CMS-718-721 CMS-718-721.Travel Detail Chart

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Overview

Year 1
Year 2
Year 3

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Sheet 1: Year 1

	TRAVEL DETAIL
	QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
RFP Number:	Name and Address of QIO Organization:				QIO Area (State):				Contract Period
0	0					0			From:	1/0/1900
	0								To:	1/0/1900
	0
YEAR 1									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 1	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR ONE:													$0
											GRAND TOTAL:		$0

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Sheet 2: Year 2

	TRAVEL DETAIL
	QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
RFP Number:	Name and Address of QIO Organization:				QIO Area (State):				Contract Period
0	0					0			From:	1/0/1900
	0								To:	1/0/1900
	0
YEAR 2									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 2	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR TWO:													$0
										GRAND TOTAL (years 1 & 2):			$0

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Sheet 3: Year 3

	TRAVEL DETAIL
	QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
RFP Number:	Name and Address of QIO Organization:				QIO Area (State):				Contract Period
0	0					0			From:	1/0/1900
	0								To:	1/0/1900
	0
YEAR 3									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 3	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR THREE:													$0
									GRAND TOTAL (years 1, 2, & 3):				$0