Letter of Intent
& Questionnaire

MTM, Inc. would like to showcase your transportation company in our response to the Nevada Department of Health and Human Service request for proposals (RFP) for non-emergency transportation (NET).
Please print clearly or type.
Transportation Provider:
The Transportation Provider listed above would like to offer this letter as a show of good faith to proceed in a timely manner, negotiating with MTM, Inc. (MTM), a mutually acceptable subcontract for participation in their non-emergency medical transportation program, following its’ successful award of a brokerage contract in the Transportation Provider’s service area.
Important: This is not a contract and does not limit you from similar agreements with other NEMT broker candidates.
Business Name:
/ Phone:
Contact Name & Title: / Fax:
Contact Email Address:
Street Address:
City: / State: / Zip:
Base County:
Additional Counties of Service:
Hours of Operation:
# of Ambulatory Vehicles: / # of Wheelchair Vehicles: / # of Stretcher Vehicles: / # of Ambulance Vehicles:
# of Bariatric Vehicles: / Bariatric Vehicle Weight Maximum:
Business License Number:
/ Tax ID Number: / Medicaid ID Number/NPI:
Are you certified as a: MBE WBE DBE Disabled Veteran Business
Signature: / Date:
Please submit documents by: September 16th, 2015
Attn: Matt Bollwerk | Fax: (800) 459-6224 | | 16 Hawk Ridge Dr. Lake St. Louis, MO 63367
Please complete the following table regarding your rates for the services listed below, as they apply to your fleet. Please note that this is for informational purposes only and actual rates will be negotiated during the next stage of the recruitment process.
Please print clearly or type.
Ambulatory Vehicle Rate:
Wheelchair Vehicle Rate:
Stretcher Vehicle Rate:
Ambulance Vehicle Rate:
Bariatric Vehicle Rate:
Other (Please specify):
Notes:
Please complete the following questions regarding your company’s existing technology. Please note that this information is for compatibility preparations only and will not impact your acceptance into our network.
Routing, Scheduling, & Dispatching Software Used (if applicable):
Do you use tablets or other mobile data terminals (MDTs) in your vehicles that capture GPS data?
No Yes (Please specify):
What two-way communication technology do you use for contacting drivers?
Notes:

Document Revised 8/15