5-26139 Form 1 Data Sheet.pdf

This is a Form 1 Data Sheet for DHHS contract number 26139, issued by the State of Utah Department of Health and Human Services for physical therapy services at the Utah State Developmental Center. The form functions as a vendor information and qualification document, requiring bidders to provide their legal business name, business address, mailing address, contact information, and email address. Prospective vendors must disclose whether they have any outstanding tax liens in the State of Utah and provide a primary contact person with their title, email, and telephone number. The form requires certification by the person completing it, with their name, date, and position or title, confirming the accuracy and completeness of all information provided.

The data sheet serves as a preliminary qualification and administrative document in the bidding process for physical therapy services contracted with the state. While the form itself does not specify pricing terms, contract duration, or award dates, it establishes baseline vendor eligibility requirements and administrative information necessary for the state to evaluate and communicate with bidders. Vendors must meet the basic requirement of having no outstanding tax liens in Utah to proceed in the contracting process.