Response Document Template.docx
DOCX document 29 KB Posted
- Attached to
- Telemedicine Services
- Solicitation number
- BD-27-1023-1023C-1023L-131709
- Issued by
- Massachusetts
About this file
This is a Response Document Template for Request for Response (RFR) TELMED-27-2 issued by the Commonwealth of Massachusetts Department of Developmental Services for telemedicine services. The Department seeks qualified providers to deliver telemedicine services as part of a pilot program in selected state-operated group homes, with the objective of promoting health, wellness, and safety for individuals receiving adult long-term residential services. The response document requires vendors to complete eleven sections addressing experience, clinical model, staff qualifications, telemedicine coverage, medical care coordination, appointment follow-up procedures, and documentation and reporting requirements, with page limits ranging from one to five pages per section. Respondents must provide organizational details including vendor name, contact person, address, phone number, and email, along with the electronic signature of an authorized agency representative and submission date.
The template mandates completion of a budget and price proposal section limited to one page and requires vendors to certify that all statements in their proposal are true and complete, with acknowledgment that misstatements may result in disqualification and legal penalties. Respondents must authorize verification of staff qualifications and permit release of information necessary to confirm provider credentials. The document does not specify pricing structures, set-asides, contract terms, renewal options, funding amounts, or award dates within the template itself, indicating that these details are contained in the accompanying RFR documentation.
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Text version
Response Document RFR TELMED-27-2
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.
Vendor Name
Contact Person
Provider Address
E-mail Address
Vendor Code
Phone Number
Vendor 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.
Question 11: Budget/Price Proposal (maximum 1 page)
File details come from the government source that posted it. Updated .