Response Document Template.docx
DOCX document 29 KB Posted
- Attached to
- Telemedicine Services
- Solicitation number
- BD-26-1023-1023C-1023L-129179
- Issued by
- Massachusetts
About this file
This is a Response Document Template for Request for Responses (RFR) TELMED-27 Telemedicine Services issued by the Commonwealth of Massachusetts Department of Developmental Services. The document serves as the official proposal submission form for qualified providers seeking to deliver telemedicine services as part of a pilot program in selected state-operated group homes. The initiative aims to enhance the health, wellness, and safety of individuals receiving adult long-term residential services. Providers must complete all required sections, including organizational information, provider details, and responses to ten substantive questions covering experience, clinical model, staffing, coverage areas, medical care coordination, appointment follow-up procedures, and documentation and reporting requirements. Responses to individual questions are subject to specific page limitations, ranging from three to five pages depending on the question topic.
The template requires provider certification that all statements in the proposal are true and complete, with acknowledgment that misstatements of fact may result in disqualification and penalties as prescribed by law. Submission requires an electronic signature from an authorized agency representative and the completion of all designated forms. The document does not specify pricing terms, set-asides, contract award dates, contract duration, or renewal options within the template itself. Providers must provide their vendor code, contact information, and grant permission for verification of staff qualifications and release of relevant information to confirm provider eligibility and compliance with requirements.
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Text version
Response Document RFR TELMED-27
Telemedicine Services Response Document
Commonwealth of Massachusetts Department of Developmental Services Response Document
This form must be completed according to the instructions below. Requirements include completion of questions, submission of required forms and certifying via signature that the provider organization will perform the service as described.
Provider Name
Contact Person
Provider Address
E-mail Address
Vendor Code
Phone Number
Provider Signatory Name
Signatory Email
Certification
I certify that the statements made in this proposal are true and complete to the best of my knowledge. Any misstatement of fact may lead to disqualification and dismissal and to such other penalties as may be prescribed by law or regulations. All statements made are subject to verification as a condition of qualification as a provider. By signing this statement, I hereby give permission for the release of any and all information necessary to verify staff qualifications.
Electronic Signature of Authorized Agency Representative
Date
Question 1: Experience (maximum 3 pages) 1A.
1B.
1C.
1D.
Question 2: Clinical Model (maximum 5 pages) 2A.
2B.
2C.
2D.
2E.
2F.
2G.
Question 3: Staff (maximum 3 pages)
3A.
3B.
3C.
Question 4: Telemedicine Coverage (maximum 3 pages)
4A.
4B.
4C.
4D.
Question 5: Medical Care Coordination (maximum 3 pages)
5A.
5B.
5C.
Question 6: Telemedicine Appointment Follow-up (maximum 3 pages)
6A.
6B.
6C.
Question 7: Telemedicine Appointment Follow-up (maximum 4 pages)
7A.
7B.
7C.
7D.
7E.
Question 8: Documentation and Reporting (maximum 3 pages)
8A & B. Samples
8C.
8D.
8E.
8F.
8G.
Question 9: Documentation and Reporting (maximum 3 pages)
9A.
9B.
9C.
9D.
Question 10: Documentation and Reporting (maximum 3 pages)
10A.
10B.
10C.
File details come from the government source that posted it. Updated .