210930 Massachusetts Impaired Driving MID Application for Response Updated 3-24-2020~1.docx

The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619

APPLICATION RESPONSE COVER PAGE

RFR TITLE: Massachusetts Impaired Driving (MID)

RFR # 210930

Organization Name: [ ]

Address:

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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):

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Organization Information

Is your agency pre-qualified to conduct business with the Commonwealth? |_| Yes |_| No

If so, which Massachusetts Department is your Principal Purchasing Agent (PPA): [ ]

Location of Proposed Service Program Name: [ ]

Program Address:

City: [ ] State: [ ] Zip: [ ]

AGENCY AFFIRMATIONS FORM

Affirm the agency’s ability to participate fully in the Massachusetts Impaired Driving (MID) program described in

RFR # 210930

Each bidder by initialing each aspect below will agree to adhere to the model of service delivery for the MID program:

1st Offender MID’s as referred from the Massachusetts Trial Court

Any out of state Court

Under 21 MID’s referred by the Massachusetts Registry of Motor Vehicles

Thoroughly assess the social, emotional and cognitive aspects of anyone under the age of 21 for appropriateness to participate with an adult group or conduct individual session for that client if they are not.

Adhere to all DPH regulations pertaining to intakes and assessment as dictated by

105 CMR 164

New admission should be schedule for their intake with a waiting period of no more than 4 weeks from initial client contact.

Use the ASUDS – RM for SAAM as described

Adhere to all regulations as they pertain to client records

Utilize the standardized client-agency agreement as developed by BSAS

Adhere to all procedures concern accepting legal indigent waivers from the courts

Adhere to a 38 hour program model comprised of 90 minute intake/assessment

Sixteen standalone psych-educational session of 2 hours each with 4 hours of introduction to self-help

Adhere to thirty (30) minute exit interview with each client that completes the program.

Any client that completes an intake should not wait for services to begin beyond 6 weeks for group services.

Adhere to addition bidder requirements as specified on page 7 of the RFR.

Adhere to requirements specified under the Specialized and/or alternative programing section found on page 7 of the RFR.

Adhere to the requirements pertaining to Individual Service Planning found on page 8 of the RFR.

Adhere to Staffing and Minimum Requirement as specified on page 8 and 9 of the RFR.

Adhere to the CORI check requirements as specified on page 9 of the RFR.

Meet all of the Results and Measures and Program Monitoring requirements as specified on page 9 of the RFR.

Affirm the agency’s compliance with all BSAS Standards of Care

Affirm the agency ability to comply with changes to the program as deemed necessary by BSAS.

I affirm that I will comply with the requirements of Request for Response 210930 and with the terms of this proposal.

Authorized Signatory:

First Name: [ ] Last Name: [ ]

Title: [ ]

By clicking the check box, the submitter attests that s/he is an agent of the Bidder with authority to sign on the Bidder’s behalf and is agreeing all affirmations listed above.