EX-10.21 190 a2163176zex-10_21.htm EXHIBIT 10.21

 

 

Exhibit 10.21

 

SECTION 9

ATTACHMENT A

APPLICATION AND QUALIFIED VENDOR AGREEMENT AWARD

 

APPLICATION and

 

ARIZONA DEPARTMENT OF

 

 

ECONOMIC SECURITY

QUALIFIED VENDOR AGREEMENT AWARD

 

 

 

 

DIVISION OF

RFQVA NO. DDD 704011

 

DEVELOPMENT DISABILITIES

 

APPLICATION

 

TO: THE STATE OF ARIZONA

 

The undersigned hereby applies and agrees to provide the service(s) in compliance with the RFQVA
For clarification of this application, contact:

 

 

 

 

Greg Torres

 

04-2893910

Name

 

Federal Employer Identification Number

 

 

 

(617) 790-4800

 

National Mentor Healthcare, Inc. DBA Arizona Mentor

Phone Number

 

Company Name

 

 

 

(617) 790-4901

 

3724 N. 3rd St. Suite 200

Fax Number

 

Mailing Address

 

 

 

greg.torres@TheMentorNetwork.com

 

Phoenix

AZ

85012

Email Address

 

City

State

Zip

 

 

 

If awarded a Qualified Vendor Agreement,

 

602-200-9494

all notices should be sent to:

 

Phone Number

 

 

 

Kay S. Moore

 

kay.moore@TheMentorNetwork.com

Name

 

E-Mail Address

 

 

 

3724 N. 3rd St. Suite 200

 

/s/ Greg Torres

Mailing Address

 

Signature & Person Authorized to Sign Application

 

 

 

Phoenix

AZ

85012

 

 

City

State

Zip

 

Greg Torres

 

 

Printed Name

602-200-9494

602-200-8588

 

 

Phone Number

Fax Number

 

CEO

 

 

 

Title

kay.moore@TheMentorNetwork.com

 

 

EMail Address

 

 

 

APPROVAL OF APPLICATION AND AGREEMENT AWARD (FOR STATE OF ARIZONA USE ONLY)

 

Your application is hereby approved.  The Qualified Vendor is now bound to provide the service (s) listed in the attached award notice based upon the RFQVA, including all terms, conditions, service specifications, scope of work, amendments, etc., and the Qualified Vendor’s application as accepted by the State.

 

This agreement shall henceforth be referred to as Qualified Vendor Agreement No. 00455. The begin date and the effective date of this agreement is either the date that this award is signed by the Procurement Officer or July 1, 2003, whichever is later.

 

 

State of Arizona

 

 

Awarded this Date:

7/1/03

 

 

/s/ Antonia Valladares

 

 

Procurement Officer

 

 

A-1


 

SECTION 1

NOTICE OF REQUEST FOR QUALIFIED VENDOR APPLICATIONS (RFQVA)

State of Arizona

Department of Economic Security (DES) or (Department)

Division of Developmental Disabilities (DDD) or (Division)

 

RFQVA Number: DDD 704011

 

o Time Limited

ý Open and Continuous

 

Application Due Date:

 

Pursuant to Arizona Revised Statutes (A.R.S.) § 36-557 and rules adopted thereunder (R6-6-2101 et seq.), which are incorporated herein by reference, Applications for the services listed below will be accepted by the Division at the time and manner specified below. Through this Request for Qualified Vendor Applications (RFQVA) the Arizona Department of Economic Security (DES or Department), Division of Developmental Disabilities (DDD or Division) will execute Qualified Vendor Agreements with providers for the provision of services.

 

Applications must be submitted electronically using the Qualified Vendor Application and Directory System as well as submitting a printable hard copy with signatures and necessary additional documentation. See Section 3 and Section 9.

 

Applications will be accepted from current contracted providers beginning April 7, 2003. To assure service continuation effective July 1, 2003 Applications should be submitted by May 1, 2003 at 5 p.m. Arizona time. Applicants new to DDD may submit Applications beginning May 5, 2003. All Applicants shall not expect to be awarded an agreement sooner than 60 days after the submittal of a complete Application. [NOTE: Applications from independent providers as defined in Section 6 will not be processed or result in an agreement until the statewide published rates for independent providers have been adopted in the fall of 2003.]

 

Submittal Location:

 

ELECTRONICALLY GENERATED HARD COPY WITH ORIGINAL SIGNATURE

AND NECESSARY DOCUMENTATION

 

In Person or By Courier to:

 

DDD Contract Unit, 4th Floor Southwest

Business Operations — Site Code 791A

Division of Developmental Disabilities

Arizona Department of Economic Security

1789 West Jefferson Street

Phoenix, Arizona 85007

(602) 542-6874

 

I-1


 

By Mail to:

 

DDD Contract Unit

Business Operations - Site Code 791A

Division of Developmental Disabilities

Arizona Department of Economic Security

P.O. Box 6123

Phoenix, Arizona 85005

 

Services:

 

Home-Based Services: Attendant Care; Habilitation, Community Protection and Treatment Hourly; Habilitation, Support; Housekeeping; and Respite. Day Treatment and Training Services: Day Treatment and Training, Adult; Day Treatment and Training, Children (After-School); and Day Treatment and Training, Children (Summer). Developmental Home Services:  Habitation, Vendor Supported Developmental Home (Child and Adult); and Room and Board, Vendor Supported Developmental Home (Child and Adult). Independent Living Services: Habilitation, Individually Designed Living Arrangement. Group Home Services: Habilitation, Community Protection and Treatment Group Home; Habilitation, Group Home; Habilitation, Nursing Supported Group Home; and Room and Board, All Group Homes. Professional Services: Home Health Aide; Nursing; Occupational Therapy; Occupational Therapy Early Intervention; Physical Therapy; Physical Therapy Early Intervention; Speech Therapy; and Speech Therapy Early Intervention. Other Services: Transportation.

 

First Pre-Application Conference:

 

Date: March 19, 2003, Arizona Time: 10 a.m. to 2 p.m.

 

Location:                      Sheraton Crescent Hotel

2620 West Dunlap Avenue

Phoenix, Arizona

(602) 943-8200

 

Second Pre-Application Conference:

 

The second pre-Application conference will be held after the electronic application is released. The purpose of the conference will be to answer specific questions about the electronic application, referred to as the Qualified Vendor Application and Directory System.

 

Date: March 28, 2003, Arizona Time: Session 1 - 9 a.m. to Noon; Session 2 - 1 p.m. to 4 p.m.

 

These two sessions will provide the same information. Applicants whose Federal Employer Identification Number (FEIN) or Social Security Number (SSN) ends with an odd number shall attend the morning (9 am to noon) session, and Applicants whose FEIN or SSN ends with an even number shall attend the afternoon (1 p.m. to 4 p.m.) session.

 

I-2


 

Location:                      Auditorium in the basement of the Arizona Land Department

1616 West Adams Street

Phoenix, Arizona

(602) 542-4631

 

Persons with a disability may request a reasonable accommodation by contacting the RFQVA contact person. (For TDD/TTY call through the Arizona Relay Service at 800 367-8939). Requests should be made as early as possible to allow time to arrange the accommodation.

 

Agreement Type: Qualified Vendor Agreement with Published Rate

 

Agreement Term: 12 months beginning no sooner than 7/1/03, with five one-year options for the Division to extend or renew the agreement, with all agreements ending 6/30/09. The agreement can be terminated as specified in Section 6, DES/DDD Terms and Conditions.

 

RFQVA Contact Person (Phone/email)

 

Cathie Rodman (602) 542-6896 /CRodman@azdes.gov

 

 

 

 

 

 

DDD Procurement Specialist

Date

 

AN EQUAL EMPLOYMENT OPPORTUNITY AGENCY

 

I-3