REQUEST FOR PROPOSALS- SFY2019

TREATMENT and RECOVERY SUPPORT SERVICES/GOVERNMENT ENTITIES:

ALCOHOL AND OTHER DRUG and MENTAL HEALTH

FACE SHEET

Original / Revision / Date Submitted:
PROVIDER INFORMATION
Agency Name:
Address:
Telephone #: / Fax #:
Agency Web-site Address:
Executive Director/CEO:
E-mail Address:
Fiscal Officer:
E-mail Address:
Clinical Director:
E-mail Address:
Board President/Chair:
E-mail Address:
Federal Tax ID (EIN) #:
DUNS #:

AUTHORIZATION

I hereby certify by my signature that this RFP has been approved for submission by this Agency’s governing authority.

Board President / Chair / Date / Executive Director / CEO / Date
StarkMHARTx & Recovery Support Services SFY 2019RFP Face Sheet & ChecklistPage 1 of 3 / Page 1 of 3
Agency Name:

Current Accreditations (JCAHO, CARF, COA, Other) and Certifications (OhioMHAS):

  • Please submit a copy of all current Accreditations and Certifications clearly showing the services certified to provide, locations (if applicable), and expiration dates.

RFP Narrative and Program Budget Required File Naming Convention

Existing Programs

RFP Narrative Responses: MIP Program Code #.Program Name Narrative.doc(x)

Example: 40054.Forensic Services Narrative.doc(x)

Program Budgets: MIP Program Code #.Program Name Budget.xls(x)

Example: 40054.Forensic Services Budget.xls

New Programs
RFP Narrative Responses: New.Program Name Narrative.doc(x)

Example: New.Forensic Services Narrative.doc(x)

Program Budgets: New.Program Name Budget.xls(x)

Example: New.Forensic Services Budget.xls

StarkMHARTx & Recovery Support Services SFY 2019RFP Face Sheet & ChecklistPage 1 of 3 / Page 1 of 3

REQUEST FOR PROPOSALS - SFY 2019

TREATMENT and RECOVERY SUPPORT SERVICES/GOVERNMENT ENTITIES:

ALCOHOL AND OTHER DRUG and MENTAL HEALTH

SUBMISSION REQUIREMENTS including format - RFPCHECKLIST

(agency name)

Deadline: Thursday, December 28, 2017by 12:00 PM

  1. Face Sheet signed by Executive Director/CEO & Agency Board President/Chair (PDF)

  1. Completed Checklist (Word)

  1. Agency Mission and Vision Statements (Word)

4. Program Budget (Excel)
5. Board Inventory Template (Excel)
6. Personnel Cost Chart (Excel)
7. Provider Table of Organization (include staff roster with credentials) (Word)
8. Roster of Provider Board Members (indicate Board officers) (Word)
9. Copies of Current Proof Accreditations, and Certifications (PDF)
10. Original RFP Face Sheet (with original signatures – hand or mail delivered)
11. RFP narrative response (Word)

COMPLETED CHECKLIST MUST BE SUBMITTED

BEHIND FACE SHEET OF RFP PACKET

StarkMHARTx & Recovery Support Services SFY 2019RFP Face Sheet & ChecklistPage 1 of 3 / Page 1 of 3