future negotiations; and a brief summary explaining how all requirements of this RFP will be
met and proposer’s ability to meet the needs and requirements of the RFP.

Section II:   Scope of Service – Provide detailed information regarding proposed services. Provide clear evidence of
your company’s ability, experience, resources, and plans to meet the requirements of the RFP. Include an Implementation

Section III:    Pricing Information

Section IV:     Questionnaire (completed)

Section V:      References

Section VI:     Agreement(s) – Include all Agreements or Contract(s) associated with response.

Section VII: Special Requirements – Certificate(s) of Insurance, exceptions to any of the requirements in this RFP,
appropriate company brochures, etc. may be included.

(CLEARLY MARKED “COPY”) of the response sealed in an envelope or package for delivery to the Harris
County Purchasing Agent per the instructions in the General Requirements (see Proposal Completion and Proposal
Returns). All documents included in the proposal and the outside of the envelope or package must be marked with
the vendor's name and the job number that corresponds to this RFP.

While Harris County appreciates a brief, straightforward, concise reply, the proposer must fully understand that the
evaluation is based on the information provided. Accuracy and completeness are essential. Omissions, ambiguous
and equivocal statements may be construed against the proposer. The proposal response may be incorporated into
any contract which results from this RFP, and vendors are cautioned not to make claims or statements it is not
prepared to commit to contractually. Failure of the vendor to meet such claims will result in a requirement that the
vendor provide resources necessary to meet submitted claims.

The vendor is expected to examine all documents, forms, specifications, and all instructions. Failure to do so will be
at vendor’s risk.

                                                                                                             Page 7 of 22

All documents will be held by the County and are NOT subject to public view until an award is made. Under the
Request for Proposal process, sealed offers will be received and opened in the Office of the Harris County
Purchasing Agent. At and after opening, proposals will NOT be part of the public record and subject to disclosure,
but will be kept confidential until time of award. When an award is made, proposals are subject to review under the
―Public Information Act‖. To the extent permitted by law, vendors may request in writing non-disclosure of
confidential data. Such data shall accompany the proposal, be readily separable from the proposal, and shall be

Harris County will not be liable for any costs incurred by the vendor in preparing a response to this RFP. Vendors
submit proposals at their own risk and expense. Harris County makes no guarantee that any services will be
purchased as a result of this RFP, and reserves the right to reject any and all proposals. All proposals and
accompanying documentation will become the property of Harris County. All proposals are open to negotiation.

All correspondence relating to this RFP, from advertisement to award, shall be sent to the Harris County Purchasing
Department. All presentations and/or meetings between CHC and the vendor relating to this RFP shall be
coordinated by the Purchasing Department.

This request for proposal in no manner obligates Harris County or any of its agencies to the eventual purchase of any
service described, implied or which may be proposed, until confirmed by a written contract and purchase order.
Progress toward this end is solely at the discretion of Harris County and may be terminated at any time prior to the
signing of a contract.

All proposals will be examined by an evaluation committee.

Proposals that do not conform to the instructions or which do not address all the services as specified may be
eliminated from consideration. Harris County, however, reserves the right to accept such a proposal if it is
determined to be in the best interest of CHC.

Harris County may initiate discussions with selected vendors. Discussions may not be initiated by vendors. Harris
County expects to conduct discussions with vendor personnel authorized to contractually obligate the vendor with an
offer. Vendors shall not contact any CHC personnel during the RFP process without the express permission from
the Office of the Harris County Purchasing Agent. Harris County may disqualify any vendor who has made site
visits, contacted CHC personnel or distributed any literature without authorization from the Purchasing Department.

Selected vendors may be expected to make a presentation to the evaluation committee. Vendor presentations may
result in negotiating sessions.

                                                                                                      Page 8 of 22

The award of the contract shall be made to the responsible vendor whose proposal is determined to be the best
evaluated offer resulting from negotiations, taking into consideration the following and other factors set forth in
the RFP.
o      Compliance with instructions and specifications
o      Proposed services
o      Vendor Qualifications
o      Demonstrated ability to provide the required services
o      Experience providing services described herein with other clients of similar size and structure to
       Community Health Choice, Inc.
o      References
o      Cost

No award can be made until approved by Community Health Choice, Inc. Board of Directors. This RFP in no
manner obligates Harris County or any of its agencies to the eventual purchase of any service described, implied or
which may be proposed. Progress toward this end is solely at the discretion of Harris County and may be terminated
at any time prior to issuance of a policy.

Submission of a proposal implies the vendor's acceptance of the evaluation criteria and vendor recognition that
subjective judgments must be made by the evaluating committee.

Proposer should submit any agreements for services, etc. which may be required by its organization to enter into a
contract with CHC. These agreements are subject to review and amendment by the Harris County Attorney's
Office, and approval by CHC.

                                                                                                    Page 9 of 22

          Waste, Fraud and Abuse Prevention Services for Community Health Choice, Inc.

Harris County is soliciting proposals from qualified vendors to assist in the prevention of waste, fraud and abuse,
as stipulated in the Texas Administrative Code, Title 1, Part 15, Chapter 353, Subchapter F, entitled Special
Investigative Units, for Community Health Choice, Inc. for a one-year period beginning on or about June 1, 2005
and ending twelve-months thereafter. For additional information, contact Vivian Groce at 713-755-2606 or email

Vendors are encouraged to review this entire solicitation upon receipt. All questions must be faxed to (713) 755-
6695 Attention: Vivian Groce or emailed to before February 21, 2005.

Harris County may consider three successive, one-year renewal options based upon the same terms, conditions and
pricing as the original year. Renewal is subject to approval by the Community Health Choice, Inc. Board of
Directors. Once the renewal option is exhausted, the contract must be rebid. If a bidder does not wish to consider a
renewal, write "N.A." in the space for the year indicated on Page 12.

Harris County retains the option to rebid at any time if in its best interest and is not automatically bound to
renewal or rebid.

Community Health Choice, Inc. (CHC) a Medicaid HMO and subsidiary of the Harris County Hospital District, is
currently providing care to approximately 54,105 Medicaid STAR members in six (6) counties. CHC is in the
process of applying through the State HHSC reprocurement process to expand to add CHIP members. CHC’s
projected member months for 2005 for the STAR program is 649,260 and 8,250 for the CHIP program. The
projected monthly membership for 2005 for the STAR program is 65,680 and 2,250 for the CHIP program.

Vendor will provide waste, fraud and abuse prevention services for Community Health Choice, Inc. (CHC) a
Medicaid HMO and subsidiary of the Harris County Hospital District. The services shall be in accordance with
Texas Administrative Code, Title 1, Part 15, Chapter 353, Subchapter F, entitled Special Investigative Units.

Services shall include, but not be limited to the following:
1.    Create a plan document to prevent and reduce waste, fraud and abuse;

2.    Prepare written standard of conduct and policies and procedures manual for detecting, investigating and
       preventing waste, fraud and abuse;

3.     Prepare web-based educational material to provide: a) general training to CHC staff; and b) specific
       training for individuals involved in data collection, provider enrollment or disenrollment, encounter data,
       claims processing, utilization review, appeals or grievances, quality assurance, and marketing;

                                       SPECIFICATIONS- CONTINUED

                                                                                                    Page 10 of 22
4.    Utilize CHC’s current published toll-free hotline which CHC staff, providers and HMO Members may call
       to report possible waste, fraud or abuse;

5.    Provide Quarterly data analysis of CHC claims data to determine possible red flags of waste, fraud or
       abuse; and

6.    Provide staff to perform follow-up investigations upon the identification of possible red flags through data
       analysis or direct reporting.

7.     Provide expert advice to CHC regarding investigation process, follow up and potential options and

Vendor must accept the claims data files provided by CHC in the file format defined by CHC. Encrypted data
files will be provided in CHC’s proprietary format as coma text delimited through a secure ftp server. See
Exhibit I for the file format.

Vendor Qualifications
Vendor must be familiar with Texas Medicaid rules and Texas waste, fraud and abuse requirements. Vendor
must have expertise in the identification, investigation and prevention of waste, fraud and abuse in managed
Medicaid plans in Texas. Vendor must have a proven software system designed to identify possible waste, fraud
or abuse in claims data. Vendor’s staff must be certified as antifraud examiners, with affiliation or membership
in the National Health Care Antifraud Association or other nationally recognized organizations.

                                                                                                  Page 11 of 22
                                   PRICING/DELIVERY INFORMATION

Provide a per member per month fee to provide the proposed services for Medicaid and CHIP membership.

                              $_____________         Per Member Per Month

Bidder agrees to renew this contract for the time frame stated below under the same terms and conditions and pricing
as the original contract. If bidder does not wish to be considered for renewal, write ―N.A.‖ in the space provided.

Renewal Year 1: (2006 – 2007) _______
Renewal Year 2: (2007 – 2008) _______
Renewal Year 3: (2008 – 2009) _______

                                                                                                   Page 12 of 22
                                                                                                              Attachment a
                                                                                                          Job No. 05/0057

                                    RESIDENCE CERTIFICATION/TAX FORM

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
                         [Company Name]
          Government Code §2252.001 and our principal place of business is _______________________________.
                                                                                  [City and State]

Taxpayer Identification Number (T. I. N.): _________________________________________________

Company Name submitting Bid/Proposal: __________________________________________________

Mailing Address: _____________________________________________________________________

If you are an individual, list the names and addresses of any partnership of which you are a general partner:

PROPERTY: List all taxable property owned by you or above partnerships in Harris County.

Harris County Tax Acct. No.*                Property address or location**
_______________________                     _____________________________________________
_______________________                     _____________________________________________
_______________________                     _____________________________________________
_______________________                     _____________________________________________

 * This is the property account identification number assigned by the Harris County Appraisal District.
** For real property, specify the property address or legal description. For business personal property, specify the
   address where the property is located. For example, office equipment will normally be at your office, but inventory may
   be stored at a warehouse or other location.

Revised 5/04

                                                                                                            Page 13 of 22
                                                                                                              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

•        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

                                                                                                        Page 14 of 22

Reference #1

Organization Name:________________________________________________________________
Contact Name/Telephone No.: _______________________________________________________
Services Provided:__________________________________________________________________

Reference #2

Organization Name:________________________________________________________________
Contact Name/Telephone No.: _______________________________________________________
Services Provided:__________________________________________________________________

Reference #3

Organization Name:________________________________________________________________
Contact Name/Telephone No.: _______________________________________________________
Services Provided:__________________________________________________________________

Reference #4

Organization Name:________________________________________________________________
Contact Name/Telephone No.: _______________________________________________________
Services Provided:__________________________________________________________________

Reference #5

Organization Name:________________________________________________________________
Contact Name/Telephone No.: _______________________________________________________
Services Provided:__________________________________________________________________

                                                                                 Page 15 of 22

Please provide the following information:

1.     Does your company have experience successfully providing similar services to those outlined in the Scope
       of Services? If yes, how long. Provide examples. How do you measure success?

2.     What are your company’s organizational goals, business philosophy and mission?

3.     What would you consider the top three (3) measures of a successful relationship between your company
       and CHC? State how you measure and report each.

4.     Indicate key personnel – by name, title, and qualifications relative to this project – who will be responsible
       for this project. Provide their roles and responsibilities for this project. Where is their office located?

5.     Does your company have a minimum of three (3) client references wherein it has provided services similar to
       those described in the Scope of Services? Please use Reference form included in RFP. Healthcare and
       governmental references are preferable.

                                                                                                     Page 16 of 22
                                  EXHIBIT I
Tran File Extended Layout


Company Number            TCO#    S    2     0   1             Company Number
Insurance Company #        TICO#  S   5      0   3             Insurance Company #
Member Number              TMBR#  A 12           8             Member Number
Member Sub Number          TSUB#  A     3        20            Member Sub Number
Attending Doctor Nbr       TADOC# S    9     0   23            Attending Doctor Nbr
Attending Doctor Name     TADOCN A 25            32            Attending Doctor Name
Payee Number               TPAYE# S    9     0   57            Payee Number
Payee Name                TPAYNM A 25            66            Payee Name
Referred By Doctor         TRFBY# S    9     0   91            Referred By Doctor
Inside/outside Doctor      TTYPE  A    1         100           Inside/outside Doctor
Claim Number              TCLAIM P    9      0   101           Claim Number
Form Type                 TFORM   A    4         106           Form Type
Diagnosis 1               TDIA1   A   7          110           Diagnosis 1
Diagnosis 2               TDIA2   A   7          117           Diagnosis 2
Diagnosis 3               TDIA3   A   7          124           Diagnosis 3
Diagnosis 4               TDIA4   A   7          131           Diagnosis 4
Diagnosis 5               TDIA5   A   7          138           Diagnosis 5
Diagnosis 6               TDIA6   A   7          145           Diagnosis 6
Diagnosis 7               TDIA7   A   7          152           Diagnosis 7
Diagnosis 8               TDIA8   A   7          159           Diagnosis 8
Diagnosis 9               TDIA9   A   7          166           Diagnosis 9
Place Of Service          TSRVPL A    3          173           Place Of Service
Date Of Service           TSRVDT L    10         176           Date Of Service
Date To Service           TSRVTDT L 10           186           Date To Service
Quantity                  TQTY    S    7       0 196            Quantity
Procedure Code            TPROC   A    8          203           Procedure Code
Service Charge Desc       TSRVDS A 25             211           Service Charge Desc
Service Type              TCODE   A    8          236           Service Type
Category Service Code    TCOS#    S    5       0 244           Category Service Code
Revenue Code              TREVCD A    8           249          Revenue Code
Charges                  TCHRGS S     8        2 257           Charges
Exclude Code              TEXCOD A    1           265          Exclude Code
Non-coverered Charges    TNCHGS S     8        2 266           Non-coverered Charges
Authorized Amount        TAUTH     S  8        2 274           Authorized Amount
Co-payment                TCOPAY S     7       2 282           Co-payment
Deductible Amount         TDED     S   8       2 289           Deductible Amount
Coordination Of Benefits TCOB      S  8        2 297           Coordination Of Benefits
Witholding Amount         TWHIAM S    7        2 305           Witholding Amount
Discount                  TDIS     S   8       2 312           Discount
% Of Charges Authorized TPCT       S   3       0 320           % Of Charges Authorized
No Withholding Flag       TNOWHI A     1          323          No Withholding Flag
Rvs Units                 TRVSU    S    6      3 324           Rvs Units
Hold Code                  THOLD   A    2         330          Hold Code
Patient Last Name         TPLNAM A 20             332          Patient Last Name
Patient First Name        TPFNAM A 12             352          Patient First Name
Patient Middle Init       TPINTL   A              364          Patient Middle Init

                                                                       Page 17 of 22
Processing Number          TPROC#      S      8   0   365   Processing Number
Date Received              TRCVDT      L    10        373   Date Received
Pay On Date                TPAYDT      L    10        383   Pay On Date
Date Paid/deny             TPADDT      L    10        393   Date Paid/deny
Invoice Number             TINV#       S     6    0   403   Invoice Number
Check Number                TCHK#       S    6    0   409   Check Number
Authorization Number       TAUTH#      A     15       415   Authorization Number
Outside Autrorize           TOSAUT     A     15       430   Outside Autrorize
Ref Number                  TREF#      A     20       445   Ref Number
Group Number                TGRP#      A     12       465   Group Number
Plan Number                 TPLAN      A     5        477   Plan Number
Payment Type               TPAYCO      A     1        482   Payment Type
Payment Percent            TPAY#       S     5    4   483   Payment Percent
Batch Number                TBATCH     S     5    0   488   Batch Number
G/l Major                  TGLMAJ      S     6    0   493   G/l Major
G/l Minor                   TGLMIN     S     4    0   499   G/l Minor
Age Of Member              TAGE        S    3     0   503   Age Of Member
Age Type                   TAGETP      A     1        506   Age Type
Region Code                TREGON      A     2        507   Region Code
County Code                TCONTY      A     3        509   County Code
Encounter Sent             TSENT        A    1        512   Encounter Sent
Enc Sent Date              TSNTDT      L    10        513   Enc Sent Date
Used With Eob Processing   TFLAG1      A     1        523   Used With Eob Processi
Not Used                    TFLAG2     A     1        524   Not Used
Not Used                    TFLAG3     A     1        525   Not Used
Seq #                       TFLAG4     S     6    0   526   Seq #
Ssi Cntl# Ecr-tmc           TFLAG5     A    10        532   Ssi Cntl# Ecr-tmc
Used Re-pricing             TFLAG6     A     1        542   Used Re-pricing
Closed Referral             TFLAG7     A     1        543   Closed Referral
Not Used                    TFLAG8     A     1        544   Not Used
Transfered To Billing      TFLAG9      A     1        545   Transfered To Billing
Not Used                    TFLAG0     A     1        546   Not Used
User Who Adjudicated       TADDUS      A    10        547   User Who Adjudicated
Date Adjudicated            TADDDT     L    10        557   Date Adjudicated
User Who Revised            TREVUS     A     10       567   User Who Revised
Date Revised                TREVDT      L    10       577   Date Revised
Record Status               TSTATS      A     1       587   Record Status
Hold Code Type              THLDTY     A      1       588   Hold Code Type
Level Of Care               TLEVEL      A     2       589   Level Of Care
Anesthesia Start Hour       TSTIMH      S     2   0   591   Anesthesia Start Hour
Anesthesia Start Minu       TSTIMM      S     2   0   593   Anesthesia Start Minu
Anesthesia End Hour         TETIMH      S     2   0   595   Anesthesia End Hour
Anesthesia End Minu          TETIMM     S     2   0   597   Anesthesia End Minu
Subscriber Number           TSCRIB      A    12       599   Subscriber Number
Subscriber Sub#             TSSUB       A     3       611   Subscriber Sub#
Sex                         TSEX        A     1       614   Sex
Tier Code                   TTIER      A      1       615   Tier Code
Cap Class Code               TCLASS    A     3        616   Cap Class Code
Pay To                       TPAYTO    A     1        619   Pay To
Point Of Service             TUSER1    A     1        620   Point Of Service
Not Used                     TUSER2    A      1       621   Not Used
Letter Sent Flag              TUSER3   A     1        622   Letter Sent Flag
User Field 4                  TUSER4   A      1       623   User Field 4
Paid Amt On Eob               TUSER5   A     1        624   Paid Amt On Eob
Pcp Or Spec                   TUSER6    A     1       625   Pcp Or Spec

                                                                   Page 18 of 22
Used As Price Ind           TUSER7   A     2         626   Used As Price Ind
Sub Location/fund          TUSER8     A    4         628   Sub Location/fund
User Field 9               TUSER9     A     6        632   User Field 9
Epo Date Received          TEPODT     L    10        638   Epo Date Received
Epo Check Number           TEPOCK     S    10    0   648   Epo Check Number
Epo Payment Amt            TEPOAM     S     8    2   658   Epo Payment Amt
User Who Logged            TLOGUS     A     10       666   User Who Logged
Date Logged                TLOGDT    L     10        676   Date Logged
Early Periodic Screening   TEPSDT    A     2         686   Early Periodic Screening
Dental Oral Cavity         TFLD01    A     2         688   Dental Oral Cavity
Dental Tooth Code          TFLD02    A     2         690   Dental Tooth Code
Plan Note                  TFLD03    A     2         692   Plan Note
Extra Field 4              TFLD04    A     3         694   Extra Field 4
Fix-only Ben-cod           TFLD05    A     3         697   Fix-only Ben-cod
Extra Field 6               TFLD06   A     3         700   Extra Field 6
Extra Field 7              TFLD07    A     4         703   Extra Field 7
Extra Field 8              TFLD08    A     4         707   Extra Field 8
Extra Field 9              TFLD09    A     4         711   Extra Field 9
Extra Field 10             TFLD10    A     5         715   Extra Field 10
Major Schedule             TFLD11    A     5         720   Major Schedule
Minor Schedule             TFLD12    A     5         725   Minor Schedule
Dental Tooth Surfaces      TFLD13    A     6         730   Dental Tooth Surfaces
Extra Field 14             TFLD14    A     6         736   Extra Field 14
Extra Field 15             TFLD15    A     6         742   Extra Field 15
Paid Amount                TFLD16    S     8     2   748   Paid Amount
Extra Field 17             TFLD17    S     8     2   756   Extra Field 17
Co-insur                   TCOINS     S    8     2   764   Co-insur
Relationship               TRELT     A     2         772   Relationship
High Risk1                 THIGH1    A     1         774   High Risk1
High Risk2                 THIGH2     A    1         775   High Risk2
High Risk3                 THIGH3     A    1         776   High Risk3
High Risk4                 THIGH4     A    1         777   High Risk4
Tribe                       TTRIBE    A     2        778   Tribe
Reservation                TRESER     A    1         780   Reservation
Occupation                 TOCCPC     A    5         781   Occupation
Modifier Two                TMOD2     A     2        786   Modifier Two
Modifier Three              TMOD3     A     2        788   Modifier Three
Modifier Four               TMOD4      A    2        790   Modifier Four
Residence Address Line 1    MADR1      A   25        792   Residence Address Line 1
Residence Address Line 2    MADR2      A   25        817   Residence Address Line 2
Residence City             MCITY      A    20        842   Residence City
Residence State            MSTAT      A     2        862   Residence State
Residence Zip Code         MZIPC      A     9        864   Residence Zip Code
Birth Date                  MBIRDT    L     10       873   Birth Date

                                                                  Page 19 of 22
Provider File Layout


Company Number            DCO#     S 2        0     1           Company Number
Doctor Number             DCTR#    P   9      0     3           Doctor Number
Last Name                 DLNAM    A   20           8           Last Name
First Name                DFNAM    A   12           28          First Name
Middle Initial            DINIT    A   1            40          Middle Initial
Title                     DTITL    A   4            41          Title
Address Line 1            DADR1    A 25             45          Address Line 1
Address Line 2            DADR2    A 25             70          Address Line 2
City                      DCITY    A 20             95          City
State                     DSTAT    A   2            115         State
Zip Code                  DZIPC    A    9           117         Zip Code
Area Code                 DAREA    P   3       0    126         Area Code
Phone #                   DPHON    P   7       0    128         Phone #
Phone Extension          DPHONX S      4       0    132         Phone Extension
Type                      DTYPE    A   1            136         Type
Pratice Code 1            DPRC1    A    3           137         Pratice Code 1
Pratice Code 2            DPRC2    A    3           140         Pratice Code 2
Pratice Code 3            DPRC3    A    3           143         Pratice Code 3
Emergency Area Code       DEACD     P   3       0 146           Emergency Area Code
Emergency Phone #        DEPHN      P   7       0 148           Emergency Phone #
Area Code Pager           DPAGEA    P   3       0 152           Area Code Pager
Phone # Pager             DPAGEP    P   7       0 154           Phone # Pager
Department                DDEPT     A   6            158        Department
Medicare #                DMCR#    A 12             164         Medicare #
Medicare Expire Date      DMCRDT L 10               176         Medicare Expire Date
Medicaid #                DMCD#     A 12            186         Medicaid #
Medicaid Expire Date      DMCDDT L 10               198         Medicaid Expire Date
Texas Provider Id Number DBC#       A 12            208         Texas Provider Id Number
Blue Cross Expire Date DBCDT        L 10            220         Blue Cross Expire Date
Malpractice#              DCP#      A 12            230         Malpractice#
Malpractice Expire Date DCPDT        L 10           242         Malpractice Expire Date
Ama #                     DAMA#      A 12                252             Ama #
Ama Expire Date          DAMADT L 10                264         Ama Expire Date
Dea #                     DDEA#      A 12           274         Dea #
Dea Expire Date           DDEADT     L 10           286         Dea Expire Date
State Lic #               DSTE#      A 12           296         State Lic #
State Expire Date         DSTEDT     L 10           308         State Expire Date
Associate 1               DREF1      P   9       0 318          Associate 1
Associate 2               DREF2      P   9        0 323         Associate 2
Associate 3               DREF3      P   9        0 328         Associate 3
Fax/other Area Code       DOACD      P   3       0 333                   Fax/other Area
Fax/other Phone #         DOPHN      P   7       0 335          Fax/other Phone #
Sex                       DSXCD      A    1          339        Sex
Birth Date                DBIRDT     L 10           340         Birth Date
Doctor Payee              DPAYEE     S   9       0 350          Doctor Payee
Primary Physician         DPRI       A   1          359         Primary Physician
Specialty Physician       DSPEC      A    1         360         Specialty Physician

                                                                        Page 20 of 22
Referral Physician   DREFL     A    1       361    Referral Physician
Record Status        DSTATS    A    1       362    Record Status
State Tax I.d.       DSTAX#   A 12          363    State Tax I.d.
Federal Tax I.d.     DFTAX#   A 12          375    Federal Tax I.d.
Region Code          DREGON    A   2        387    Region Code
County Code          DCONTY    A   3        389    County Code
Maximum Members      DMXMBR   S   4     0   392    Maximum Members
Upin Number          DUPIN#   A 12          396    Upin Number
Mailing Name         DNAME2    A 30         408    Mailing Name
Mailing Address 1    DADR12    A 25         438    Mailing Address 1
Mailing Address 2    DADR22    A 25         463    Mailing Address 2
Mailing City         DCITY2    A 20         488    Mailing City
Mailing State        DSTAT2    A    2       508    Mailing State
Mailing Zip Code     DZIPC2    A    9       510    Mailing Zip Code
Mailing Area Code    DAREA2    S   3    0   519    Mailing Area Code
Mailing Phone #      DPHON2    S   7    0   522    Mailing Phone #
Mailing Extension    DPEXT2    S   4    0   529    Mailing Extension
Mailing Fax Area     DOACD2    S   3    0   533    Mailing Fax Area
Mailing Fax #        DOPHN2     S   7   0   536    Mailing Fax #
Watch This Doctor    DWATCH    A    1        543   Watch This Doctor

                                                          Page 21 of 22
Pharmacy File Layout


Claim Number              PCLAIM# A    9        1     Y      Claim#
Claim Status              PCLAIMS A    2        10    Y      Cs
Received Date             PRCDATE A 10          12    Y      Recv Date
Cardholder Id             PCRDID# A 20          22    Y      Card Id
Patient Last Name         PPLNAME A 20          42    Y      Patient Last Name
Patient First Name        PPFNAME A 10          62    Y      Patient First Name
Patient Dob               PPDOB     A 10        72    Y      Dob
Patient Sex               PPSEX     A   1       82    Y      Sex
Eligibility Category      PELGCAT A     2       83    Y      Cat
Mngd Access Claim Lock PLOCKIN A        1       85    Y      L
Pharmacy Number           PPHARM# A     6       86    Y      Pharm #
Pharmacy Name             PPHARNM A 30          92    Y      Pharmacy Name
Pharmacy Address          PPHARAD A 30          122   Y      Pharmacy Address
Pharmacy City             PPHARCT A 20          152   Y      Pharmacy City
Pharmacy State            PPHARST A     2       172   Y      Pharmacy State
Pharmacy Zip              PPHARZP A 10          174   Y      Pharmacy Zip
Prescriber Number         PPRESC# A 15          184   Y      Prescriber Number
Prescriber Last Name       PPRESLN A 30         199   Y      Prescriber Last Name
Prescriber First Name      PPRESFN A 30         229   Y      Prescriber First Name
Prescription #            PPRSCRP A    7        259   Y       Prescription #
Prescription Sequence #    PPRSCRS A    5       266   Y      Prescription Seq #
Date Filled                PDTEFIL A 10         271   Y      Date Filled
Date Prescription Written PDTEWRT A 10          281   Y      Date Written
New/refill Code            PNEWREF A      1     291   Y      New Ref
Number Of Refills Authori PREFAUT A      1      292   Y      # Ref
National Drug Code #       PNDCNBR A 19         293   Y      Ndc Number
Tx Therapeutic Class        PTHERAP A     8     312   Y      Therapeutic
Drug Label Name             PDRUGNM A 30        320   Y      Drug Name
Compound Code               PCMPCOD A 1         350   Y      Cc
Daw/production Selection PDAWCOD A 2            351   Y      Wc
Source Type                PSRCTYP    A 1       353   Y      St
Dea Code                    PDEACOD A 1         354   Y      Dc
Legend Indicator           PLGNDIN A      1     355   Y      Li
Metric Decimal Quantity PQUANTY A         6     356   Y      Quantity
Unit Dispensed Type        PUNITTY   A    3     362   Y      Unit Type
Estimated Days Supply      PDAYSUP A      2     365   Y      Days Supl
Amount Billed From Phar PBILLD$      S 12   2   367   Y      Billed $
Amount Paid By Vendor      PPAID$$   S 12   2   379   Y      Paid $
Copay For Chip Only        PCOPAY$ S 12     2   391   Y      Copay $
Cost Of Drug               PICOST$   S 12   2   403   Y      Drug Cost $
How Drug Claim Calculated PBCOSTD A       2     415   Y      Cd
Prior Auth Med Certificat PMDCERT A 12          417   Y      Med Cert Code
Customer Location          PCUSTLC A     2      429   Y      Cl
Other Coverage Code         POTHCOV A     2     431   Y      Oc
Line Feed                   PLINEFD A     1     433   Y      Lf
File Date                   PFLEDTE L 10        434   Y      File Date
Create Date                 PCRTDTE L 10        444   Y      Create Date
Create User                 PCRTUSR A 10        454   Y      Create User

                                                                    Page 22 of 22

Description: Lic Proposal Form 340 document sample