4-HSS 26-021B - AppE-Supplemental Questionnaire.docx
DOCX document 65 KB Posted
- Attached to
- Home and Community based Services State and local contract opportunity
- Solicitation number
- HSS-26-021B
- Issued by
- Delaware
About this file
This is a Supplemental Questionnaire (Appendix E) issued by the State of Delaware Division of Developmental Disabilities Services (DDDS) for vendors seeking authorization to provide home and community-based services to individuals with intellectual and developmental disabilities. The questionnaire is a mandatory requirement for all vendors applying to contract with DDDS and must be completed in its entirety as part of the vendor authorization process. Services requested include assistive technology, behavior consultation, benefits counseling, career assessment, community participation, day habilitation, personal care, respite care, supported employment, supported living, and residential habilitation, among others. The contract is funded through a Medicaid Home and Community-Based 1915(c) waiver that DDDS has continuously operated since 1987.
The questionnaire requires vendors to provide comprehensive organizational information, including business identification, contact details, tax identification, and proof of required insurance coverage. Vendors must carry Commercial General Liability, Automobile Liability, and Worker's Compensation & Employer's Liability insurance, with additional coverage such as Medical/Professional Liability or Miscellaneous Errors and Omissions insurance depending on services provided. Certificates of Insurance must accompany the completed questionnaire. Vendors must also attest that they are not excluded from participation in the Medicaid Program by the U.S. Office of Inspector General. DDDS establishes non-negotiable fee-for-service rates for all services, which are computed pursuant to CMS-approved methodologies and published annually on the DDDS website. Vendors must agree to accept published rates as a condition of contract award, with no rate negotiation permitted.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 5-HSS 26-021B - AppF-FAQ.docx | DOCX document | |
| 2-HSS-26-021B - AppC-Vendor Frms.xlsx | XLSX spreadsheet | |
| 3-HSS-26-021B - AppD-Templates PSA, BAA DTI TCs.docx | DOCX document | |
| 1-HSS-26-021B - Home and Community Based Svcs.docx | DOCX document |
On GovTribe
Work with this file on GovTribe
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
STATE OF DELAWARE
DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
STATE OF DELAWARE
DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
Appendix E Supplemental Questionnaire
Vendors are required to complete Part One of this questionnaire in its entirety.
I. PART ONE: ORGANIZATION INFORMATION
Name of Individual/Organization: Click here to enter name.
Current Street Address: Click here to enter address.
City: Click here to enter city.
State: Click here to enter state. Zip Code: Click here to enter zip code.
Primary Contact First Name: Click here to enter name. Last Name: Click here to enter name.
Primary Phone Number: Click here to enter number.
Primary E-mail Address: Click here to enter address.
Alternate Contact First Name: Click here to enter name. Last Name: Click here to enter name.
Alternate Phone Number: Click here to enter number.
Alternate E-mail Address: Click here to enter address.
Tax ID Number: Click here to enter number.
(OR) Delaware Business License: Click here to enter number.
IRS 501(c)(3) Determination Letter (if applicable): Click here to enter number.
Commercial General Liability Insurance Policy Number: Click here to enter number.
Automobile Liability Insurance Policy Number: Click here to enter number.
Worker’s Compensation & Employer’s Liability Insurance Policy #: Click here to enter number.
Umbrella/Excess Liability Insurance Policy Number: Click here to enter number.
Depending on services provided, Vendor must carry at least one of the following insurances:
Medical/Professional Liability Insurance Policy Number: Click here to enter number.
Miscellaneous Errors and Omissions Insurance Policy Number: Click here to enter number.
Product Liability Insurance Policy Number: Click here to enter number.
*Mandatory Requirement- Certificate(s) of Insurance for each policy in effect must accompany Supplemental Questionnaire. For Automobile Liability Insurance, declaration page listing covered vehicles is required.
II. PART TWO: ATTESTATION
I hereby certify the information provided in this supplemental questionnaire is true and complete.
Further, signature below, indicates that Vendor applying for authorization to provide home and community based services for individuals with intellectual and developmental disabilities is not excluded from participation in the Medicaid Program by the United States Office of Inspector General (OIG), Division of Health and Human Services (DHHS).
| PRINT VENDOR REPRESENTATIVE NAME AND TITLE: |
| Click here to enter representative name. |
Click here to enter title.
SIGNATURE:
File details come from the government source that posted it. Updated .