Sample Provider Letter Of Intent (Loi) To Contract (Page 3 of 4) in pdf

Sample Provider Letter Of Intent (Loi) To Contract Page 3

STAR Kids RFP

March 2014

LETTER OF AGREEMENT TO CONTRACT WITH

[The Respondent]

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 Agreement unless the Provider seriously intends to enter into a

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

Letter of Agreement obligates 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 agrees to contract with [Respondent’s name],

for the provision of services to 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

STAR+PLUS HMO contract in the Service Area(s) applicable to the provider.

NOTICE TO PROVIDERS:

This Letter of Agreement 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 Agreement if you agree to contract 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 Agreement to HHSC. Completed Letter of Agreement needs to be

returned to [Respondent’s name and address].

1. PROVIDER’S SIGNATURE

______________________________________

2. DATE

______________________________________

3. PRINTED NAME OF SIGNER

______________________________________

4. TITLE

______________________________________

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 3