V--Ambulance Service

CONTINUATION PAGE STATEMENT OF WORK GROUND AMBULANCE SERVICES Louis A. Johnson VA Medical Center Clarksburg, West Virginia 1. SCOPE. Contractor shall furnish 24-hour ground ambulance services to eligible veterans of the Department of Veterans Affairs, Louis A. Johnson VA Medical Center, Clarksburg, West Virginia. It will be necessary for the contractor to have a staff of State of West Virginia certified paramedics currently certified to receive radio command medical orders from an appropriate hospital thereby being able to render life saving techniques to patients. The sole purpose of this contract is to provide cost effective, efficient and expeditious transfer of patients (to include indoor pick-up and indoor delivery) services. a. The contractor agrees to provide all services specified in the contract for any person determined to be eligible by the VA, regardless of race, creed, color, or national origin of the person for whom services are being ordered. Additionally, the contractor warrants that subcontracting shall not be used as a means of circumventing this provision. b. Requests for services will be written or made via telephone by the VA's designated representatives. A list of authorized representatives will be provided upon award of the contract. Offerors are advised that the minimum number of ambulance vehicles that must be available to the VA at any given time is one (1). Offerors must also be advised that the maximum number of ambulance vehicles that will be required to provide within a reasonable period of time is five (5). c. Proposals will be considered only from offerors who are regularly established in ground ambulance services, and who are financially responsible to have all necessary equipment and personnel to furnish services in the volume required for herein. The successful offeror shall meet all requirements of the Federal, State, or City codes regarding operations of services in this solicitation. Each bidder must submit, along with a bid, a letter in duplicate fully describing the make of the vehicles, model and year which the offeror agrees to furnish under this proposal, including the location and telephone numbers of the establishment where calls are received and vehicles are immediately available for dispatch. d. The Government will not be responsible for any loss, theft, or missing equipment belonging to the contractor. The contractor shall ensure all stretchers, restraint straps, wheelchairs, and blankets, etc., are permanently stenciled or taped making such property readily identifiable as belonging to the contractor. The contractor further agrees that his/her technicians and/or attendants will make all reasonable efforts to pick up any of his/her equipment immediately after completing the trip. Failure to do so will in no way require the Government to assume financial responsibility for any loss, damage, or theft. 2. LOCATION OF WORK. For the purpose of this solicitation, local trip is defined as any trip within a 50 mile radius of the Louis A. Johnson VAMC. Long distance is defined as any trip within a radius of the Louis A. Johnson VAMC greater than 50 miles but not more than 125 miles. For trips requiring travel beyond the 125 mile radius, an additional mileage charge shall apply for each additional mile required to be traveled outside the 125 mile radius. The contracting officer will rely on the VA Travel Clerk on areas of any disputed mileage. 3. PERIOD OF PERFORMANCE. The anticipated Base Period of performance for contract services will begin 1 July 2009 through 30 September 2009. Contingent upon need and subject to the availability of funds, the government reserves the right to exercise four 1 year option periods. The exercise of each option year is at the sole discretion of the government. The First Option period will provide services from 1 October 2009 through 30 September 2010 the Second Option period will provide services from 1 October 2010 through 30 September 2011 the Third Option period will provide services from 1 October 2011 through 30 September 2012 and the Fourth Option period will provide services from 1 October 2012 through 30 September 2013. 4. DELIVERY SCHEDULE. a. The contractor must ensure that transports are scheduled so that the total distance will result in the most economical means to the Government. The contractor agrees that the rates charged herein are not to excess of those charged to the general public for the same services. b. The VA Medical Center, Clarksburg, WV shall determine the type of vehicle to be ordered. The contractor shall verify the specific type of patient-care vehicle and provide the same within the time period acceptable. If the vehicle is not provided within the acceptable time period, the VA reserves the right to order services from another source. Any additional charges incurred by the Government will be passed on to the contractor. c. Standard emergency transports that do not require specialized staff are required to be provided within 30 minutes of notification. Transportation requiring specialized staff (i.e. RN) is expected to be provided within 45 minutes of notification. RN to be provided by VAMC. d. In the event a vehicle must wait for a patient beyond the contractor's control, reimbursement must be authorized and claimed. The payment will be at one-fourth (1/4) the negotiated hourly rate. Fractional times will be in hours (15 minute) increments. e. The Contractor shall report any/all delays as soon as the driver is aware of the situation. Delays occurring between the hours of 7:30 a.m. and 4:00 p.m. shall be reported to the Travel Clerk at the VA Medical Center. Delays that occur between the hours of 4:00 p.m. and 7:30 a.m. shall be reported to the Administrative Officer of the Day (AOD). f. Ambulance services shall be available upon request twenty-four (24) hours a day, three hundred sixty-five (365) or sixty-six (366) days per year, including all National Holidays. National Holidays are: New Year's Day, Martin Luther King's Birthday, President's Day, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day and Christmas Day. 5. APPLICABLE PERFORMANCE STANDARDS. a. Only one patient may be transported per trip by ambulance, unless specifically authorized in writing by the VA. When more than one patient is transported on a trip, payment will be made at the rate not exceeding the cost of transporting a single patient; however, the contractor may claim payment at the rate that would apply for the patient that is transported the greater distance. An authorized official of the VA may, when in the best interest of the veteran, allow a relative or caregiver to accompany the veteran. This will be done at no additional cost to the VA Medical Center. b. All patient charts and records transported with the patient are confidential and limited to a "need to know basis" for the Contractor's personnel. Appropriate administrative and medical information will be provided to the Contractor for patient transport. If the medical record is transported with the patient, it may be used as a source of information if the situation warrants. In all other instances, all documents will remain intact and secured. A veteran's personal belongings may be transported with him/her. The belongings shall be handled with the utmost care and be in the same condition after transport as before. c. If the contractor fails to furnish ambulance services in an emergency situation within 30 minutes after receiving the request or an order, the VA reserves the right to obtain the services from another source and charge the contractor any excess costs above the negotiated rates agreed to. If the service is provided late, the contractor will provide plausible explanation to the VAMC within 24 hours of the call. The VA will be the sole judge in determining when to order services from another source. d. There are occurrences when a patient will be scheduled for appointments requiring transportation from the medical center, a nursing home, or a place of residence. Patients shall not wait more than 15 minutes beyond the scheduled pick-up time. Failure of the vehicle to arrive at the patient's residence, the medical center, or a nursing home within the time frame established without prior notification will result in cancellation of the trip. Any additional/excess charges incurred by the Government due to the delay will be forwarded to the contractor for payment. e. The Government reserves the right to thoroughly inspect and investigate the establishment, facilities, business reputation, and other qualifications of any offeror and to reject any proposal irrespective of price that shall be administratively determined lacking in any of the essentials necessary to ensure acceptable standards of performance. f. THE CONTRACTOR IS REQUIRED TO IMMEDIATELY NOTIFY THE COTR OF ANY INCIDENT THAT INVOLVES A VA BENEFICIARY AND FOLLOW-UP IN WRITING WITHIN 8 HOURS OF NOTIFICATION. g. The Contracting Officer shall be notified in writing of any ambulance vehicles or equipment added after award of contract. If any vehicles are added after inspection and subsequent award of contract, it shall be inspected and approved by the Contracting Officer or his designee before being placed in use under this contract. In the event the above mentioned statutes change or are updated, all current and appropriate Federal, State, and Local codes shall apply. h. Inspections. All vehicles shall be inspected prior to usage under this contract. The contractor shall notify the COTR of any new vehicles purchased after award of this contract. Upon notification, the COTR, CO, or designees will conduct an inspection of said vehicles. The VAMC further reserves the right to make random inspection of said vehicles. i. The successful bidder will provide a copy of current policy for chemical and physical restraints and protective devices. Documentation must be made in transport medical sheet indicating which devices and/or restraints were used and that use was in compliance with said policy. j. Any and all equipment, machinery, linens, etc taken with patients must be returned in same serviceable condition within 48 hours of departure. The Contractor must provide linens and must not be exchanged with VA linens. k. CENTRAL CONTRACTOR REGISTRATION (CCR): Federal Acquisition Regulations (FAR) require that federal contractors register in the Central Contract Registration (CCR) database at http://www.ccr.gov and enter all mandatory information into the system. Award may not be made until the contractor has successfully registered. Offerors are encouraged to ensure that they are registered in CCR prior to submitting their offer. l. OIG/HHS: Office of Inspector General of the Department of Health and Human Services (OIG/HHS) has made a determination that prior to obligating VA contracts, purchase orders, task and delivery orders, and any purchase card orders paid with VA health care funds may not be entered into with any individual; entity or organization that has been listed on the OIG/HHS Exclusionary List. VA does not have the burden of defending the merits of the OIG/HHS decision established under 42 USC 1320a-7. m. HIPAA COMPLIANCE: HIPAA compliance is required. The Contractor must adhere to the provisions of Public Law 104-191, Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the National Standards to Protect the Privacy and Security of Protected Health Information (PHI). As required by HIPAA, the Department of Health and Human Services (HHS) has promulgated rules governing the security and use and disclosure of protected health information by covered entities, including the Department of Veterans Affairs (VA). In accordance with HIPAA, the Contractor may be required to enter into a Business Associate Agreement (BAA) with VA. VACO has recognized ambulance service as an entity that does not require a BAA with their contractors as long as they are conducting health care on behalf of the VA - ground ambulance program qualified as a medical service - therefore, no BAA is required. n. PATIENT CONFIDENTIALITY: Contractor shall insure the confidentially and security of all patient information and shall be held liable in the event of breach of confidentiality. The contractor shall comply with the provisions of the Privacy Act (5 USC 522a), Confidentiality of Drug Abuse, Alcohol Abuse, Sickly Cell Anemia, and HIV/AIDS Treatment Records (38 USC 7332 and 38 USC 4132) and Confidentiality of Medical Quality Assurance Records (38 USC 5705 and 38 USC 3305). The contractor shall comply with all pertaining to confidentiality and security statutes. The contractor shall be Health Insurance Portability and Accountability Act (HIPAA) compliant. Failure to comply with statues regarding confidentiality and security of patient health information/individually identifiable information may result in financial sanctions. o. CRITICAL CARE TRANSPORT: It is the responsibility of the contractor to comply with all current and modified critical care transport program requirements for the West Virginia EMS System as maintained by the Department of Health and Human Resources Bureau for Public Health Office of Emergency Medical Services. 6. SPECIAL REQUIREMENTS. a. Contractor Personnel. Upon award of the contract, the contractor shall supply the VA a complete listing of all employees, with their name, social security number, date of birth, place of birth, and a photo copy of their current WV driver's. The VA Police will conduct a Drivers Verification Background Check on all employees. The VA reserves the right to restrict the contractor from using employees to transport veterans if the employee's record has non-favorable indicators. Records to be updated every six (6) months. b. Records of each employee as to character and physical capabilities of performing the services of a driver and/or attendant must be maintained and will be made available for inspection upon request. The Contractor shall maintain competency folders on all employees in accordance with current VA Education/Human Resource guidelines. Contractor will furnish the following education and/or training to all employees providing services on this contract: 1. Annual education on Tuberculosis and OSHA's Blood borne Pathogen Standards 2. Annual screening for Tuberculosis (PPD by Mantoux) These records are to be updated annually. c. Emergency Medical Technicians providing emergency services under this contract must have the following qualifications: 1. Completed training in accordance with the standards published by the Department of Health and Human Services with a minimum curriculum of 81 hours or "equivalent" including in-hospital training period. Such training programs must be acceptable under the regulating requirements for local EMS systems by DHHS under PL93-154, 39 Federal Register 24-304 (1974). 2. Evidence of the "equivalent" training program successfully completed by the EMT. Evidence must be submitted with proposal. 3. Certification, license, or otherwise recognized by the local, state, or regional government or public entity where the emergency ambulance service is operated or by which it is governed. 4. Enrolled periodically in a "refresher" continuing education, or advance training program as required by local or state government entity in which the service is rendered to the veterans. In no instance shall this be less frequently than every two (2) years. Such refresher training must be equivalent to that developed by the Department of Transportation National Highway Safety Administrative under Contract F-11-11-7474 (Dunlap and Associated, March 1971). Evidence of successful completion of training must be submitted to the Contracting Officer at: Louis A. Johnson VA Medical Center Attn: Contracting Officer One Med Center Drive Clarksburg, WV 26301-4199 d. Registered nurses shall have all necessary training and certifications. e. Reports. Contractor must provide the following monthly reports: 1. Total cost billed to the VA 2. Total number of each trip ordered 3. Count of individuals transported 4. Count of destinations 7. INVOICES: Monthly invoices must contain the following information: " Contractor reference number " Patient name and social security number " Name of the representative requesting service " Name of ambulance operator " Pick up date and time " Origin " Destination " Reason (i.e., eye exam, MRI, CAT scan, etc, " Mileage " Charge based on Contract Cost Schedule " Summary page indicating total number of trips and costs. a. Proportional Economic Price Adjustment of Contract Price(s) Based on a Price Index- Refer to Section D of Solicitation. 8. DEFINITIONS: BCLS Vehicle: Ambulance equipped with Basic Cardiac Life Support System and qualified staff (in accordance with Specification KKK-A-1822C) BASIC LIFE SUPPORT (BLS) - will be staffed with non-emergency attendant/drivers. Vehicles shall be dispatched immediately and arrive at the site within forty-five (45) minutes of calls for BLS ambulance. ACLS Vehicle: Ambulance equipped with Advance Cardiac Life Support System and qualified staff (must be in accordance with Specification KKK-A-1822C) ADVANCED LIFE SUPPORT (ALS) - Advanced Life Support Unit shall be staffed with Paramedics, ALS trained Registered Nurse (RN) and/or Certified Emergency Medical Technician 9EMT) with controlling capabilities for, but not limited to, Endotracheal Intubation, IV Therapy, Cardiac Monitoring, Defibrillation, and Drug Therapy, to be used in and out of town. EMT to be provided by the Contractor. ALS and BLS ambulance drivers shall assist the patient as necessary, to enter and exit vehicles, enter, locate, and sign in at appropriate clinic areas upon arrival at destination. Vehicles transporting VA beneficiaries will be dedicated exclusively to VA transports. The contractor may not carry non-VA contract beneficiaries or private pay patients with VA beneficiaries. INCIDENT: Any situation that occurs with a veteran patient that produces or has the potential to produce an adverse outcome, complication, injury or abuse during transport. The definition of an incident may be met through commission or omission of standard of care, whether intentional or unintentional on the part of the vendor staff involved with the transport. COTR: Contracting Officer's Technical Representative CO: Contracting Officer AOD: Administrative Officer of the Day MAA: Medical Administrative Officer B.2 PRICE/COST SCHEDULE ITEM DESCRIPTION OF NO# SUPPLIES/SERVICES 0001 - BASE PERIOD 1 July 2009 through 30 September 2009 Contractor to furnish 24-hour Ambulance Services to eligible veterans at the VA Medical Center, Clarksburg, WV. Estimated Qty Unit Unit Price Total Price 0001a Contractor to provide local trips 77 EA ____________ ____________ without assistance needed for patients. (BLS) 0001b Provide long distance trips with no 3 EA ____________ ____________ assistance needed for patients (BLS) 0001c Local Trip. Wheelchair van to include 44 EA _____________ _____________ Driver/attendant to assist patient in And out of vehicle 0001d Long Distance. Wheelchair van to 14 EA ____________ ____________ Include driver/attendant to assist Patient in and out of vehicle 0001e Local Trip. Ambulance Stretcher 139 EA ____________ ____________ transport only. Patients would require an attendant (EMT) but would be classified as "non-emergent" patient.(BLS) 0001f Long Distance. Ambulance Stretcher 23 EA ____________ _____________ transport only. Patients would require an attendant (EMT) but would be classified as non-emergent patients. (BLS) 0001g Local Trip. Ambulance-emergency 45 EA ____________ ____________ transport to include a paramedic or RN based on patient needs. (ACLS) 0001h Long Distance Trip 34 EA ____________ ____________ Ambulance-Emergency transport to include a paramedic or RN based on patient needs. (ACLS) 0001i Transportation to support Life Flight. 1 EA ____________ ____________ Includes all associated ground trans- portation to/ from location, and RN. (ACLS) 0001j Additional attendant when required 1 EA ____________ ____________ and ordered. Additional attendant pricing is based on "per round trip" (ACLS) 0001k Waiting time hourly price 1 HR ____________ ____________ when required and verified by the the VA Medical Center. 0001l Rate for travel over 125 miles 700 MI ____________ _____________ 0001m Critical Care Transport: Local trip 2 EA ____________ _____________ With RN (ACLS) 0001n Critical Care Transport: Long 2 EA ____________ _____________ Distance with RN (ACLS) SUMMARY COST FOR BASE PERIOD: $__________________ 0002 FIRST OPTION PERIOD_ 1 Oct 2009 through 30 Sep 2010 Contractor to furnish 24-hour Ambulance Services to eligible veterans at the VA Medical Center, Clarksburg, WV pending availability of funds. Estimated Qty Unit Unit Price Total Price 0002a Contractor to provide local trips 306 EA ____________ ____________ without assistance needed for patients. (BLS) 0002b Provide long distance trips with no 12 EA ____________ ____________ assistance needed for patients (BLS) 0002c Local Trip. Wheelchair van to include 192 EA _____________ _____________ Driver/attendant to assist patient in And out of vehicle 0002d Long Distance. Wheelchair van to 56 EA ____________ ____________ Include driver/attendant to assist Patient in and out of vehicle 0002e Local Trip. Ambulance Stretcher 544 EA ____________ ____________ transport only. Patients would require an attendant (EMT) but would be classified as "non-emergent" patient.(BLS) 0002f Long Distance. Ambulance Stretcher 92 EA ____________ _____________ transport only. Patients would require an attendant (EMT) but would be classified as non-emergent patients. (BLS) 0002g Local Trip. Ambulance-emergency 194 EA ____________ ____________ transport to include a paramedic or RN based on patient needs. (ACLS) 0002h Long Distance Trip 132 EA ____________ ____________ Ambulance-Emergency transport to include a paramedic or RN based on patient needs. (ACLS) 0002i Transportation to support Life Flight. 2 EA ____________ ____________ Includes all associated ground trans- portation to/ from location, and RN. (ACLS) 0002j Additional attendant when required 2 EA ____________ ____________ and ordered. Additional attendant pricing is based on "per round trip" (ACLS) 0002k Waiting time hourly price 2 HR ____________ ____________ when required and verified by the the VA Medical Center. 0002l Rate for travel over 125 miles 2600 MI ____________ _____________ 0002m Critical Care Transport: Local trip 4 EA ____________ _____________ With RN (ACLS) 0002n Critical Care Transport: Long 4 EA ____________ _____________ Distance with RN (ACLS) SUMMARY COST FOR FIRST OPTION PERIOD $__________________ 003 SECOND OPTION PERIOD 1 Oct 2010 through 30 Sep 2011 Contractor to furnish 24-hour Ambulance Services to eligible veterans at the VA Medical Center, Clarksburg, WV pending availability of funds. Estimated Qty Unit Unit Price Total Price 0003a Contractor to provide local trips 306 EA ____________ ____________ without assistance needed for patients. (BLS) 0003b Provide long distance trips with no 12 EA ____________ ____________ assistance needed for patients (BLS) 0003c Local Trip. Wheelchair van to include 192 EA _____________ _____________ Driver/attendant to assist patient in And out of vehicle 0003d Long Distance. Wheelchair van to 56 EA ____________ ____________ Include driver/attendant to assist Patient in and out of vehicle 0003e Local Trip. Ambulance Stretcher 544 EA ____________ ____________ transport only. Patients would require an attendant (EMT) but would be classified as "non-emergent" patient.(BLS) 0003f Long Distance. Ambulance Stretcher 92 EA ____________ _____________ transport only. Patients would require an attendant (EMT) but would be classified as non-emergent patients. (BLS) 0003g Local Trip. Ambulance-emergency 194 EA ____________ ____________ transport to include a paramedic or RN based on patient needs. (ACLS) 0003h Long Distance Trip 132 EA ____________ ____________ Ambulance-Emergency transport to include a paramedic or RN based on patient needs. (ACLS) 0003i Transportation to support Life Flight. 2 EA ____________ ____________ Includes all associated ground trans- portation to/ from location, and RN. (ACLS) 0003j Additional attendant when required 2 EA ____________ ____________ and ordered. Additional attendant pricing is based on "per round trip" (ACLS) 0003k Waiting time hourly price 2 HR ____________ ____________ when required and verified by the the VA Medical Center. 0003l Rate for travel over 125 miles 2600 MI ____________ _____________ 0003m Critical Care Transport: Local trip 4 EA ____________ _____________ With RN (ACLS) 0003n Critical Care Transport: Long 4 EA ____________ _____________ Distance with RN (ACLS) SUMMARY COST FOR SECOND OPTION PERIOD: $______________________ 0004 THIRD OPTION PERIOD 1 Oct 2011 through 30 Sep 2012 Contractor to furnish 24-hour Ambulance Services to eligible veterans at the VA Medical Center, Clarksburg, WV pending availability of funds. Estimated Qty Unit Unit Price Total Price 0004a Contractor to provide local trips 306 EA ____________ ____________ without assistance needed for patients. (BLS) 0004b Provide long distance trips with no 12 EA ____________ ____________ assistance needed for patients (BLS) 0004c Local Trip. Wheelchair van to include 192 EA _____________ _____________ Driver/attendant to assist patient in And out of vehicle 0004d Long Distance. Wheelchair van to 56 EA ____________ ____________ Include driver/attendant to assist Patient in and out of vehicle 0004e Local Trip. Ambulance Stretcher 544 EA ____________ ____________ transport only. Patients would require an attendant (EMT) but would be classified as "non-emergent" patient.(BLS) 0004f Long Distance. Ambulance Stretcher 92 EA ____________ _____________ transport only. Patients would require an attendant (EMT) but would be classified as non-emergent patients. (BLS) 0004g Local Trip. Ambulance-emergency 194 EA ____________ ____________ transport to include a paramedic or RN based on patient needs. (ACLS) 0004h Long Distance Trip 132 EA ____________ ____________ Ambulance-Emergency transport to include a paramedic or RN based on patient needs. (ACLS) 0004i Transportation to support Life Flight. 2 EA ____________ ____________ Includes all associated ground trans- portation to/ from location, and RN. (ACLS) 0004j Additional attendant when required 2 EA ____________ ____________ and ordered. Additional attendant pricing is based on "per round trip" (ACLS) 0004k Waiting time hourly price 2 HR ____________ ____________ when required and verified by the the VA Medical Center. 0004l Rate for travel over 125 miles 2600 MI ____________ _____________ 0004m Critical Care Transport: Local trip 4 EA ____________ _____________ With RN (ACLS) 0004n Critical Care Transport: Long 4 EA ____________ _____________ Distance with RN (ACLS) SUMMARY COST FOR THIRD OPTION PERIOD: $______________________ 0005 FOURTH OPTION PERIOD 1 Oct 2012 through 30 Sep 2013 Contractor to furnish 24-hour Ambulance Services to eligible veterans at the VA Medical Center, Clarksburg, WV pending availability of funds. Estimated Qty Unit Unit Price Total Price 0005a Contractor to provide local trips 306 EA ____________ ____________ without assistance needed for patients. (BLS) 0005b Provide long distance trips with no 12 EA ____________ ____________ assistance needed for patients (BLS) 0005c Local Trip. Wheelchair van to include 192 EA _____________ _____________ Driver/attendant to assist patient in And out of vehicle 0005d Long Distance. Wheelchair van to 56 EA ____________ ____________ Include driver/attendant to assist Patient in and out of vehicle 0005e Local Trip. Ambulance Stretcher 544 EA ____________ ____________ transport only. Patients would require an attendant (EMT) but would be classified as "non-emergent" patient.(BLS) 0005f Long Distance. Ambulance Stretcher 92 EA ____________ _____________ transport only. Patients would require an attendant (EMT) but would be classified as non-emergent patients. (BLS) 0005g Local Trip. Ambulance-emergency 194 EA ____________ ____________ transport to include a paramedic or RN based on patient needs. (ACLS) 0005h Long Distance Trip 132 EA ____________ ____________ Ambulance-Emergency transport to include a paramedic or RN based on patient needs. (ACLS) 0005i Transportation to support Life Flight. 2 EA ____________ ____________ Includes all associated ground trans- portation to/ from location, and RN. (ACLS) 0005j Additional attendant when required 2 EA ____________ ____________ and ordered. Additional attendant pricing is based on "per round trip" (ACLS) 0005k Waiting time hourly price 2 HR ____________ ____________ when required and verified by the the VA Medical Center. 0005l Rate for travel over 125 miles 2600 MI ____________ _____________ 0005m Critical Care Transport: Local trip 4 EA ____________ _____________ With RN (ACLS) 0005n Critical Care Transport: Long 4 EA ____________ _____________ Distance with RN (ACLS) SUMMARY COST FOR FOURTH OPTION PERIOD: $______________________ GRAND TOTAL OF BASE PLUE FOUR OPTION PERIODS $