2-Agency Profile Contact Sheet PDF version 2025.pdf
PDF 195 KB Posted
- Solicitation number
- 26-08
- Issued by
- Montgomery County, Pennsylvania
About this file
This document is a certification form and agency profile contact sheet developed by the Montgomery County Office of Aging Services for providers seeking to deliver Personal Emergency Response System (PERS) services to older adults enrolled in the OPTIONS program. The form requires agencies to provide comprehensive organizational information including office location, contact details, taxpayer identification, parent company information, and agency status (profit/non-profit, public/private, minority-owned status). Agencies must document their founding date, number of service locations, hours of operation, and after-hours contact information for in-home service providers. The certification process requires documentation of the total unduplicated persons served in the previous calendar year and current staffing levels broken down by administrative/supervisory, service, and other personnel categories. The form establishes specific contact requirements for three critical functions: billing contact, contract and enrollment contact (responsible for all contract, certification, enrollment, and compliance issues), and a designated service order email address to be used exclusively by care managers for submitting new service orders, reauthorizations, changes, and terminations.
The document establishes standardized communication protocols requiring agencies to designate authorized signers and witness signers with documented titles and email addresses. As a revised form dated January 2025, this certification sheet serves as the foundational intake document for all prospective PERS service providers, ensuring Montgomery County has verified contact information and organizational credentials before engaging providers. The single email address requirement per agency and per site streamlines service order processing and administrative coordination. No specific pricing information, set-asides, incumbent vendor details, or funding amounts are contained within this administrative form, which functions solely as a collection mechanism for provider organizational data and contact information necessary for contract administration and service delivery coordination.
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Other files
| File | Type | Posted |
|---|---|---|
| 6-Grant Addendum TCs (13).pdf | ||
| 3-PRICE CERTIFICATION FORM FOR IN HOME SERVICES 2026.docx | DOCX document | |
| 8-Instructions to Bidders Template.docx | DOCX document | |
| 5-Contract Cover and Signature Page (SAMPLE).doc | DOC document | |
| 7-Exhibit A - HHS Standard Terms and Condition for Services revised 6-3-24.pdf | ||
| 4-RFP 26-08 Personal Emergency Response System (PERS) Services.docx | DOCX document | |
| 1-Appendix A document.docx | DOCX 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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