Form CMS-718-721 Business Proposal Forms

TRAVEL DETAIL
QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICES

1. RFP Number:

2. Name and Address of QIO
Organization:

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6. Area

3. QIO Area
(State):
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7. Trip Title &
Description/Purpose

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10. # of
8. # of Days per 9. # of Nights per Travelers per 11. Airfare per 12. Departing
Trip
Trip
Trip
Person
from:

23. GRAND TOTAL:
** Please note, the totals for these activities DO NOT roll into the TRAVEL line item listed on the forms entitled, "Q

4. Contract
Period
From:
To:

01/00/1900
01/00/1900

5. Mileage
Rate:

14. FTR
Meals &
15. FTR
13. Arriving Inc. Daily Lodging per
Rate
to:
Night

16.
# of Trips

17. Total #
of miles per
trip

18. # of
Rental Cars
Per Trip

19. Daily
Rental Car
Rate

20. Misc. Cost
per Person per
Trip (includes
parking, gas,
taxi, etc.)

21. TOTAL

22. Notes
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QIO F719", "QIO ODC", or "BFCC Sup Sch".