Attachment_J.3.1_-_Past_Performance_Questionnaire_Contractor_Request_Letter.docx

RFP-CMS-2016-8A-0008

Attachment J.3.1 – Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE

[COMPANY LETTERHEAD (Prime or subcontractor)]

Reference Name, Address and Contact information Date

SUBJECT: RFP-CMS-2016-8A-0008 – Workers Compensation Review Contractor

Dear _________________:

We are currently responding to the Centers for Medicare & Medicaid Services (CMS) Request for Proposal number RFP-CMS-2016-8A-0008 (as a subcontractor to______ (If applicable)). The purpose of this contract is to evaluate Worker’s Compensation Medicare Set-Aside Arrangement (WCMSA) proposals and project the future medical costs related to the Workers compensation injury that would be otherwise reimbursable by Medicare.

There is an increased emphasis on past performance in the federal source selection process. CMS is requesting that customers and clients of Offerors provide the information as described within the attached questionnaire and return it to them for evaluation. We have identified you as one of our references and respectfully request that you complete and sign the attached questionnaire and then return it to CMS.

Questionnaires are due to CMS no later than ____________ (to be filled in by Offeror); however, we would appreciate an earlier response if at all possible.

We sincerely appreciate your cooperation in this matter.

Sincerely, Reference Name Title

Source Selection Information – See FAR 2.101 and 3.104