REQUEST_FOR_CONFIDENTIAL_DOCUMENTS_FORM_260125.pdf

REQUEST FOR CONFIDENTIAL DOCUMENTS FORM

Email:tacompton@mcgriff.com/ troy.rombough@tucsonaz.gov/tracy.garcia@tucsonaz.gov

Attn: Taylor Compton/Troy Rombough/Tracy Garcia

RE: City of Tucson RFP #260125

We are in receipt of the above referenced RFP and requesting the census and additional documents for the service(s) indicated below. We understand that documents containing confidential data (census, claims, etc.) cannot be sent to us without a current signed Confidentiality Agreement on file. Upon receipt of the confidential documents form, Purchasing will release these additional documents.

For Medical and Pharmacy Proposals, Vendors must submit a repricing file for City of Tucson’s claims to be reviewed as part of the cost analysis. The City’s Consultant McGriff/MMA Dallas will be submitting this data and instructions via secure file transfer. A Non Disclosure Agreement will be needed if your organization does not currently have one on file with McGriff/MMA Dallas. Responses to the repricing must be returned back to McGriff securely via the instructions and by the deadline that will be provided. Indicate below if you are requesting repricing files. This form is due within 1 week of RFP Release Date.

_____ Offeror is requesting the Confidential Documents (census, claims, etc.)

_____ Offeror is requesting repricing documents from McGriff/MMA Dallas

Service(s) Respond (mark x if you will submit a proposal)

Decline (mark x if you will NOT submit a proposal)

Reason for Decline

A. Medical/Telehealth, and HSA & HRA Admin

B. Pharmacy Benefit Management (PBM)

C. Wellness

D. EAP

E. Dental

Name of Company

Address

Phone Number

Email Address of Person(s) to receive confidential & repricing files

Signature