UPHS CONTRACT APPROVAL FORM

0 comments

file time: 2008-02-16

filetype:doc

Click Here To Download...

> UPHS CONTRACT APPROVAL FORM

AND PENNTRACT ENTRY FORM (00AF00

SECTION 1 - COMPLETE BOTH SECTIONS FOR ALL CONTRACTS Name of Company/Vendor: Lawson Accounting Unit (LAU#): PO Number: Name of first responsible person: Phone Number: E-Mail Address: Name of second responsible person: Phone Number: E-Mail Address: Name of third responsible person (if applicable): Phone Number: E-Mail Address: Entity: Site: Department: If this is a renewal or an attachment to an existing agreement, please provide the PennTract Number of the existing agreement: If this is an attachment, what type is it?     c   Certificate of Insurance     c   Addendum or Amendment     c   Other, please describe: Length of term or duration of contract: (e.g., 1 year): Start date and End date of contract: HIPAA: Is Company/Vendor our Business Associate?

c Yes   c No

HIPAA:  Are we Company/Vendor's Business Associate?       c Yes   c No Does this contract contain language confirming that this Vendor has not been excluded or debarred from any federally or state funded health care programs?    c Yes   c No Does this contract have a provision for the Vendor to abide by Accreditation Standards?

c Yes   c No

Type of Contract (Please refer to the PennTract website "http://uphsxnet.uphs.upenn.edu/PennTract" for list of contract types): SECTION 2 00IF CONTRACT REVIEWS AND SIGNATURES ARE REQUIRED BEFORE EXECUTION Attach Executive Summary for Contract Approval (section 3 of CAF) if contract is $100,000 or greater. Description of key services & critical business issues (use additional sheet, if necessary): Significant Issues of Note(use additional sheet, if necessary): Dollar ($) amount / value of contract: Amount budgeted: Payment to entity: Payment terms (Please describe if periodic payments are requested): Contract to be executed by:   REVIEW AND APPROVALS: See UPHS Contracting and Signature Authority Policy (03-02) for authorized delegated signature authority and contract review process  c   UPHS Originator Printed Name/Signature/Date: c   Chair/Department Head Printed Name/Signature/Date: c   Corporate Purchasing Printed Name/Signature/Date: c   Administrative Review (e.g.: Assoc. Exec. Dir./Exec. Dir., VP) Printed Name/Signature/Date: c   Additional Functional Review, if applicable (e.g.:  SOM, IS, Managed Care, GME, RE&A) Printed Name/Signature/Date: c   Office of the General Counsel

OGC Kbase #

Printed Name/Signature/Date: c   Finance (entity CFO and/or Associate VP of Finance if < $100,000; plus UPHS CFO if 00$100,000) Printed Name/Signature/Date: Reviewer Comments:  All Comments Must Be Initialed:   RETURN FULLY EXECUTED CONTRACT AND COMPLETED CAF TO OGC FOR ENTRY INTO PENNTRACT

 

UPHS CONTRACT APPROVAL AND PENNTRACT ENTRY FORM 

SECTION 3 00EXECUTIVE SUMMARY FOR CONTRACT APPROVAL  An Executive Summary for Contract Approval must be included with the CAF for all contracts with a total financial obligation of $100,000 or greater.  In a few paragraphs, the Originator should include: the background for contracting; what the contract is about; key terms; why it should be entered into; the return on investment (ROI); payment terms; and significant or unusual issues of note.  Please describe the 00ho, what, where, when and why00of the contract so that the reviewer/approver can understand what he/she is being asked to approve and its significance to UPHS. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

   download UPHS CONTRACT APPROVAL FORM