RFP, RFV, & OPPs

Attachment A - Proposal Title Page Attachment B - Statement of Obligation Attachment C - Statement of Equity and Diversity

ATTACHMENT A - HCBS PROPOSAL TITLE PAGE FY 24 25 ATTACHMENT B - STATEMENT OF OBLIGATION ATTACHMENT C - DS 1891 Medicaid Integrity Form

Project 1- Socialization Training Program (028) Project 2- Social Recreational Programs (525) Project 3- Specialized Recreational Therapy (106) Project 4- Art Therapist (691) Project 5- Dance Therapist (692) Project 6- Music Therapist (693) Project 7- Recreation Therapist (694) Project 8- Camping Services (850) Project 9- Sports Club (008) Attachment A: Title Page Attachment B: Statement of Obligation Attachment C: Statement of Equity and Diversity Guide

SDP Standardized Vendorization Packet for Pre-Enrollment Services Person Centered Planning and Self-Directed Supports Guidance Attachment A: Vendor Packet Checklist Attachment B: General Self-Directed Supports Qualifications and Agreement Form Attachment C: Financial Management Services Self-Directed Supports Qualifications and Agreement Form Attachment D: DS 1890 Vendor Application Attachment E: DS 1891 Applicant/Vendor Disclosure Statement Attachment F: Conflict of Interest Form Attachment G: Business Associate Agreement/HIPAA Form Attachment H: Home and Community Based Services Provider Agreement Form Attachment I: W9 Request for Taxpayer Identification Number and Certification

Attachment A: Proposal Title Page Attachment B: Statement of Obligation Attachment C: Statement of Equity and Diversity Attachment D: Cost Statement Attachment E: Proposal Writing Requirements Attachment F: DDS Directive Attachment G: Business Plan Attachment H: CFS Service Code Attachment I: CFS Fact Sheet Attachment J: CFS Referral and Service Need form Attachment K: CFS Provider Quarterly Reporting Tool

Attachment A: Proposal Title Page Attachment B: Statement of Obligation Attachment C: Business Plan Attachment D: Statement of Equity and Diversity Attachment E: NLACRC Cost Statement

Attachment A: Proposal Title Page Attachment B: Statement of Obligation Enclosure C: CCP Referral and Service Need Evaluation Form Attachment F: CCP Program Design Guidance Enclosure A: CCP Service Code Description Enclosure B: Person Centered Career Plan Service Provider Fact Sheet Enclosure C: CCP Referral and Service Need Evaluation Form Enclosure D: CCP Fact Sheet for Potential Service Providers Enclosure E: CCP Fact Sheet for Individuals and Families

Attachment A: Proposal Title Page Attachment B: Statement of Obligation Attachment C: Proposal Writing Requirements Attachment D: Program Design Requirements Attachment E: DS1890 Attachment F: DS1891 Attachment G: HCBS Provider Agreement Attachment H: Sample Transportation Contract Attachment I: NLACRC Board of Trustees Service Provider Insurance Policy Attachment J: Cost Statement Attachment K: Statutes and Regulations Attachment L: W-9