Program Response Form.3.11.2024.docx

Department of Mental Health Request For Response Medical Equipment Inspections, Inventory Services, and Repairs DMH Document #2025-DMH-3134-01

PROGRAM RESPONSE FORM

RESPONSE FORM, INSTRUCTIONS, AND CHECKLIST

General Instructions:

1. All bidders must complete and submit this Program Response Form.

2. Bidders must respond to each question and request for information set forth in the Program Response Form. Responses must demonstrate that the bidder understands and can meet the requirements of the RFR.

3. If the bidder is submitting responses for multiple bids, a separate Program Response Form must be filed per location.

5. Bidders must save and upload this Program Response Form and all permitted attachments to COMMBUYS using the file naming conventions identified in Subsection 9.4 of the RFR. Bidders are advised to allow adequate time for submission by considering potential online submission impediments like Internet traffic, Internet connection speed, file size, and file volume.

Formatting Instructions:

This document was prepared using Microsoft Word’s forms feature. Complete the form on your computer using Microsoft Word.

1. TO COMPLETE THIS FORM, YOU MUST FIRST SAVE IT TO YOUR COMPUTER.

Enter your responses in the text box, moving between the text boxes using the tab key on your keyboard. Enter your response in the text boxes using Microsoft Word.

1. Responses to check boxes are made by clicking once on the check box. To remove the X from a check box, click on the check box again.

1. Text responses are limited to a maximum number of characters and the limits are noted in each question. Once the maximum character limit is reached, MS Word will not allow more than this limit. Please note that a space is counted as a character, and using the enter key to begin a new line in a response is also counted as a character. It is not recommended that bidders insert graphics into the responses. Spell-check does not work in text boxes.

1. Those with visual impairments may use an electronic text reader by unlocking the Program Response Form.

1.

RFR #______

RESPONSE COVER PAGE

Make this the first page of your proposal.

Request For Response Medical Equipment Inspections, Inventory Services, and Repairs DMH Document #2025-DMH-3134-01

Organization Bidder’s Name:

Address:

City: State: Zip:

State Vendor Customer Code (if bidder currently has one): If not, provide FEIN

Website (if applicable):

Contact Person First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) - FAX: ( ) -

E-Mail: [ ]

Contact Person Address (if different):

City: [ ] State: [ ] Zip: [ ]

Contract For which the Response Is Being Submitted

|_| Central Mass Area Contract (Attachment B) |_| Southeast Area Contract (Attachment C) |_| Central Office Area Contract (Attachment D)

Medical Equipment Inspections, Inventory Services, and Repairs RFR A note about the text boxes: Text input is limited to a maximum number of characters. MS Word will not allow more than this limit. Spaces, commas, line breaks, etc. are counted as characters. The spell-check feature does not work in a text box.

Part I Program Proposal

1. Type of organization (check all that apply);

|_| Sole Proprietorship. Indicate name of individual and Doing Business As name (DBA), if different than individual’s name:

|_| Partnership. Indicate name(s) of Partners: [ ]

|_| Corporation. Indicate type (e.g., |_|For Profit, |_|Non-Profit, |_|Limited Liability

|_| Registered Participant of the Massachusetts Small Business Purchasing Program

2. Overview of Bidder’s Business.

Provide a description of the bidder’s business (e.g., history, years in business, principal services offered, number of current customers; primary customers, service population, number of full and part time employees, hours of operation; licenses and certifications; and awards and recognition in the last 3 years. (Text input limit 8,500 characters, approximately 2 pages with spaces)

Enter text here; text limit 8500 characters

3. Medical Equipment Inspections, Inventory Services, Preventative Maintenance and Repairs Experience.

Describe the Bidder’s experience and expertise related to medical equipment inspections, inventory services, preventative maintenance and repair services of the type described in the RFR. Provide specific examples throughout this response. (Text input limit 8,500 characters, approximately 2 pages).

Enter text here; text limit 8500 characters

4. Proposed Service Schedule for Onsite Medical Equipment Attach a proposed service schedule for all medical equipment listed in the provided inventory for the location your company is bidding on.

|_| Proposed Service Schedule uploaded to COMMBUYS.

5. Detailed Description of Experience with “The Joint Commission” (JCAHO) Standards and Practices Describe in detail your company’s experience in dealing with “The Joint Commission” (JCAHO) Standards & Practices and how your company will represent the Department of Mental Health in accreditation evaluations.

Enter text here; text limit 1200 characters

6. Detailed Description of Training Offered Describe in detail what type of training will be offered to the facility and what is your response time for questions pertaining to medical equipment.

Enter text here; text limit 1200 characters

7. Warranty of Work Describe the company’s warranty of work and what the process would be to address this type of situation.

Enter text here; text limit 1200 characters

8. Central Mass Area - WRCH ONLY Dexis Agreement Confirm if your company will be able to administer the attached Dexis agreement and if so, what will the associated costs for this service be. If bidding on another location, please skip this question.

Enter text here; text limit 1200 characters

9. Detailed Description of Electronic Management System Describe the electronic information management system your company currently offers and how it will meet the needs of the Department of Mental Health.

Enter text here; text limit 8500 characters

10. Reports Describe what type of reports are available through your company. Attach an example of a report(s) for review.

Enter text here; text limit 1200 characters

|_| Example of Report(s) uploaded to COMMBUYS.

11. Proposed Cost Sheets Attach proposed cost sheets for all medical equipment listed in the provided inventory for the location your company is bidding on.

Note: If bidding on the Central Mass Area, please include any associated costs with administering the Dexis Dental Equipment agreement.

|_| Proposed Cost Sheet uploaded to COMMBUYS.

12. Organizational Chart.

Attach an organization chart that shows where the Contact awarded under this RFR will fall within the bidding organization. This chart shall show reporting lines and what service support it will get within the organization (Human Resources, Information Technology, legal, etc.).

|_| Organizational chart uploaded to COMMBUYS.

13. Fiscal Solvency.

a. Financial Statements. Attach a complete set of audited financial statements by an independent Certified Public Accountant or CPA firm of the Bidder’s most recently completed fiscal year for which such statements are available. DMH may request a bidder to furnish supplementary information as is sufficient, in the opinion of DMH, to assure DMH that the Bidder’s business organization and financial resources are adequate to successfully provide the services as set forth in the response.

|_| Financial Information uploaded to COMMBUYS.

b. Affirmations. Affirm the following:

If one or more of the above boxes is checked No, please explain. (Text input limit 1,500 characters, approximately half a page).

Enter text here; text limit 1,500 characters

c. Reserves. Describe the Bidder’s current fiscal reserves and/or line of credits and the ability to provide the service as described in your response for three or more months pending payment by DMH. (Text input limit 1,500 characters, approximately half a page).

Enter text here; text limit 1,500 characters

14. References and Government Experience.

a. References. A Bidder must provide three professional references prepared to provide examples of similar or comparable services the bidder has provided within the last three years, as applicable. DMH or its agents may contact any individual(s) named as references. Bidders must use the Business Reference Form included in this Bid’s COMMBUYS file for this purpose.

|_| Business Reference Form uploaded to COMMBUYS

b. Federal/State Work. Indicate any Medical Equipment Inspections, Inventory Services, and Repair Services for which the Bidder has provided for a State or Federal Agency in the last three years. Provide names and address of the applicable State or Federal agency(ies); locations where services were provided; brief description of the services provided; dates services were provided; and the annual value of the contract. Text input limit 1,500 characters, approximately half a page).

Enter text here; text limit 1,500 characters

15. Subcontractors If the Bidder intends to use subcontractors in providing the proposed service component, complete and attach the Subcontractor Identification List included in the Bid’s COMMBUYS file. All subcontracts are subject to DMH approval and are required to comply with the same terms and conditions as the awarded Contractor.

|_| Subcontractor Identification List is uploaded to COMMBUYS (if applicable).

RESPONSE SUBMISSION PAGE

Organization

I affirm, on behalf of the Bidder, that the Bidder will comply with the requirements of the Request for Response and with the terms of this proposal.

Authorized Signatory:

First Name: Last Name:

Title:

By clicking the check box, the submitter attests that s/he is an agent of Bidder with authority to sign on the Bidder’s behalf and is agreeing all affirmations listed above.

CHECKLIST OF ATTACHMENTS TO THE RESPONSE FORM

All documents listed below (other than the ones marked optional) must be submitted via COMMBUYS for your response to be considered complete. Files must be uploaded and follow the naming convention indicated in the chart. These attachments are referenced throughout the Response Form.

Assign when creating documents

Scanned documents will be accepted. All scanned documents must be scanned in such a way that they can be read on a computer monitor and printed on 81/2” x 11” paper, unless otherwise specified. Attachments must be uploaded in a zipped file.

Addendums or uploads not specifically requested in this document, the RFR or on the COMMBUYS Bid Solicitation screen will not be reviewed.

RESPONSE INSTRUCTIONS

1. Save, read, and review the completed Response Form. Check entries in the text boxes to assure that the input limits did not shorten your response. Proofread text; spell-check does not work in the text boxes.

2. Upload in COMMBUYS the Response Form with the attachments according to the Response Checklist.

3. Confirm that “No Charge” is checked or a dollar amount entered in the Unit Cost field on the Item screen in COMMBUYS. The “No Charge” selection will not be construed by the Purchaser to mean an offer to provide service or products at no charge.

4. Submit your electronic quote in COMMBUYS. (Bidders must be registered in COMMBUYS to submit quotes)