180327 Application for Response for Organization updated 8-24.docx
DOCX document 60 KB Posted
- Solicitation number
- BD-17-1031-ADMIN-ADM07-10814
- Issued by
- Suffolk County, Massachusetts
About this file
This document is an Application Response Form for Request for Response (RFR) 180327 issued by the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health (MDPH). The RFR is seeking contractors to provide a variety of medical services, including physician, nursing, dental, and other medical services, on an as-needed basis across multiple MDPH hospitals, bureaus, and laboratories. Eligible applicants are limited to corporations or professional groups employing the required medical providers. The contract term is up to 5 years with an option to renew for an additional 5 years, with an anticipated start date of January 2017. Responses must be submitted by the final submission date of June 30, 2027.
The RFR emphasizes that there is no guarantee of work for the selected vendors, and reimbursement will be at individually negotiated rates, with no travel or lodging costs covered under the contract. The Supplier Diversity Program (SDP) is a factor, with a 10% weighting in the proposal review. The Commonwealth has not disclosed the current medical services environment, fee structures, or annual budget amounts, but prompt payment discounts are encouraged. The RFR is open to all qualified applicants, with no indication of any set-asides or incumbent providers.
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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 or Health Care Related Services Provided by Individual within Organizations
RFR: 180327
Organization Organization Name: [ ]
Address:
City: [ ] State: [ ] Zip: [ ]
Vendor Code: [ ]
CEO (Chief Executive Officer) First Name: [ ] Last Name: [ ]
FEIN: [ ]
Contact Person First Name: [ ] Last Name: [ ]
Title: [ ]
Telephone: ( ) - FAX: ( ) -
E-Mail: [ ]
Contact Person Address (if different):
City: [ ] State: [ ] Zip: [ ]
INITIAL APPLICATION LOCATION(s)
|_| Bureau of Infectious Disease and Laboratory Sciences |_| Bureau of Health Care Safety and Quality |_| Lemuel Shattuck Hospital |_| Pappas Rehabilitation Hospital for Children |_| Tewksbury Hospital |_| Western Massachusetts Hospital |_| Other: [ ]
Please indicate the area(s) of professional healthcare service for which you are applying :
|_| Dental Services |_| Nursing Services |_| Physicians |_| Other Medical Services: [List which other medical services you are applying for ]
PRIORITY HEALTH CARE OR RELATED SPECIALTY
List specific discipline applying for:
Enter text here; text limit 1250 Characters
Provide a brief overview of your clinical practice experience including number of years in practice.
Enter text here; text limit 1250 Characters
APPLICATION PACKET
Assemble the following documents in this order:
|_| The Application Response Form |_| Business Reference Form |_| Employee Orientation Documents |_| Business Associate Agreement (Complete if you are planning to work one of the Massachusetts State Hospitals) |_| Confidentiality form (Complete if you are planning to work for BIDLS or any other DPH Bureau) |_| Rate Sheet |_| Shift Schedules, including nights and weekends |_| Supplier Diversity Plan (SDP) |_| Obtain and maintain certificate of liability insurance
AFFIRMATION
All applicants should initial next to the following statements to affirm that you will: Initials
· Perform CORI checks on all employees. ________
· Provide for their employees’ salaries, any fringe benefits, malpractice insurance, ________
· Provide annual professional training and competency information. ________
Only applicants planning to work at one of the 4 DPH Hospitals should initial the following:
· Ensure that all employees maintain licensure and CPR certification ________
· Maintain documentation of an employee’s annual TB testing ________
I affirm that I will comply with the requirements of this Request for Response and with the terms of this proposal.
Signature (blue ink preferred): _______________________________________________
Date:
Providers need only apply once to the hospital or bureau in which they want to provide services. If approved to contract for the hospital or bureau of their choice, the provider will be eligible to contract at other Department of Public Health State Hospitals or bureaus.
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File details come from the government source that posted it. Updated .