Business Reference Form~11.docx

DOCX document 37 KB Posted

Attached to
26EHSPMMHPROBSS MassHealth Provider Operations Business Support Services RFR
Solicitation number
BD-26-1039-EHS01-ASHWA-128591
Issued by
Suffolk County, Boston City, Massachusetts

About this file

This is a Business Reference Form template used by a government agency to evaluate bidder qualifications and past performance. The form requires bidders to provide a specified number of business references (to be determined by the agency) who can verify the bidder's abilities and qualifications as stated in their proposal. The agency reserves the right to deem a bidder's response unresponsive if any listed reference cannot be reached after reasonable contact attempts. The template includes fields for the bidder's name, the Request for Response title and number, and detailed information for each reference including the reference organization name, contact person, address, email, phone number, fax or other contact information, and a description of the commodities or services provided with relevant dates.

The form accommodates three business references as currently formatted, though the actual number required will be specified by the issuing agency for each solicitation. This document serves as a standard evaluation tool to verify contractor experience and reliability through direct contact with previous clients or partners. No pricing information, set-asides, incumbency status, funding sources, or contract terms are addressed in this reference form template.

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Other files

File Type Posted
Attachment A - BSS Model Contract.docx DOCX document
BSS RFR - Bidders Conference Presentation.pdf PDF
Provider Application - Independent Clinic.pdf PDF
Contractor Authorized Signatory Listing Form CASL for Corporations~6.pdf PDF
BSS RFR Amendment 1.docx DOCX document
Appendix A - Service Level Agreements.xlsx XLSX spreadsheet
Appendix D - Secretariat Application Reference Manual.pdf PDF
Provider Application and Contract Ordering Referring and Prescribing ORP.pdf PDF
Commonwealth Terms and Conditions~32.pdf PDF
Amended Appendix E - MES Outcomes - CMS-Required Provider Management.xlsx XLSX spreadsheet
Provider Application Cover Letter and Check List - Medical Practitioner.pdf PDF
Appendix C - Data Management and Confidentiality Agreement~1.docx DOCX document
Virtual Bidders Conference Attendance Report.xlsx XLSX spreadsheet
Appendix F - Regulatory References.docx DOCX document
Amended Attachment B - Cost Response Instructions and Workbook.xlsx XLSX spreadsheet
Provider Application - Medical Practitioner.pdf PDF
Appendix B - Payment Schedule.docx DOCX document
Prompt Pay Discount Form~17.pdf PDF
Massachusetts Substitute Form W-9~14.pdf PDF
Contractor Authorized Signatory Listing Form CASL for Sole Proprietors~7.pdf PDF
Appendix G - Medicaid Enterprise Technical Requirements.docx DOCX document
MassHealth Provider Operations Business Support Services RFR - Q and A.docx DOCX document
Standard Contract From Instructions and Contractor Certifications~1.pdf PDF
Provider Types PTs.xlsx XLSX spreadsheet
SDP_Plan_Form~6.xlsx XLSX spreadsheet
Amended BSS Average Monthly Volume.docx DOCX document
Business Support Services RFR.docx DOCX document
Standard Contract Form~14.pdf PDF
Provider Application Cover Letter and Check List - Independent Clinic.pdf PDF
Appendix H - Business Support Services - Concept of Operations ConOps Diagram.pdf PDF
Evaluation Criteria~18.docx DOCX document
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Text version

Business Reference Form

Reference Guidelines The bidder must provide Insert number here business references.

References will be contacted to confirm the bidder’s abilities and qualifications as stated in the bidder’s response. The department may deem the bidder’s response unresponsive if a reference is not obtainable from a listed reference after reasonable attempts.

Request for Response (RFR) Information

Bidder:Click here to enter text.
RFR Name/Title:Click here to enter text.
RFR Number:Click here to enter text.

Reference Information

Reference Name:Click here to enter text.Contact:Click here to enter text.
Address:Click here to enter text.Email Address:Click here to enter text.
Phone Number:Click here to enter text.Fax/Other Number:Click here to enter text.

Description and dates(s) of commodities/services provided: Click here to enter text.

Reference Name:Click here to enter text.Contact:Click here to enter text.
Address:Click here to enter text.Email Address:Click here to enter text.
Phone Number:Click here to enter text.Fax/Other Number:Click here to enter text.
Reference Name:Click here to enter text.Contact:Click here to enter text.
Address:Click here to enter text.Email Address:Click here to enter text.
Phone Number:Click here to enter text.Fax/Other Number:Click here to enter text.

Sensitivity Level: Low

File details come from the government source that posted it. Updated .