5-RFP 05 Verification of Authorized Offeror Form.pdf

This is a Verification of Authorized Offeror Form issued by the Incorporated County of Los Alamos Procurement Division in New Mexico for the Health Commons Services solicitation. The form is designed to collect information about the authorized officer who can obligate the selected Offeror in providing health care services to the County. The requested services encompass four primary areas: Family Planning services (confidential, no-cost services to teens and sliding scale fees for reproductive-age individuals from Los Alamos Public Schools, UNM LA Students, and the community); STI screening, testing, treatment, and partner services; Primary Care Services (including immunization compliance, vaccinations, annual physicals, diagnosis and treatment of acute and chronic conditions with follow-up care, health promotion, screenings and referrals, healthcare planning and education); and Behavioral Health Services (including mental health and substance use services). All programs and services must provide opportunities for participant feedback and incorporate such information into the design and implementation of new and existing programs.

The form requires Offerors to provide comprehensive organizational and contact information, including the authorized offeror's printed name, title, signature, organization's legal name, state of incorporation, email address, mailing address, physical address, telephone number, Federal Tax I.D. number, New Mexico BTIN (if in-state), and contract manager details. The form does not specify pricing terms, set-asides, funding amounts, response dates, or other contractual terms, as it serves solely as a verification document to confirm the authorized representative who can obligate the selected Offeror to the County for the provision of Health Commons services.