Quarterly Sales Report General Rules and Information

Transcription

1 Attachment M Medical and Dental Contract No. XXXXXXXXX Quarterly Sales Report General Rules and Information The Quarterly Sales Report shall be submitted within fourteen (14) working days after the quarter end to the Contract Manager; even if there are zero sales for the quarter the vendor is still required to submit a report. The Contractor is required to report all sales for which the payment has been received; all open or pending orders shall not be included. Important Note: The Quarterly Sales Report is separate from the MFMP Transaction Fee Reports. Vendors MUST submit all Other Eligible Users (OEU's) and State Agency payments into MFMP. Instructions & Color Key The cells highlighted in yellow require information to be filled in or selected via drop down. Important: If all requested information must be completed for the autocalculation cells to work (turquoise). Line 46 highlighted in orange, contains an example of how products should be reported. The cells highlighted in turquoise automatically calculate or fill in information. Data may not be entered in these cells. Prior to inputting information, these cells may contain text such as: ***Autofill***, #Value!, or #Div./. If the ***Autofill***, #Value!, or #Div./ text still shows after all yellow cells are filled, contact the contract manager.

2 Attachment M Quarterly Sales Report Medical and Dental Supplies Contract No. ##########161 Last Updated: 6/13/16 Please see the Information Guide on Tab 1 for Detail on Acronyms and Instructions. Submit to: ATTN: All vendors MUST provide quarterly and annual sales reports, including no sales, within fourteen (14) calendar days following the end of each quarter (ex: January, April, July and October). (State Agency) (Other User) Quarterly Sales Summary All Information in this Table AutoCalculates Total Reminder This report is separate from MFMP Transaction Fees. Vendor Information: Ordered Service Level % #DIV/! Vendor Address City State Zip Code: FEIN # Reporting Period Choose from Drop Down Choose From Reporting Periods (Drop Down) Reporting Date Contact Contact Phone Number Under penalties of perjury, I declare that this is a true and accurate report of all sales due under the terms and conditions of this state term contract for the specified quarterly reporting period. Authorized Typed Signature: Authorized Electronic Signature: Group No. State Agency Spend Ordered X Example Example for DMS 125,. 1, Automated External Defibrillators (AED) A. AED packages B. Pads, batteries, cases, chargers, 2 Medical and Patient Apparel ; Blood Collection Diabetic Supplies (excludes Insulin needles and syringes) 42 Nursing and Surgical Caps, masks, shields, aprons, Lab Coats, Lab Jackets, Exam Capes, Exam Shorts, Briefs, Examination Gowns and Isolation Gowns Vacutainers, tubes and vials, IVS and catheters, lancets, tourniquets, trays/carriers, port protectors, collection sets, Pumps, tubes, injection kits, cartridges,

3 Group No. State Agency Spend Ordered 5 Diagnostic Equipment/Instruments/Supplies ; ; ; ; 42182; ; ; Blood pressure monitoring, pulse oximeter, ekg tabs, paper (printer, EKG/ECG, fetal monitor, thermal), stethoscope, prep solutions/gels, procedure lights, otoscope, spirometer and stadiometer, ophthalmoscope and accessories, scissors, razors/blades, specula, speculum and accessories. 6 Emergency and Surgical Equipment/Supplies 7 Equipment and Furniture 8 Exam Room Supplies (excludes Equipment and Furniture) 9 Feeding Supplies 1 First Aid/Wound Care ; ; ; ; ; ; ; ; ; Gloves/Dispensers Hospital Supplies Infection Control Janitorial Supplies 15 Laboratory ; ; ; ; Emergency kits, eye wash supplies, masks and misc. supplies, tourniquets, first aid kits, clamps, scalpels, CPR and misc. supplies Lights/lamps, scales, carts, furniture, cabinets, shower chair, bedside commode, bed pan/pail, suction pump and canister, suction tubing, aspirator and other misc. supplies Trays, partitions, curtains, covers, table paper, towels, drapes, sharps containers, and misc. supplies Ttubes, bottles/nipples, formulas, Ointments, alcohol, prep pads, gauze, pads, sutures/staples, packing strips/sponges, Hot/Cold compresses, gel packs, first aid kits, bandages, bandaids, tape, Includes powder and powderfree latex, nitrile and vinyl exam and surgical gloves. All dispensers included. Blankets, sheets (stretcher, bed), underpads, privacy curtains, barrier drapes, pillows and covers. Sterilization cleaners, autoclave pouches/tubing, bio indicator test kits, sharps containers, sanitizers, spill kits, Cleaning supplies, facial/toilet tissue, paper towels, seat covers, scrub brushes, Microscopes, slides/tubes and holders, glasses, brushes and cleaning kits, acid, strainers, pipette tips, centrifuge, 16 Orthopedics 17 Patient/Personal Care 18 Respiratory 19 Syringes and Needles ; ; ; ; ; ; Torso, head/neck, knees, arms, hands/wrists, feet/ankles stabilizers and support, casts, tape and bandages, exercise machinery, soft seats, Patient Clothing, briefs/underwear, hair care, hygiene products, soap, lotion and skin care, Regulators, meters, sensors, tubes, holders, filters, masks, kits, mouthpiece, nasal piece, nebulizers, Insulin/tuberculin needles and syringes, biopsy, blunt, IV port, spinal, vented, anesthesia, hypodermic and other needles and syringes, trays and holders, containers/carts, caps,

4 Group No. 2 Testing Supplies Tests, strips, solutions, containers and cups, State Agency Spend Ordered 21 Urology and Ostomy ; Catheters, plugs, clamps, bags, meters, trays, tubes, procedure packs/sets, straps/fasteners, ostomy supplies, 22 Aids for Physically Challenged (Wheelchairs/Walking Aids) 4221 Crutches, walkers, canes, bathing chairs, gripping aids, and other accessories, 23 Autopsy Equipment and Supplies Medical Training Equipment and Supplies Saws, body bags, dissection tables, tools, and other misc. supplies Medical Manikins, ECG simulators, IV training arms, moulage kits,

5 Attachment M Quarterly Sales Report Medical and Dental Supplies Contract No. ##########161 Last Updated: 6/13/16 Please see the Information Guide on Tab 1 for Detail on Acronyms and Instructions. Submit to: Quarterly Sales Summary All Information in this Table AutoCalculates (State Agency) (Other User) ATTN: All vendors MUST provide quarterly and annual sales reports, including no sales, within fourteen (14) calendar days following the end of each quarter (ex: January, April, July and October). Total Reminder This report is separate from MFMP Transaction Fees. Vendor Information: Ordered Service Level % #DIV/! Vendor Address City State Zip Code: FEIN # Reporting Period Choose from Drop Down Choose From Reporting Periods (Drop Down) Reporting Date Contact Contact Phone Number Under penalties of perjury, I declare that this is a true and accurate report of all sales due under the terms and conditions of this state term contract for the specified quarterly reporting period. Authorized Typed Signature: Authorized Electronic Signature: Group No. State Agency Spend Ordered X Example Example for DMS 125,. 1, Bonding agents, adhesives and etchants, Adhesive Agents, Materials and cements, desensitizers, temporary fillings, Accessories 2 Air/Water Syringes and Evacuation system parts Air/Water syringe and evacuator assembly and replacement parts, syringes, tubing, tips, adapters, filters, traps, vacuum pumps, cleaning solutions and brushes,

6 Group No. State Agency Spend Ordered 3 Cotton and Paper Supplies Sponges, cotton pellet and roll dispensers/holders, tongue depressors, drinking cups/dispensers, hand towels/tissues, toilet paper and covers, bibs and clips, 4 Crown and Bridge Crowns (metal, plastic, ), bands (copper, ), shells (aluminum, ), retraction materials (cord, liquids, paste, pellets, ) temporary materials (crown or bridge, porcelain, inlay onlay, ) 5 Dispensing Syringes, guns and mixing supplies Automatic/Manual/Vacuum mixing supplies, containers, units, mounts, stands, bowls/dishes/cups/wells, spatulas, dispensing guns, syringes and applicators, needles/caps, pipettes and droppers, 6 Endodontics Endontic files, drills, gauges, rulers, reamers, shapers, pluggers, rotary files, stops and paste fillers, endontic points and medicaments, Apex locators and obturation systems. 7 Finishing and polishing Rotary instruments, materials (abrasive and polishing) and strips (wheels, cones, discs and stones, ) 8 Gloves/Dispensers Includes powder and powderfree latex, nitrile and vinyl exam and surgical gloves. All dispensers included. 9 HandpiecesAir and Electric Attachments, sets, motors, control units, adapters, cables, tubing, rings, belts, cleaners, lubricants, brushes, wires, 1 Impression material and accessories Alginate, compounds, hydrocolloid, polyether, silicone, trays (metal/plastic) bite trays, adhesives, cleaners, 11 Infection control Autoclave supplies, sanitizers, biohazard and medical waste supplies, barrier protection, sterilization and disinfectants, 12 Instruments Forceps, pliers, excavators, mirrors, scalpels, scissors, knives, rubber dams, carvers and hoes, burnishers, carriers, pluggers, condensers, chisels, mallets and files, packers, retractors, elevators, periosteals, periotomes, bracket holders, band sealers, 13 Lab products Denture materials, ceramics, porcelain, gypsums and investments, lab instruments (brushes, tools), vacuum forming machines and materials, wax (boxing, casting, sticky, utility, rope, ) 14 Miscellaneous Supplies Trays (cabinets/drawers, setup, organizer), tubs and accessories, instrument labels, light bulbs (fluorescent, halogen, LED, xenon, ), cleaning kits for instruments, cleaning supplies,

7 Group No. State Agency Spend Ordered 15 Orthodontic Personal Apparel ; Preventive Bands, tubes, brackets, wires, headgear, storage boxes, Lab coats, jackets, scrubs, gowns, face masks/shields, shoe covers, surgical caps, protective eyewear, Oral hygiene products (floss, cleaners, brushes, toothpaste, ), preventive products (fluoride, prophy paste, sealants, ),prophy angles, brushes and cups, 18 Restorative/Cosmetic Amalgam (capsules, pellets, powder, ), articulating materials, bleaching kits, composites (flowable, glazes, sealers, ), curing lights, pins and posts, retainer bands/wedges, rubber dams, 19 Rotary Instruments Carbide, diamond and steel burs, diamond discs, cleaning brushes, stones, holders, sets and accessories, 2 Safety Small equipment Surgical Xray and Digital Imaging First aid kits, monitoring devices (capnographs, oximeters, ), spill kits, signs, fire extinguishers, eye wash stations, Dental chair and delivery systems, cushions, booster seats, die pinning machines, headlamps, laser parts & accessories, loupes and magnifiers, nitrous oxide products, sandblaster, vibrators and Anesthetics syringes (lidocaine; septocaine,), needles and accessories, IV sets and solutions, scalpel and suture materials, medicaments, dressings, splints, Aprons, hangers, developing and processing supplies, solutions, duplicators, film, sensors and holders, plates, mounts, markers, labels, waste disposal,