180227 Application for Response Final.docx
DOCX document 60 KB Posted
- Attached to
- RFR 180227 Medical Services Provided by Indiv including Physician Nursing Dentist & Other Med Prov
- Solicitation number
- BD-17-1031-ADMIN-ADM07-10815
- Issued by
- Suffolk County, Boston City, Massachusetts
About this file
This document is an Application Response Form for the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health's RFR 180227 for Medical Services Provided by Individual including Physician Nursing, Dentist and Clinician. The application requests information from vendors interested in providing dental, nursing, physician, or other medical services to the Bureau of Infectious Disease and Laboratory Sciences, Lemuel Shattuck Hospital, Pappas Rehabilitation Hospital for Children, Tewksbury Hospital, or Western Massachusetts Hospital. Applicants must submit copies of relevant credentials, licenses, certifications, and a resume or CV. Vendors need only apply once to be eligible for contracting at any of the Department of Public Health State Hospitals.
The application indicates that approved providers will be eligible to contract with multiple state hospitals. Pricing terms, set asides, incumbent information, funding requirements, and other salient details are not provided in this document. Applicants must sign the form in blue ink and submit it along with the required supporting documentation.
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Text version
The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619
APPLICATION RESPONSE FORM
RFR TITLE : Medical Services Provided by Individual including Physician Nursing, Dentist and Clinician
RFR 180227
First Name: [ ] Last Name: [ ]
Title: [ ] Federal Employee Identification Number/SS: [ ]
Address:
City: [ ] State: [ ] Zip: [ ]
Telephone: ( ) - FAX: ( ) -
E-Mail: [ ]
Commonwealth Vendor Customer Code (VCC)* (if available): [ ] Address Code: [ ] *for contract execution
PREFERRED LOCATION SERVED
|_| Bureau of Infectious Disease and Laboratory Sciences |_| Lemuel Shattuck Hospital |_| Pappas Rehabilitation Hospital for Children |_| Tewksbury Hospital |_| Western Massachusetts Hospital
Please indicate which area of professional healthcare service you which to apply for:
|_| Dental Services |_| Nursing Services |_|Physicians |_| Other Medical Services: [List which other medical services you are applying for ]
APPLICATION PACKET
Assemble the following documents in this order:
|_| The Application Response Form |_| Attach copies of credentials if requested. Physicians must be board certified or eligible. Attach copies of license(s) and certification(s).
|_| Attach a résumé or CV detailing your experience in your priority health care or safety specialty.
|_| Business Reference Form |_|Confidentiality form ( Complete if you are planning to work for the Bureau of Infectious Disease and Laboratory Sciences or any other DPH Bureau) |_| Business Associate Agreement ( if you are planning to work at any Massachusetts State Hospitals)
Signature (blue ink preferred): _______________________________________________
Date: Wednesday, November 16, 2016
Vendors need only apply once to the hospitals or bureaus in which they want to provide services. If approved to contract for the hospital of their choice the provider will be eligible to contract at other Department of Public Health State Hospitals
11/16/16 image1.png
File details come from the government source that posted it. Updated .