1-Agency Profile Contact Sheet PDF version 2025.pdf
PDF 195 KB Posted
- Attached to
- Older Adult Personal Care Services
- Solicitation number
- 26-07
- Issued by
- Montgomery County, Pennsylvania
About this file
This is an Agency Profile and Provider Contact Sheet certification form issued by the Montgomery County Office of Aging Services in Pennsylvania for providers seeking to deliver personal care services to older adults enrolled in the OPTIONS program. The form requires agencies to provide comprehensive organizational information including office location, contact details, agency status (profit/non-profit, public/private), company founding date, number of offices, hours of operation, and staffing levels. Providers must document the total number of unduplicated persons served during the previous calendar year and designate specific points of contact for billing inquiries, contract and enrollment matters, service order submissions, and authorized signatories. The form requires completion by an authorized representative and must be submitted as part of the provider certification process to deliver in-home personal care services, defined as assistance with activities of daily living that individuals cannot independently manage.
The certification form does not specify pricing structures, set-aside designations, or funding amounts within the document itself. However, the related RFP indicates that Montgomery County is soliciting proposals for personal care services through the OPTIONS program, with services to be provided directly in eligible older adults' homes. Agencies must maintain current contact information and designate a single service order email address through which care managers will submit new service orders, reauthorizations, service changes, and terminations. For in-home service providers, completion of an after-hours contact phone number is mandatory. The form serves as the initial certification documentation required for agencies to become eligible providers within the Montgomery County aging services network and must be revised annually, with the current version dated January 2025.
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| 5-Grant Addendum TCs (13).pdf | ||
| 3-Montomery County Service Zones Map.pdf | ||
| 8-RFP 26-07 Older Adult Personal Care Services.docx | DOCX document | |
| 4-PA DOH TB Risk Assessment.pdf | ||
| 10-Instructions to Bidders Template.docx | DOCX document | |
| 11-Appendix A document.docx | DOCX document | |
| 6-PRICE CERTIFICATION FORM FOR IN HOME SERVICES 2026.docx | DOCX document | |
| 2-Exhibit A - HHS Standard Terms and Condition for Services revised 6-3-24.pdf | ||
| 7-Contract Cover and Signature Page (SAMPLE).doc | DOC document |
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Text version
Revised 1/2025
MONTGOMERY COUNTY
OFFICE OF AGING SERVICES
CERTIFICATION FORM/AGENCY PROFILE
Local Office:
Agency Name: ________________________________________________________ Office/Site Name: ____________________________________________________ Address: _____________________________________________________________
Name and Title: _______________________________________________________ Telephone Number: ____________________Fax Number: __________________ E-Mail Address: ______________________________________________________ Website: _____________________________________________________________
Taxpayer ID Number: ___________________________
MA ID # (9 digits + 4 for service location):______________________________
Parent Company:
Company Name: __________________________________________________ Address: __________________________________________________________
Agency Status (check all that apply):
____Profit ____Non-Profit ____Public ____Corporation ____Privately Owned ____Publicly Traded ____Minority
Agency Data: Company Founded______ Initiation of this office______ Number of offices______
Hours of Operations: Open: __________ Close: __________
After hours contact phone number: ________________________________________ (Must be completed for all in-home service providers)
Total unduplicated persons served by this office during the last calendar year:
Year___________ Total#____________
Total Number of current staff: Admin/Supervisory______, Service______, Other______, Total______
(Signature of Authorized Representative) (Title) (Date)
Revised 1/2025
PROVIDER CONTACT SHEET
AGENCY NAME: ___________________________________________________________
1. Billing Contact Person: ____________________________________________
Phone Number: __________________________________________________
Email Address: ___________________________________________________
2. Contract and Enrollment Contact: ________________________________
Phone Number:____________________________________
Email Address:__________________________________________
(This is the person who will handle any and all Contract, certification, enrollment issues, and compliance issues.)
3. Service Order Email Address: _____________________________________
Phone Number: _______________________________________________
(This is the email that all care managers will use to submit new service orders, reauthorizations, changes and terminations. Only one email address per agency and per any site of an agency).
4. Agency Authorized Signer and Witness
Signer Name:_________________________________________________________ Signer Title: _________________________________________________________ Signer Email:_________________________________________________________ Witness Name: _______________________________________________________ Witness Title: _______________________________________________________ Witness Email: _______________________________________________________
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