State of West Virginia
Purchasing Division
VERBAL BID QUOTATION SUMMARY
WV-49 (REV. 10/04)
Agency _________________________________________________ S.A. P.O. Number ___________________________________________
Date ___________________________________________________ WVFIMS Account Number _____________________________________
Purpose _____________________________________________________________________________________________________________________
Delivery Requirements: Quotes Received By:
Vendor:
1.
2.
3.
Telephone Number:
Contact Person's
Name:
Terms:
Shipping Date:
Reason for Award (No Bids Reason): _______________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
WVFIMS Vendor #: ___________________________________________ Purchase Authorized By: ______________________________________
TEAM Vendor #: _____________________________________________ Title: ______________________________________________________
Unit Unit Unit
Item Quantity Description Price Amount Price Amount Price Amount
HIPAA Business Associate Addendum - The West Virginia State Government HIPAA Business Associate Addendum (BAA), approved by the Attorney
General, and available online at the Purchasing Division’s web site (http://www.state.wv.us/admin/purchase/vrc/hipaa.htm) is hereby made part of
the agreement. Provided that, the Agency meets the definition of a Covered Entity (45 CFR §160.103) and will be disclosing Protected Health Information
(45 CFR §160.103) to the vendor.
TOTAL:
