Sample Provider Letter Of Intent (Loi) To Contract (Page 2 of 4) in pdf

STAR Kids RFP

March 2014

LETTER OF INTENT TO ENTER INTO CONTRACT NEGOTIATIONS WITH

[The Resondent]

FOR PROVISION OF SERVICES TO HHSC HMO MEMBERS

This letter is subject to verification by the Texas Health and Human Services Commission (HHSC). A

Provider should not sign this Letter of Intent unless the Provider intends to enter into contract negotiations

with [Respondent’s name] for the provision of services to _______________ Members. Signing this Letter

of Intent does not obligate the provider to sign a contract with [Respondent’s name] for the provision of

services to____________ Members.

[Respondent’s name] is proposing to participate in the _________ Program in the

_______________Service Areas. The provider signing below is willing to enter into contract negotiations

with [Respondent’s name], for the provision of ___________ services to HMO members enrolled with

[Respondent’s name] as indicated below.

This provider intends to sign a contract with [Respondent’s name] if [Respondent’s name] is awarded a

HMO contract in the Service Areas applicable to the provider and an acceptable agreement can be

reached between the provider and [Respondent’s name].

NOTICE TO PROVIDERS:

This Letter of Intent may be used by HHSC in its bid evaluation and contract award process for the

RFP for Managed Care Services for the______________ Service Areas. You should only sign this

Letter of Intent if you intend to enter into contract negotiations with (Respondent’s name) should

they receive a contract award. If you are signing on behalf of a physician, please provide evidence

of your authority to do so.

Do not return completed Letter of Intent to HHSC. Completed Letter of Intent needs to be

returned to [Respondent’s name and address.]

1. PROVIDER’S SIGNATURE

______________________________________

2. DATE

______________________________________

3. PRINTED NAME OF SIGNER

______________________________________

4. TITLE OF SIGNER

______________________________________

5. PRINTED NAME OF PROVIDER (IF DIFFERENT FROM SIGNER)

______________________________________

6. RESPONDENT REPRESENTATIVE’S SIGNATURE

______________________________________

7. DATE

______________________________________

8. PRINTED NAME OF SIGNER

______________________________________

9. TITLE OF SIGNER

______________________________________

Sample Provider Letter Of Intent (Loi) To Contract Page 2