· Web viewMicrosoft Word 2003-97 format, with file name ending in “.doc” or “.docx”...

Request forProposals (RFP)NSW Community based Palliative Care ServicesHAC: 12/70Closing Date: 7 January 2013 (10am)

Inter-Government and Funding Strategies and Integrated Care BranchStrategy and Resources Division NSW Ministry of Health https://tenders.nsw.gov.au/health/

Request for ProposalsNSW Community Based Palliative Care Services

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Table of Contents

1. Introduction and Background ..................................................................................... 2

2. This Request for Proposals......................................................................................... 3

3. Description of Services ............................................................................................... 4

4. Submission details ...................................................................................................... 5

5. Information required in the proposals........................................................................ 6

6. Submission questions and clarifications ................................................................... 7

7. Scope of services to be proposed .............................................................................. 8

8. Evaluation criteria ...................................................................................................... 10

9. Evaluation process .................................................................................................... 13

10. Ethics .......................................................................................................................... 13

11. Terms and conditions ................................................................................................ 14

12. Disclosure of contract information ........................................................................... 17

13. Price and payment ..................................................................................................... 17


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1. Introduction and Background

The NSW Minister for Health, Jillian Skinner recently launched a four year plan to increase access to palliative care throughout NSW - the NSW Government Plan to increase access to palliative care 2012-20161 and announced a tender to expand community based services. The NSW Government will provide an additional $35 million over four years on top of the existing annual budget of approximately $86 million for specialist palliative care. This will enable new patient care services to bedeveloped, foster new partnerships and establish linkages to create an integrated network of primary care, specialist palliative care, aged care and community services.

1.1 Key strategic objectives for palliative care in NSWThe NSW Government Plan to increase access to palliative care 2012-2016 (thePlan) has four key strategic objectives:

Expanded community based palliative care services especially in rural areas and for special populations

Greater cooperation between specialist palliative care services and existingprimary and aged care services across the stateExpanded support for families and carersExtended capacity of palliative care services in NSW

The NSW Ministry of Health is seeking innovative community based palliative care services including those involving public-private partnerships. As described in the Plan, access to palliative care is not evenly distributed across the state of NSW. For example, residents of rural and remote areas, Aboriginal and Torres Strait Islander people and people of culturally and linguistically diverse (CALD) populations may have less access to services. As well as state-wide service offerings, the Ministry is interested to consider how tenderers will address the needs of those affected by lack of access in their proposal and provision of regional, district or local services that will integrate with existing specialist palliative care services. This RFP is not intended to restrict tenderers to particular geographic regions or the boundaries of Local Health Districts (LHDs).

The NSW Ministry of Health is also interested to hear how tenderers will bring in additional investment to add to the seed funding provided by the NSW Government and in proposals which leverage revenue from other government and non-government sources.

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Tenderers are encouraged to consult with relevant LHDs in preparing their proposals. The NSW Ministry of Health will seek feedback from referees and other relevant parties, including requesting input from the LHDs, during the tender evaluation period.

1.2 AimThe overall aim of the new funding stream is to increase access to palliative care, and in particular to address current service gaps through innovative approaches to service delivery.

1.3 Key expectationsKey expectations are for these new services to:

Facilitate provision of services as close to the client‟s home as possibleMeet service gapsSupport interdisciplinary teamwork and draw on the skills and expertise of a range of clinicians and community inputsForm or strengthen existing links with a specialist palliative care serviceBe complementary to existing servicesBuild capacity of primary health, community and private healthcare providers(including residential aged care facilities)Maximise the benefits from alternative funding streams.Utilise the National Standards for providing quality Palliative Care for allAustralians as a benchmark to guide service development.

1.4 OutcomesExpected outcomes of the community based palliative care services being sought by the NSW Ministry of Health include:

Improved access to community based palliative care servicesImproved integration of palliative care services with a person-centric approach Empowerment of the person needing palliative care in decisions about their care, including providing real choice about being able to support a wish to die at home

Improved support and clinical advice for people at home needing palliativecareImproved quality of life for people needing palliative care.

2. This Request for Proposals

This RFP seeks submissions for community based palliative care services able to integrate with and enhance existing services in NSW LHDs.


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Proposals may represent one or more service strategies and span the catchments of one or more NSW LHDs, or even the whole state of NSW.

Proposals will be welcomed from all service sectors whether private not-for-profit, private for profit, public and affiliated health organisations. Partnerships between any of these providers will be welcomed.

Successful tenderers are expected to commence implementation of services from March 2013.

3. Description of Services

Under a contract with the Health Administration Corporation, successful tenderers will operate innovative community based palliative care services. These services will be integrated with primary care, aged care and specialist palliative care services across the state; will expand support for families and carers; and extend the capacity of palliative care services in NSW.

3.1 Definition of Palliative CareAs outlined in the NSW Government Plan to increase access to palliative care 2012-2016, “palliative care provides treatment for those who are dying and supports their families and carers. It neither hastens nor postpones death, but affirms life and approaches dying as a normal process”.2

3.2 Target GroupsTarget groups are expected to include people with cancer and/or people with life limiting conditions.

3.3 Service activitiesIn order to encourage innovation, service activities are not being prescribed. The list of services that follows is indicative of the type of services that might be expected to be included in proposals.

Palliative care clinical services, including assessment and referral services Palliative care specialist consultation services, including after hours services Patient support services, including care navigation/case management services

Carer/family support services, including after hours advice/support servicesand bereavement servicesSupport services including volunteer services

2 NSW Ministry of Health. The NSW Government plan to increase access to palliative care 2012-2016. Sydney: NSW Ministry of Health, 2012.


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Home nursing services Domestic support services Equipment servicesE-health, Telehealth and IT infrastructure and IT management.

3.4 Term

The NSW Ministry of Health is seeking information from tenderers regarding the timeframe over which they wish to provide services. This could range from 1 up to 4 years.

3.5 Indicative Timetable

Submission of proposals Monday 7 January 2013

Advice to tenderers Week commencing 11 February 2013

Service commences implementation March 2013

4. Submission Details

Responses to this RFP must be lodged via the NSW eTendering Web site www.tenders.nsw.gov.au/health by 10am Monday 7 January 2013 (Sydney Daylight Saving Time).

Electronic submissions must meet the following criteria:

Submitted documents (the proposal and Attachment A) must be in:

Microsoft Word 2003-97 format, with file name ending in “.doc” or “.docx”and/or Acrobat (*.pdf);

Attachment B must be in Excel 97-2003 or 2007 format, with file ending in“.xls” or “.xlsx”.

Tenderers should not wait until the nominated closing time to lodge their responses as difficulties in uploading responses to the website may be encountered where:

many users attempt to upload responses at the same time, or

the upload of large files sizes or volumes is attempted.

Due to probity considerations, responses submitted by email or hard copy will notbe permitted.


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A response lodged wholly or partly after the closing time will be registered as a LateResponse and may be excluded from evaluation.

The NSW Ministry of Health may, at its absolute discretion, allow the evaluation of a Late Response, if it judges that the lateness is due to circumstances outside the control of the Respondent.

5. Information required in the Proposals

The proposal is to contain the following completed schedules in the form of the attachments, noting that any variation from them may result in exclusion of the proposal from further evaluation:

A. Tenderer Particulars;B. Proposed Annual Service Budget

Tenderers should note that submissions to this RFP are made at the tenderer‟s own cost, and that NSW Health, whilst making the RFP in good faith, is not obliged to proceed with this project.

Short-listed tenderers may be requested to deliver a presentation to the NSW Ministry of Health outlining their proposal. Tenderers should be prepared to present during the fortnight beginning 21st January 2013.

5.1 Validity period

Tenderer submissions will become the property of HAC on its receipt and will be valid for twelve (12) months from the closing date.

5.2 Consortium and Joint Proposals

The NSW Ministry of Health will welcome joint and consortium proposals. If multiple entities are cooperating in the submission of a proposal, the NSW Ministry of Health requires one entity to be nominated as the contracting entity. Any variation to the tendered consortium must be agreed with the NSW Ministry of Health.

5.3 Subcontractors

If the tenderer uses contractors or brokers‟ services, the tenderer agrees that the contractor shall be bound under the tenderer responsibility in accordance with any contract that may be entered into with the HAC.

This RFP is protected by crown copyright.


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Addenda to this RFP may be issued via www.tenders.nsw.gov.au/health before the closing date/time, and become part of this RFP.

6. Submission Questions and Clarifications

The following people should be contacted if you have any questions or require clarification on any topics covered in this RFP:

Ms Stefanie Williams or Ms Christina SummerhayesManager, Dementia Carers Disability TeamNSW Ministry of HealthLocked Mail Bag 961NORTH SYDNEY 2059

Telephone:9391 9512 – Ms Williams (Mon, Tues, Wed)9391 9240 – Ms Summerhayes (Mon, Wed, Thurs, Fri)

Email: [email protected]

Please note that questions and answers of broad impact or significance will be communicated to all tenderers by issue of addenda through the NSW eTendering Web site w w w . tender s. n s w . go v. au / h ea l t h .

Tenderer telephone and email queries must be raised p r i o r t o F r i d a y 2 1 De ce m b e r 201 2 as offices of the NSW Ministry of Health will be closed from this date, re-opening on Monday 7 January 2013.


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7. Scope of Services to be Proposed

7.1 Tender focusAs outlined in Section Three of this document, the intention of this RFP is to encourage innovation. Accordingly, service activities are not being prescribed. The list of services that follows is indicative but not exclusive of the type of service orservices that might be expected to be included in proposals.

Palliative care clinical services, including assessment and referral services Palliative care specialist consultation services, including after hours services Patient support services, including care navigation/case management services

Carer/family support services, including after hours advice/support servicesand bereavement servicesSupport services including volunteer servicesHome nursing services Domestic support services Equipment servicesE-health, telehealth and IT infrastructure and IT management

Further, the NSW Government Plan to increase access to palliative care 2012-2016 outlines key service areas. Tenderers are invited to consider their response to these service areas in their proposals.

7.2 Desirable features of a palliative care serviceAs outlined in the NSW Government‟s plan, the Agency for Clinical Innovation (ACI)is working to develop patient care models for palliative care services.

Tenderers should consider the following features as a guide in developing their responses to this RFP.

Key desirable features of a palliative care service include:

Taking a multidisciplinary approach to care involving family members, carers and all appropriate health care providers

In the case of community-based services, have formalised links with a specialist palliative care service

Have the capacity to provide, or be networked with a service to provide, after- hours support and advice from health professionals

Use innovative technology such as telehealth and e-health to share information


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Have broad access to clinical networks


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Provide comprehensive assessment, case management, coordination and clear communication across care settingsEnsure coordinated and integrated services across settingsWork in partnership across government, non-government and community services

Provide coordination of health care with other services such as carer respite and home care services

Tailor services to the target population and setting, particularly when addressing cultural needs

Offer dynamic models that can respond to the needs of individuals in rural or remote areas

Provide an explicit, easy-to-navigate process for the transfer of individuals from acute to palliative services, with the individual informed and involved in decisionsHave a data-driven culture aimed at clinical practice improvementPromote formal relationships between primary care services and specialist palliative care services to achieve a more integrated and coordinated approach

Initiate linkages between palliative care service providers and networks ofAboriginal health professionals and Aboriginal community-controlled health services

Initiate partnerships between palliative care services and CALD health and community services

Integrate state-based programs with work being done in palliative care services by the NGO, federal, primary care and community-based sectors

Use the National Standards for providing quality palliative care for allAustralians as a benchmark to guide service development

Work in partnership with palliative care research bodies to ensure an evidence base for all features of a palliative care service model

Expand community-based palliative care services, especially in rural areas and for special needs populations.


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8. Evaluation Criteria

Selection will be primarily based on the tenderer‟s submission to this RFP, especiallythe proposal‟s capacity to fulfill the evaluation criteria.

The Evaluation Panel will assess submissions in accordance with the evaluation criteria specified below:

8.1 Evaluation Criterion One: Demonstrates that the proposed service will meet NSW Government strategic objectives to increase access to palliative care services.

In responding, tenderers should provide a description of their proposed service demonstrating how it will work to meet one or more of the NSW Government‟s four key strategic objectives of:

Expanding community based palliative care services especially in rural areas and for special populations;

Greater cooperation between specialist palliative care services and existing primary and aged care services across the state;Expanded support for families and carers; andExtended capacity of palliative care services in NSW.

In responding to this evaluation criterion, tenderers should describe:

8.1.1 The aims of the proposed service.

8.1.2 The scope and priority of services contained in the service offering.

8.1.3 The target client group and estimated number of clients to be seen (including priority populations), any exclusions or expected issues/complexities.

8.1.4 The geographical area/LHDs being targeted.

8.1.5 Proposed innovative strategies.

8.1.6 Proposed engagement strategies with relevant agencies and LHDs to ensure appropriate referrals to the service are made.

8.1.7 Proposed staff resourcing and support (type and quantum), including multidisciplinary inputs.

8.1.8 How the proposed service will:

contribute to, enhance and integrate with existing services;build capacity, including educative and consultation services to existing services; and


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link with LHDs, other services including GPs, community health services;specialist palliative care services; residential aged care; and Medicare Locals.

8.1.9 How the proposed service will access support and advice from a specialist palliative care physician where indicated. For example, the specialist palliative care physician will be part of the service or access through a memorandum of understanding with an existing palliative care service.

8.1.10 How the proposed service will, in consultation with families and carers, provide care as close to home as possible.

8.2 Evaluation Criterion Two: Demonstrated capacity to establish and operate the proposed service in the chosen area

In responding to this criterion tenderers should provide a description of how the entity will establish and operate the proposed service in the chosen area including:

8.2.1 Successes/outcomes of the tenderer‟s previous experience in the provision ofthe proposed services or similar services.

8.2.2 The skills, knowledge and experience of the organisation overseeing the service, as well as partners involved, and providing information that demonstrates the tenderer‟s capacity to undertake their proposed role.

8.2.3 Details of how the service will be established in the timeframes proposed.

8.2.4 Details (including justification/reasons) of where the service will operate from together with strategies as to how the service will provide access to vulnerable individuals across all areas within the catchment, e.g. proposed base with outreach to specified areas within the catchment, locations where a telephone service will be based.

8.2.5 Details on the information and communication technology and telephony available to the provider and how this will be utilised to support the service, or a detailed proposal of how this technology will be acquired and timeframe for implementation.

8.2.6 Information on the proposed use of brokerage funding to facilitate service access.

8.2.7 Details of governance arrangements for the proposed service.

8.2.8 Details of infrastructure to support the service.


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8.3 Evaluation Criterion Three: Costs and benefits of the service proposed tenderers must complete the budget template provided at Appendix B

In responding to this criterion tenderers must include in the template provided:

8.3.1 Detailed budget for service set up, inclusive of related one-off implementation costs, capital and operating, revenue expenses including brokerage fees for the proposed period.

8.3.2 Projected estimated costs for the period tendering for and associated benefits.

8.3.3 Projected revenue from other sources (government and non-government).

8.3.4 Advice as to whether the proposal relies on access to/usage of NSW Health infrastructure, for example, E-Health, Telehealth and IT infrastructure and IT management

8.4 Evaluation Criterion Four: Quality of Services and EvaluationIn responding to this criterion tenderers should describe how the proposed service will:

8.4.1 Use the national Standards for providing quality palliative care for allAustralians as a benchmark to guide service development and quality.

8.4.2 Assess and measure achievement of the stated goals and objectives, including service access and numbers of clients supported .

8.5 Evaluation Criterion Five: Achievable Implementation PlanIn responding to this criterion tenderers should:

8.5.1 Provide an implementation plan highlighting phases which may include planning, recruitment, infrastructure installation and commencement of service delivery.

8.5.2 Outline the proposed strategic approach to addressing the number of patients or services as applicable, over the proposed period.

8.5.3 Identify an estimate of the number of patients and/or services to be provided over the proposed period for each financial year of the project.


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9. Evaluation Process

Following consideration of the evaluation report prepared on tendered proposals, the NSW Ministry of Health may at its discretion conduct negotiations with the preferred tenderer(s).

10. Ethics

Tenderers are to comply with:

the NSW Health Code of Conducth ttp :/ /www.hea l th .n sw.go v.au /p oli ci e s/pd /20 12 /pd f/ PD2012 _018 .pd f

the NSW Government’s Code of Practice for Procurement h t tp : / / w w w . pro c ure m en t .n s w . go v. au / Go v ern m en t - P ro c u re m en t - F ra m e w or ks/ F i l e s/c ode _ o f _ p ra c - c u rr . a s p x

the NSW Department of Finance and Services Business Ethics Statementh ttp :/ /se rvi ce s.n sw.go v.au /a bou t - u s/bu si ne ss-e th i cs

and [if applicable] the NSW Code of Behaviour for the Protection of Children and other Vulnerable Peopleh t tp : / / w w w . n s w pro c ure m en t . c o m . au / P D F / T ender s/C h i l d - P r o t e c t i o n - Co d e - o f- B eha v i o u r - f o r- t h e- P ro t e ct .a s p x


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11. Terms and Conditions

Tenderers are to comply with the terms and conditions described below.

This section of the RFP lists the rights and responsibilities of the NSW Ministry ofHealth/the HAC and the tenderers in regard to the actual tendering process.

11.1 Tender Responses

By responding to the “RFP” the NSW Ministry of Health will treat the bid as an acknowledgement that the tenderer understands and accepts all relevant terms and conditions pertaining to this RFP.

All necessary additional information shall be provided by completing and returningSections A and B and providing a proposal.

Tenderers are to ensure that all information required is completed and returned to the NSW Ministry of Health as per the section on Completion and Lodgement of Submissions outlined below.

11.2 Completion and lodgement of submissions

Consistent with the NSW Government Electronic Procurement Implementation Strategy, where one of the key elements is the adoption of an electronic tendering system, the collection and lodgement of tenders will be done through the NSW Health e-Tendering website. The NSW Health e-Tendering website ish ttp s:/ /te nder s.n sw.go v.au /he al th

The RFP available on the “Electronic Tendering System” requires tenderers to pre- register onto the system prior to viewing and downloading the RFP documents. This process ensures that the tenderer‟s contact details, specifically the tenderer‟s email address, are recorded.

Tenderers should note that their contact e-mail address, as registered with the NSW Health e-Tendering website at the time of downloading a RFP from that website, will be used to forward system-generated notices including notifications of amendments, clarifications and/or addenda to the RFP.

Upon lodgement and receipt of an electronic tender response, a system-generated email is forwarded to the tenderer as an acknowledgement of receipt of the RFP response.

11.3 Right not to proceed

NSW Health reserves the right to terminate this RFP at its discretion at any point in time.


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11.4 Right to discuss proposal

NSW Health reserves the right to discuss each proposal with the tenderer to clarify issues and address priority needs.

Tenderers are encouraged to consult with Chief Executives of Local Health Districts (LHDs) in preparing their proposals. The NSW Ministry of Health will seek feedback from referees and other relevant parties, including requesting input from the LHDs, during the tender evaluation period.

11.5 Contractual relationship

11.5.1 This RFP does not confer any contractual relationship.

11.5.2 Responses submitted to this RFP are not a contractual relationship between HAC and the tenderers, nor do they bind HAC to proceeding beyond this Tender.

11.5.3 Tenderers may be required to submit responses to enquiries regarding thisRFP in writing.

11.5.4 Verbal explanations or instructions given to tenderers do not bind NSW Health/the HAC. It is the responsibility of the tenderers to seek written confirmation from the NSW Ministry of Health/the HAC to any enquiries. Written information used to clarify any part(s) of this RFP may be provided to all tenderers.

11.6 Copyright

The copyright in this document remains the property of the NSW Ministry of Health. It is Crown Copyright and may not be copied, communicated to any third party, or used for any purposes or activities other than those directly associated with thepreparation of responses to this document.

11.7 Probity

Tenderers shall state in their proposal whether they have any potential conflicts of interest which require disclosure. A record of unethical behaviour may lead to a tenderer‟s submission not receiving further consideration.

Overall probity for this tendering process is being provided by the Procurement Advisory Service of the NSW Ministry of Health‟s Business and Asset Services Branch.

This RFP has been approved for release by the Deputy Director-General, Strategy and Resources.


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11.8 No Economic Opportunity

11.8.1 By lodgement of this RFP with the NSW Ministry of Health/the HAC the tenderer affirms that it has not given, offered to give, nor intends to give at any time thereafter any inducement or reward including any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favour or service to any public servant or employee agent, customer or the Government ofNSW in connection with the submitted RFP.

11.8.2 If the tenderer is found to have offered any inducement or reward in accordance with paragraph 8.1, or is found to have committed corrupt conduct in accordance with the provisions of the Independent Commission against Corruption Act 1988, the tenderer‟s response shall be disqualified and any resulting contracts shall be void.

11.8.3 The tenderer should note that any offer of an inducement or reward to any employee or agent of the Government of NSW in connection with the RFP and submitted Tender Response may constitute a criminal offence under the Crimes Act 1900 and/or corrupt conduct under the Independent Commission Against Corruption Act 1988.

11.9 Non-Return of the Tender

The proposal submitted by the tenderer will be retained by the NSW Ministry ofHealth.

11.10 The Respondent’s Costs

All costs and expenses incurred by tenderers in any way associated with the development, preparation and submissions of proposals, including but not limited to attending meetings and discussions, and providing additional information if required by NSW Ministry of Health or HAC, will be borne entirely by the tenderers, including in the event of the RFP having been withdrawn and/or the tendering process discontinued.

11.11 Tender Controls

The requirements of this RFP have been compiled in accordance with:

Public Sector Employment and Management Amendment (Procurement ofGoods and Services) Act 2012;NSW Ministry of Health Procurement policies;NSW Government Procurement Guidelines and Tendering Guidelines w w w . n s w pro c ure m en t . c o m . a u

Appropriate consultations with industry, Government and non-government agencies and other experts.


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12. Disclosure of Contract Information

12.1 Government Information (Public Access) Act 2009

The Government Information (Public Access) Act 2009 (GIPA) provides for rights of access to official documents of the NSW Government and its agencies. The GIPA extends, as far as possible, the right of community to access information (generally documents) in the possession of the NSW Government, limited only by considerations of the protection of essential public interest and of the private and business affairs of persons in respect of whom information is collected and held by departments and public authorities.

12.2 Public disclosure of contract arrangements

NSW Government normally makes public the arrangement of contracts, including the contract price. Should a request be made under the GIPA Act, a decision by theNSW Government to grant or refuse access to tender and/or contract documents considered to be „commercial in confidence‟ would normally be made only after consultation with the Tender applicant or Supplier concerned. Such consultation would nevertheless be without prejudice to any decision to release the information, such decision ultimately determined by the requirements of GIPA Act.

Tenderers are to note that, in accordance with the Government Information (Public Access) Act 2009, certain details of the prospective contract are to be displayed on the NSW Government tenders website, w w w . t ender s. n s w . go v. a u .

13. Price and Payment

A quote for the total value of the proposal is to be submitted, noting that prices are to be fixed, and be exclusive of GST, with the GST element shown separately where it is applicable. The template at Attachment B must be completed.


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Attachment A

Section A1: Declaration

HEALTH ADMINISTRATION CORPORATION

TENDER NO. HAC

12/70

"DECLARATION"

We agree to be bound by the conditions of this Tender.

ACCEPTED BY THE TENDERER:

Information Sought ResponseTrading Name:Contact Name:Telephone: ( ) -Fax: ( ) -Email:Signature of tenderer orauthorised officer:

Name of Signatory:Title of Signatory:Date Signed:


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Section A2 Organisational Information and History1. INTRODUCTION

This section provides information for assessing the tenderer‟s financial and operational capacity and history. It requires information on the legal identity, financial history and organisational structure of the applicant. The information provided will be used to determine the probity of the applicant to deliver the service and may be supported by independent audits, where deemed necessary, in function the scope of the service to be provided and related potential level of financial risks.

2. ELIGIBILITY OF APPLICANT

LEGAL ENTITIES

HAC will only tender with a legal entity. Tenderers must provide relevant documentation to show proof of the organisation being a legal entity.

If the tenderer is a consortium, a lead organisation which will be the contracting entity must be nominated. HAC will only contract with one entity and not enter into a contract will all members of a consortium.

3. ORGANISATIONAL INFORMATION

3.1 ORGANISATION IDENTIFICATION

Information Sought Response

Registered name of the organisationresponding to this RFP:

Trading as:

ABN:

ACN:

Years trading under current CompanyName (ABN / ACN):

Year of Incorporation:

If submitting on behalf of a c o n s o r t i u m , the tenderer (the lead organisation) is required to complete all part of this Section. In addition, the lead organisation must


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provide the name and contact details of the other members of the consortium(including ABN number/s) as an attachment to this Section.

To ensure the tendering process is competitive and results in the best service for the best value, tenderers are required to specify affiliated or linked companies and ifapplicable the parent organisation.

Affiliated Companies ABN / ACN

3.2 HEAD/REGISTERED OFFICE ADDRESS

Please complete the table below:

Information Sought Response

Street Name:

P.O. Box:

Suburb:

State:

Post Code:


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3.3 CONFLICT OF INTEREST

Information Sought Response (x)

Will the awarding of this Contract give riseto any relationships, including but not limited to LHDs or other government agencies, direct or indirect, or potential conflicts of interest, which will require disclosure?

Yes ( ) No ( )

If Yes, please provide details:

3.4 PUBLIC LIABILITY AND MEDICAL MALPRACTICE COVER

Information Sought Response (x)

Does your organisation/company hold a Public Liability Cover of $20m for your services?

Yes ( ) No ( )

Does your company hold a ProfessionalIndemnity Cover of $20m for your services?

Yes ( ) No ( )

Does your company hold a MedicalMalpractice Cover of $20m for your services?

Yes ( ) No ( )

If answered No above please indicate ifsuccessful, those insurances will be included.

Provide a copy of Certificate for Public Liability and Professional Indemnity Cover. Attach document with appropriate label at the end of this attachment.


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3.5 REFERENCES

Please identify 2 Referees within Australia that you are offering similar services to, with the following details to enable the NSW Ministry of Health to obtain referee reports.

Where the services are to be offered through a consortium, please provide one referee for each member of the consortium.

Information Sought ResponseCompany Name:

Contact Name:

Telephone number ofcontact person:

Email address of contactperson:


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Certificate of Public Liability and Professional Indemnity Cover


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Application ChecklistTo ensure your application is complete, use the following checklist

Part 1 Eligibility: Have you responded to all relevant areas including EvaluationCriteria?

Attachment A

Declaration: Have you read and completed the declaration carefully?

Organisational Information and History: Completed

Attachment B Have you completed the template?

Note: applications that are incomplete may not be considered.


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Attachment B– Proposed Annual Service BudgetThis Budget template is for estimating yearly costs associated with the key service components. This information will be used as guide for the Evaluation Panel to consider whether:

The breakdown of costs is a reasonable mix of administrative/on costs and client service delivery.

The breakdown of costs in the organisation‟s budget for the service supports theapplicant‟s ability to deliver the services outlined in the RFP.

Proposed BudgetFor the Financial Year ending 30 June

2013 2014 2015 2016 2017$ $ $ $ $

INCOMEA Funding Required

B Other IncomeMBS/PBS IncomeNon-Government SourcesSundry Income

TotalTOTAL INCOME

C Staff Salaries Salary and Wages On CostsOther employee related

TotalD Service Costs Professional

Services Equipment and Supplies Advertising and Promotion BrokerageLanguage and CulturalServicesOther

TotalE Management Costs

Administration Management costs Other

TotalTOTAL EXPENSES

F Capital Costs - please list

Total

BUDGET TOTAL (C+D+E+F-B)

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