10925_AttachmentJ_Price Sheet.docx

RFP #10925

ATTACHMENT J

PRICE SHEET (MANDATORY)

* * * A PRICE SHEET SHALL BE SUBMITTED FOR EACH CIRCUIT PROPOSED * * *

CIRCUIT

THIS IS A MANDATORY FORM. IT MUST BE COMPLETED AND RETURNED WITH THE PROPOSAL.

I. REQUIRED SERVICES (ALL MODALITIES)

The Respondent shall propose a rate for all required services listed in the table below. The proposed rate for each service must include all services, materials, and labor necessary to complete the service as outlined in Attachment A and the Respondent’s proposal. The rates should be expressed as two-decimal amounts ($##.##); rates provided without decimals shall be interpreted at whole amounts ($##.00). Any proposal without a proposed rate for each required service listed below shall be rejected.

Individualized Treatment Plan Review (not to exceed one per month per youth)

Clinical Case Management (per activity, not to exceed four activities per month per youth)

Legal Testimony (per hour, not to exceed five hours per appearance)

II. COUNSELING/THERAPY (MODALITY SPECIFIC)

The Respondent shall propose a rate for the applicable session type(s) listed in the table below FOR EACH MODALITY PROPOSED. Proposed rates are for 15-minute units; for example, if a treatment session lasts for 60 minutes, the Respondent would invoice the department for four units. Proposed rates must include all services, materials, and labor necessary to complete the treatment session as outlined in Attachment A and the Respondent’s proposal; the proposed rate should contemplate the qualifications and training required to deliver the proposed modality. The rates should be expressed as two-decimal amounts ($##.##); rates provided without decimals shall be interpreted at whole amounts ($##.00).

Any proposal for a treatment modality that is not included on the Respondent’s submitted Attachment I, Proposed Treatment Modality, shall be rejected. For each modality proposed, a rate must be provided for the session type(s) indicated on Attachment I. Using the example provided on Attachment I, the Respondent would be required to provide rates for Individual Session and Group Session; the rate for Family Session would be “N/A” since the proposed treatment modality does not include family sessions.

MODALITY:

Family Session Unit (per 15-minute unit, not to exceed six units per session, i.e., 90 minutes)

Group Session Unit (per 15-minute unit, not to exceed six units per session, i.e., 90 minutes)

MODALITY:

Family Session Unit (per 15-minute unit, not to exceed six units per session, i.e., 90 minutes)

Group Session Unit (per 15-minute unit, not to exceed six units per session, i.e., 90 minutes)

MODALITY:

Family Session Unit (per 15-minute unit, not to exceed six units per session, i.e., 90 minutes)

Group Session Unit (per 15-minute unit, not to exceed six units per session, i.e., 90 minutes)

The tables above may be duplicated as needed to ensure that the treatment modality(ies) included on the Respondent’s submitted Attachment I, Proposed Treatment Modality, is included on this attachment if the Respondent is proposing the modality(ies) for the specific circuit identified at the top of this attachment.

By submission of and signature on this form, the Respondent agrees to all terms and conditions of this RFP and commits the proposer to the prices stated.

NAME: _______________________________________________________________

TITLE: _______________________________________________________________

COMPANY: ___________________________________________________________

ADDRESS: ____________________________________________________________

E-MAIL ADDRESS: _____________________________________________________

TELEPHONE NUMBER: _________________________________________________

SIGNATURE: _______________________________________ DATE: _____________