D5 _ Attachment _ Reference Contract Worksheet.docx

D5 – Attachment – Reference Contract Worksheet

RFP # 36C25625R0058

Attachment D.5 Reference Contract Worksheet

Reference Contract Worksheet for Offeror’s Response to Factor 1 – Experience Offeror’s shall use this form for their response to Factor 1 – Experience. The form may be expanded but NOT edited except for the examples in italics which shall be removed.

Reference Contract

2.The contract number;

3.Whether the contract was for establishing, or operating, or both establishing and operating a CBOC providing Primary Care services to an adult population age 18 and older. (check one as applicable)

____ Contract was for establishing a CBOC providing Primary Care Services to an adult population age 18 and older.

____ Contract was for operating a CBOC providing Primary Care Services to an adult population age 18 and older.

____ Contract was for both establishing and operating a CBOC providing Primary Care Services to an adult population age 18 and older.

4.A narrative describing the specific tasks the Offeror (or Offeror’s proposed subcontractor) performed to establish the Primary Care CBOC under that contract (e.g., site acquisition; build-out; staffing; clinic opening, etc.);

5. A narrative describing the specific medical services the Offeror (or Offeror’s proposed subcontractor) performed while operating the Primary Care CBOC under that contract (e.g., primary care, telehealth, audiology, pharmacy, other specialty services);

The dates during which the Offeror (or the Offeror’s proposed subcontractor) performed the contract;

The average number per month of adult patients age 18 and older to whom the Offeror (or the Offeror’s proposed subcontractor) provided Primary Care services to under that contract;

Whether the provided reference contract is for services provided by the Offeror or provided by a proposed subcontractor of the Offeror’s;

Whether the Offeror or its proposed subcontractor was the prime contractor or a subcontractor for that provided reference contract;

The name, phone number, and email address of a person at the entity with whom the Offeror (or Offeror’s proposed subcontractor) held the contract who can verify the information the Offeror provides in the narrative description for this factor.