Sample Provider Letter Of Intent (Loi) To Contract printable pdf download

STAR Kids RFP

March 2014

SAMPLE PROVIDER LETTER OF INTENT (LOI) TO CONTRACT

AND SAMPLE LETTER OF AGREEMENT (LOA) TO CONTRACT

Letter of Intent and Letter of Agreement Instructions:

The following two pages depict the mandatory information that a Respondent must include in its Provider

Letter of Intent (LOI) and Provider Letter of Agreement (LOA), respectively, for the HHSC RFP for

Managed Care Services for the ________________ Service Areas. This information is mandatory for

any LOIs or LOAs signed after the date on which these LOI/LOA formats are posted on the HHSC

website, as indicated by the date in the header of this document. A Respondent may also include

additional information in its LOI or LOA forms.

The LOI and LOA must clearly show a provider’s intention, (LOI), or a provider’s agreement, (LOA), to

enter into a contract with a Respondent for the provision of services to HHSC HMO Members if the

Respondent is awarded an applicable HHSC HMO Contract by HHSC.

The completed LOI, LOA, or an executed contract, will be acceptable evidence of a Respondent’s

proposed Network for purposes of the RFP. No scoring distinction will be made between an LOI, an LOA,

or an executed contract. HHSC will not require Respondents to submit provider LOIs or LOAs with the

Proposal, but the Respondent must make copies of such executed LOIs and LOAs available to HHSC

upon request.

If a provider has multiple sites that offer identical services, only one LOI or LOA should be signed, with

additional service site information attached to the LOI or LOA. If services differ between sites, the LOI or

LOA, or attachments to such documents, must clearly indicate the services at each site to be offered by

the provider to HHSC HMO Members enrolled with the Respondent.

If a representative signs an LOI or an LOA on behalf of a provider, evidence of authority for the

representative must be available to HHSC upon request.

Respondents should complete the bracketed information in the LOI or LOA, as applicable to the

Respondent’s Proposal.

In addition to the mandatory information in the one page LOI and LOA formats, a Respondent must

collect the additional provider and services information, (numbered items 1 though 12), for each LOI and

LOA between a provider and the Respondent for provision of services to HHSC HMO Members as

indicated in the last page of this file, entitled, “ADDITIONAL PROVIDER AND SERVICES INFORMATION

FOR LOI/LOA BETWEEN PROVIDERS AND RESPONDENTS FOR PROVISION OF SERVICES TO

HHSC HMO MEMBERS.”

Sample Provider Letter Of Intent (Loi) To Contract