Application Cover Sheet Restated.doc
DOC document 45 KB Posted
- Solicitation number
- BD-21-1022-DMH08-8220A-53630
- Issued by
- Massachusetts
About this file
This document is an Application Cover Sheet for the Amended and Restated Respite Services - Master Agreement Request For Applications (RFA) issued by the Massachusetts Department of Mental Health (DMH). The RFA seeks to establish a pool of qualified providers from which DMH can purchase Site-Based Respite and/or Mobile Respite Services on an as-needed basis. The application cover sheet requires bidders to provide information about their organization, the service model they are proposing (Site Only, Blended Capacity, Peer Respite, or Mobile Only), and the type of application (new, re-application, or additions to increase capacity or add locations). Bidders must submit a full application or updates to their previously submitted application, depending on the type selected.
The RFA does not provide specific details on pricing terms, set asides, incumbents, funding requirements and sources, or award amounts. It focuses on the application process and requirements for the different service models that bidders can propose.
View the file
Other files
Show all 34
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
DEPARTMENT OF MENTAL HEALTH
Amended and Restated Respite Services – Master Agreement Request For Applications DMH Document Number: RFA # 2017-DMH-3048-03
APPLICATION COVER SHEET AMENDED AND RESTATED
A. Bidder Information Name:
Address:
Contact Person Name:
Contact Person Phone:
Contact Person Email:
Contact Person FAX:
B. Service Model
| Service Model |
| Check Applicable Model |
| Site Based Location(s) for Site Only, Blended Capacity or Peer and Site Office(s) for Mobile Only |
| Proposed Capacity |
Site Only
Site Based Location(s) by Town(s):
Proposed capacity per location:
Blended Capacity
| Site Based Location(s) by Town(s): |
| Proposed rate model A or B and site based capacity and mobile capacity per location*: |
Peer Respite
Site Based Location(s) by Town(s):
Proposed capacity per location**:
Mobile Only
| DMH Site Office(s): |
| Proposed capacity per DMH Site Office: |
*Blended Capacity: Model A is for a total capacity of 13 individuals 4-6, must be site based and the remainder 7-9) mobile; Model B is for a total capacity of 20 individuals of which 7-9 must be served in site based and the remainder 13-11 in mobile) **Peer Respite: the program must have 3-5 beds.
C. Type of Application:
| Type |
| Check Applicable Type |
New
Re-Application
Add to Increase Capacity
Add Site-Based Location to Site only, Blended Capacity or Peer Respite
Add Site Office to Mobile Only
If this is a re-application, attached to this Cover Sheet a summary of the changes made in this application from the previous application. The summary is not to exceed 2 pages. Complete and submit a full application.
If this application is to add on to your existing qualified respite model, attach a summary of any updates that need to be made to the information of your previously submitted application and a summary of the additions that you are proposing. The update and summary should not exceed 3 pages. Complete and submit only the following Categories of the Application that are need to reflect the proposed additions: Category II, Staff Positions, Qualifications and Requirement; and Category V Site-Based Locations and Mobile Respite Site Office(s).
Signature (must be an individual authorized to negotiate for and execute the contract on behalf of the Bidder):
(Signature)
(Print Name)
(Title)
(Date)
FOR DMH USE ONLY
Date Response Received:
Time:
Received by:
Title/Department:
File details come from the government source that posted it. Updated .