Att 14 - Client Reference Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 2025-0200-0177 / 02-101-25
- Issued by
- Alaska
About this file
This document is a Client Reference Form associated with a Pharmacy Benefit Manager (PBM) services Request for Proposal (RFP # 2025-0200-0177 / 02-101-25). The form is a mandatory submission requirement for offerors, requiring three completed reference forms from previous clients. Each form must be fully completed by a responsible party from a prior client organization, providing detailed information about the services rendered, including start and end dates, number of employee and retiree participants, and average monthly claims processed.
The reference form includes comprehensive performance evaluation criteria, where the client reference rates the offeror across multiple dimensions using a scale ranging from "Strongly Agree/Very Positive" to "Failed". Specific evaluation areas include project delivery timeliness, resource allocation, service knowledge, relationship quality, communication effectiveness, and overall satisfaction. The form also requires numerical ratings (1-10) for cost management, schedule management, quality expectations, and overall customer satisfaction, with 10 representing high satisfaction and 1 representing very low satisfaction. The state reserves the right to verify submitted information, with potential point deductions or proposal rejection for incomplete or inaccurate submissions.
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Text version
pharmacy benefit manager services
RFP # 2025-0200-0177 / 02-101-25
CLIENT REFERENCE FORM
· A complete and separate Client Reference Form must be provided for each reference.
· Offeror must complete the first part of the Client Reference Form, filling in the information for Company (Offeror) Name, Company (Offeror) Address, and the Name of Project.
· A responsible party of the organization for which the services were provided (the Client) must provide the reference information.
· The person providing the reference must sign and date the form.
· The Client Reference Form(s) must be submitted with the Offeror’s proposal.
· The State may contact the reference to verify the information given within the Client Reference Form and within the proposal. If the State finds erroneous information, points may be deducted or the proposal may be rejected.
· If all questions are not answered on the Client Reference Form, if information is missing, or if the form is not signed, points may be deducted or the proposal may be rejected.
· If a proposal is submitted without three Client Reference Forms, points may be deducted or the proposal may be rejected.
Client Reference Form
Offeror Information
| Company Name (Offeror): |
| Company (Offeror) Address: |
Name of Project:
Client Information
| Organization Name (Client): |
| Organization Address: |
| Person Providing the Reference: |
| Title: |
| Phone Number: |
| Email address: |
| Start Date of Service: |
| End Date of Service: |
| # of Employee Participants: |
| # of Retiree Participants: |
Average # of Claims Processed Per Month:
Reference Signature & Date:
The person providing the reference, as identified above, must provide the following information. This person must be a responsible party of the organization for which the work was performed. This person should have comprehensive knowledge about the project and the company's (Offeror) role and responsibilities within the project.
1. Briefly describe the services provided by the company identified above.
2. Rate each of the following concerning this company’s performance using the ratings below:
S – Strongly Agree/Very Positive A – Agree/Positive N – Neutral D – Disagree/ Negative F – Failed
Rating
| _____ | This company ensured the project deliverables were completed on time and within the agreed budget. |
| _____ | This company provided the appropriate resources to the project. |
_____ This company was knowledgeable in providing the services.
| _____ | The business relationship with this company was positive and cooperative, versus negative and adversarial. |
| _____ | This company provided open, timely communications, and was responsive to our needs and requirements. |
| _____ | I would choose to work with this company again. |
Please rate your overall level of satisfaction on a scale of 1 to 10 for the following items:
| CRITERIA |
| UNIT |
| RATING |
| Ability to manage costs |
| (1-10) |
| Ability to manage schedule |
| (1-10) |
| Ability to meet quality expectations |
| (1-10) |
| Overall customer satisfaction |
| (1-10) |
10 representing that you were highly satisfied and 1 representing that you were very unsatisfied.
Please provide any additional comments below:
File details come from the government source that posted it. Updated .