5-HDM Agency Profile Contact Sheet PDF version 2025.pdf
PDF 401 KB Posted
- Attached to
- Home Delivered Meal Services
- Solicitation number
- 26-23
- Issued by
- Montgomery County, Pennsylvania
About this file
This is a certification form and agency profile contact sheet for the Montgomery County Office of Aging Services (OAS) Home Delivered Meals (HDM) program in Pennsylvania. The form serves as the primary documentation tool for agencies seeking to provide home delivered meal services to homebound individuals aged 60 and over in Montgomery County. The HDM program targets economically disadvantaged older adults who are unable to prepare or procure their own meals and lack informal support systems. Agencies applying to participate must complete detailed organizational information including business structure, operational hours, meal types offered (hot, cold, frozen, kosher, vegan, or other), number of unduplicated persons served annually, staffing levels, and company history. The form requires designation of specific contact personnel for billing, contract and enrollment matters, service order submissions, and authorized contract signers with witness designations to ensure proper administrative oversight and compliance management.
The certification form requires providers to supply comprehensive organizational data including taxpayer identification numbers, Massachusetts identification numbers for service locations, agency status classifications (profit/non-profit, public/private, publicly traded), and minority agency designation information. Agencies must document their operational capacity through metrics such as total staff counts separated by administrative/supervisory and service categories, along with historical service volume data from the preceding calendar year. The form emphasizes administrative accountability by requiring a single dedicated email address per agency location for all care manager service orders, reauthorizations, changes, and terminations, with separate designated contacts for billing inquiries and contractual or compliance issues. The revised form is dated February 2026, indicating it represents the current certification requirements for HDM service providers seeking to contract with Montgomery County OAS.
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Other files
| File | Type | Posted |
|---|---|---|
| 2-Federal Grant Addendum for Standard Terms and Conditions - 4-14-26.pdf | ||
| 12-REVISED Bidders Conference Link.docx | DOCX document | |
| 6-PDA Assurance of Compliance 3-3-26.docx | DOCX document | |
| 4-Revised 5-25 Contract Cover and Signature Page (SAMPLE)..doc | DOC document | |
| 11-RFP 26-23 Home Delivered Meal Services.docx | DOCX document | |
| 8-Montomery County Service Zones Map.pdf | ||
| 10-Appendix A document.docx | DOCX document | |
| 9-Instructions to Bidders - 4.14.2026.pdf | ||
| 3-HDM Project Income Log Blank.xlsx | XLSX spreadsheet | |
| 7-Exhibit A - HHS Standard Terms and Condition for Services revised 6-3-24 (4).pdf | ||
| 1-PDA Lobbying Certification 3-3-26.docx | DOCX document |
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Text version
Revised 2/2026
MONTGOMERY COUNTY
OFFICE OF AGING SERVICES
HOME DELIVERED MEALS
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: __________
Types of Meals offered:
____Hot ____Cold ____Frozen ____Kosher ____Vegan ____Other
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 2/2026
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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