FY23 Guardianship Service Encounter Form V1.xls
XLS spreadsheet 163 KB Posted
- Solicitation number
- BD-23-1022-DMH08-8210C-81963
- Issued by
- Massachusetts
About this file
This document is a Guardianship Quarterly Service Encounter and Invoice Form for the Massachusetts Department of Mental Health (DMH) Guardianship Services Master Agreement Request for Response. The DMH is seeking to establish a pool of individuals and non-profit corporations from which it can purchase, subject to court approval, guardianship and/or conservatorship services for individuals receiving services from or paid for by DMH. The form includes sections for recording guardianship service hours, travel time, mileage, and ancillary costs on a quarterly basis. The hourly rate for guardianship services is $60, with travel time billed at $30 per hour in 15-minute increments, and mileage and ancillary costs not to exceed $150 per year.
The form provides a detailed tracking mechanism for the invoicing of guardianship services provided to DMH clients, with separate sections for each quarter of the fiscal year. The contract opportunity is specific to the state of Massachusetts, and the successful respondents will be awarded a master agreement to provide these services.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| DMH SOW template Guardianship RFR final1-23.docx | DOCX document | |
| First Amendment Guardianship Master Agreement RFR.docx | DOCX document | |
| OSD Instructions for Vendors Responding to Bids via Commbuys~49.docx | DOCX document | |
| Guardian Services RFR_1-2023 Final~1.docx | DOCX document | |
| Guardianship Services Master Agreement RFR Qualified Vendors.xlsx | XLSX spreadsheet | |
| Guardianship Services RFR Questions and Answers.xlsx | XLSX spreadsheet | |
| OSD Required Specifications for Commodities and Services~8.docx | DOCX document | |
| RFR Cover Sheet for Guardianship MA RFR_.pdf | ||
| Business Reference Form~19.docx | DOCX document | |
| Commonwealth Standard Contract Instructions_Contractor Certifications_Terms~14.pdf | ||
| Contractor Authorized Signatory Listing Form~18.doc | DOC document | |
| Electronic Funds Transfer Sign Up Form~25.pdf | ||
| MA Form_W-9~28.pdf |
Show all 13
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Text version
Encouter Form Q1
| FY23 Guardianship Quarterly Service Encounter and Invoice Form | ||||
| SOW Document ID#: | Date Submitted: | |||
| Fiduciary Name: | ||||
| Guardianship Services Hours | Per Hour rate: | 60.00 | ||
| Date of Service Delivery | Description of Service Delivery | Time Increment | 1st qrt | |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Guardianship Service Hour Costs | - 0 | |||
| Travel Time. Travel time rate is $30.00 per hour billed in 15 min increments (i.e. $7.50/15 minutes), not to exceed $200/yr unless stated otherwise in SOW. | ||||
| Date of Travel | Description of Travel (e.g., to, from and purpose) | Time Increment | 1st qrt | |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Travel Time Costs | - 0 | |||
| Mileage and Ancillary Costs (e.g., tolls, parking, copies). Mileage and Ancillary costs cannot exceed $150/yr unless stated otherwise in SOW. | ||||
| Date of Incurred Cost | Description (traveled to/from, or ancillary item) | Mileage | Ancillary Cost | 1st qrt |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Mileage and Ancillary Costs | - 0 | |||
| 1st qrt | ||||
| TOTAL: Quarterly Invoiced Amount: | - 0 |
Encouter Form Q2
| FY23 Guardianship Quarterly Service Encounter and Invoice Form | ||||
| SOW Document ID#: | Date Submitted: | |||
| Fiduciary Name: | ||||
| Guardianship Services Hours | Per Hour rate: $60 | |||
| Date of Service Delivery | Description of Service Delivery | Time Increment | 2nd qrt | |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Guardianship Service Hour Costs | - 0 | |||
| Travel Time. Travel time rate is $30.00 per hour billed in 15 min increments (i.e. $7.50/15 minutes), not to exceed $200/yr unless stated otherwise in SOW. | ||||
| Date of Travel | Description of Travel (e.g., to, from and purpose) | Time Increment | 2nd qrt | |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Travel Time Costs | - 0 | |||
| Mileage and Ancillary Costs (e.g., tolls, parking, copies). Mileage and Ancillary costs cannot exceed $150/yr unless stated otherwise in SOW. | ||||
| Date of Incurred Cost | Description (traveled to/from, or ancillary item) | Mileage | Ancillary Cost | 2nd qrt |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Mileage and Ancillary Costs | - 0 | |||
| 2nd qrt | ||||
| TOTAL: Quarterly Invoiced Amount: | - 0 |
Encouter Form Q3
| FY23 Guardianship Quarterly Service Encounter and Invoice Form | ||||
| SOW Document ID#: | Date Submitted: | |||
| Fiduciary Name: | ||||
| Guardianship Services Hours | Per Hour rate: $60 | |||
| Date of Service Delivery | Description of Service Delivery | Time Increment | 3rd qrt | |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Guardianship Service Hour Costs | - 0 | |||
| Travel Time. Travel time rate is $30.00 per hour billed in 15 min increments (i.e. $7.50/15 minutes), not to exceed $200/yr unless stated otherwise in SOW. | ||||
| Date of Travel | Description of Travel (e.g., to, from and purpose) | Time Increment | 3rd qrt | |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Travel Time Costs | - 0 | |||
| Mileage and Ancillary Costs (e.g., tolls, parking, copies). Mileage and Ancillary costs cannot exceed $150/yr unless stated otherwise in SOW. | ||||
| Date of Incurred Cost | Description (traveled to/from, or ancillary item) | Mileage | Ancillary Cost | 3rd qrt |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Mileage and Ancillary Costs | - 0 | |||
| 3rd qrt | ||||
| TOTAL: Quarterly Invoiced Amount: | - 0 |
Encouter Form Q4
| FY23 Guardianship Quarterly Service Encounter and Invoice Form | ||||
| SOW Document ID#: | Date Submitted: | |||
| Fiduciary Name: | ||||
| Guardianship Services Hours | Per Hour rate: $60 | |||
| Date of Service Delivery | Description of Service Delivery | Time Increment | 4th qrt | |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Guardianship Service Hour Costs | - 0 | |||
| Travel Time. Travel time rate is $30.00 per hour billed in 15 min increments (i.e. $7.50/15 minutes), not to exceed $200/yr unless stated otherwise in SOW. | ||||
| Date of Travel | Description of Travel (e.g., to, from and purpose) | Time Increment | 4th qrt | |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Travel Time Costs | - 0 | |||
| Mileage and Ancillary Costs (e.g., tolls, parking, copies). Mileage and Ancillary costs cannot exceed $150/yr unless stated otherwise in SOW. | ||||
| Date of Incurred Cost | Description (traveled to/from, or ancillary item) | Mileage | Ancillary Cost | 4th qrt |
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| - 0 | ||||
| Total Mileage and Ancillary Costs | - 0 | |||
| 4th qrt | ||||
| TOTAL: Quarterly Invoiced Amount: | - 0 |
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