# REGIONAL MEDICAL CENTER RM1707632HM

FORM AUTH USE/DISCLOSURE PHI, 9090 08/2020; (ENTERPRISE) IMM, ENG - MIN ORDER 5PK; FORM PHYSICIAN CERTIFCTN 1361A 3/1...

**Recipient:** 5003980 RR DONNELLEY

**Award Amount:** $2,262.50
**Ceiling:** $2,262.50

**Awarded:** August 25, 2026

**Identifier:** RM1707632HM

Regional Medical Center, a public hospital in San Jose, California, awarded PO RM1707632HM to RR Donnelley (listed as “5003980 RR DONNELLEY”) for printed forms, with a total obligated amount of $2,262.50. Items: 5 authorization-for-use/disclosure-of-PHI forms (9090, 08/2020) at $29.50 each; 20 enterprise immunization forms in English at $41.80 each (minimum order 5 packs); 5 physician certification forms (1361A, 3/16) at $45 each; 10 detailed notices of discharge (100 per pack; minimum order 5) at $33 each; 5 patient transfer acknowledgments (1361B, 04/2015; minimum order 5) at $1.80 each; 5 enterprise immunization forms in Spanish at $49 each (minimum order 5 packs); 5 consent-to-patient-transfer forms at $45 each (minimum order 5 packs); and 5 enterprise immunization forms in Vietnamese at $49 each (minimum order 5 packs). The listed minimum-order requirements apply to specified items. No additional OEMs, contacts, or contract-duration requirements are identified.

### Description

FORM AUTH USE/DISCLOSURE PHI, 9090 08/2020; (ENTERPRISE) IMM, ENG - MIN ORDER 5PK; FORM PHYSICIAN CERTIFCTN 1361A 3/16; (ENTERPRISE) DETAILED NOTICE OF DISCHARGE, 100/PK MIN ORDER 5; FORM PATIENT TRSFER ACKN 1361B 04/2015 (MINIMUM ORDER 5 QTY); (ENTERPRISE) IMM, SPAN - MIN ORDER 5PK; FORM CONSENT TO PATIENT TRANSFER (MINIMUM ORDER 5 PKS); (ENTERPRISE) IMM, VIET - MIN ORDER 5PK