Contract Partnerships for Startup by otx13495

VIEWS: 6 PAGES: 4

Contract Partnerships for Startup document sample

More Info
									ATTACHMENT - Form: RFP-2a

                          Request for Proposal
                   Mental Health Clinic Development
                                   &
           Mental Health Clinic Development Start-Up Services
                         Queen Anne's County




Applicant (Organization) Name:

Contact Person:

Phone:

Address:



Email:

Instructions
Read the entire RFP before completing these worksheets. Special attention should be given to section: E7. Cost Proposal on
page 9. These forms were developed in order to help assure that thoughtful analysis occurred in the development of the
business plan for the mental health clinic in Queen Anne's County. Applicants are encouraged to discuss further budgetary
analysis they conducted that was not specifically requested in the narrative portion of the RFP if it could demonstrate
increased likelihood of the clinic being sustained. There are three forms that need to be completed: RFP-2a, RFP-2b and RFP-
2c. RFP-2d is a chart and will self populate based on the data provided in the previous forms.
Form RFP-2a
The purpose of form RFP-2a is to gather general information about the applicant and provide instructions for the following
worksheets. Complete the items above and then proceed to the next form.

Form RFP-2b
The purpose of form RFP-2b is to provide a 12 month budget including startup costs and to show the various revenue streams
that will be utilized to cover the expenses. The budget is based on a 12 month year (and startup costs) starting from date the
clinic is opened.

The first column on the left hand side is a list of budget categories. Please complete and type in specific information where
indicated. In the second column entitled: “Total 12 Mos.” place the total cost of the expense next to item in the first column.

Across the top under “Revenue Source” there are multiple revenue sources listed. Add any additional revenue sources as
needed to cover the expenses listed in the second column. The applicant should then break down the revenue by source that
will cover each expense. Expenses may be covered by multiple revenue sources. The next column entitled “Total” will
automatically add each category by row and should equal the amount in the column labeled: “Total 12 Mos.” The final column
on the right hand side is labeled: Justification.” A justification is required for each budget category with an expense.

Note that some cells are locked and shouldn’t be typed in or the embedded formulas will be compromised.


Form RFP-2c
The purpose of form RFP-2c is to provide the grant review committee an idea of what the revenue flow will be over the first 12
months of the project and to provide additional clinical forecasts. In the top left hand corner there is a yellow box. In that box
put the proposed starting date of the clinic. The months will then adjust automatically starting from the chosen date.

The chart is separated horizontally by three sections. In the top section, "Revenue Categories," the applicant shall put the
types of revenue they plan to receive in the first column as shown. Next put the amount of revenue forcasted corresponding to
the month and type.

Expenses by month should be listed in the second horizontal section entitled “Expenses Out.” Expense titles should be given
the same titles as in form RFP-2c and the totals should match to figures provided in form RFP-2b.

The third section, entitled “Other Operating Data” is a similar format but requests information about the numbers of clients
that are planned and the means by which they will pay for the service. The form should be filled out accordingly.
Form RFP-2d
No data is required to be entered into the Chart on form RFP-3c. It is meant to show the cash flow based on information
provided on the other forms.


                                                                                                                                     16
                                                                                         Queen Anne's County Mental Health Clinic Revenue Flow Projection
                                                                                                                       0
Form RFP-2b

                                                                                                                      REVENUE SOURCE


                                            TOTAL 12   Community                    Third Party   Third Party
                                             MOS. &    Partnerships       Fee for   Payments      Payments            Loan        Other        Owner
BUDGET CATEGORY                              Startup      Grant*          Service     Private         MA            Proceeds   Grant: (List) Contribution Other: (List) Other: (List)   Other: (List)       Total       Justification
Advertising                                                                                                                                                                                             $           -
Contractual                             $         -    $       -      $        -    $       -     $      -      $         -    $       -    $         -    $       -     $       -      $        -      $           -
          Type in name of Contract 1                                                                                                                                                                    $           -
          Type in name of Contract 2                                                                                                                                                                    $           -
          Type in name of Contract 3                                                                                                                                                                    $           -
Employee Salaries                       $         -    $       -      $        -    $       -     $      -      $         -    $       -    $         -    $       -     $       -      $        -      $           -
            Type in title of Position 1                                                                                                                                                                 $           -
            Type in title of Position 2                                                                                                                                                                 $           -
            Type in title of Position 3                                                                                                                                                                 $           -
            Type in title of Position 4                                                                                                                                                                 $           -
            Type in title of Position 5                                                                                                                                                                 $           -
            Type in title of Position 6                                                                                                                                                                 $           -
            Type in title of Position 7                                                                                                                                                                 $           -
            Type in title of Position 8                                                                                                                                                                 $           -
            Type in title of Position 9                                                                                                                                                                 $           -
           Type in title of Position 10                                                                                                                                                                 $           -
           Type in title of Position 11                                                                                                                                                                 $           -
           Type in title of Position 12                                                                                                                                                                 $           -
           Type in title of Position 13                                                                                                                                                                 $           -
           Type in title of Position 14                                                                                                                                                                 $           -
           Type in title of Position 15                                                                                                                                                                 $           -
Employee Fringe Costs                   $         -    $       -      $        -    $       -     $      -      $         -    $       -    $         -    $       -     $       -      $        -      $           -
            Type in title of Position 1                                                                                                                                                                 $           -
            Type in title of Position 2                                                                                                                                                                 $           -
            Type in title of Position 3                                                                                                                                                                 $           -
            Type in title of Position 4                                                                                                                                                                 $           -
            Type in title of Position 5                                                                                                                                                                 $           -
            Type in title of Position 6                                                                                                                                                                 $           -
            Type in title of Position 7                                                                                                                                                                 $           -
            Type in title of Position 8                                                                                                                                                                 $           -
            Type in title of Position 9                                                                                                                                                                 $           -
           Type in title of Position 10                                                                                                                                                                 $           -
           Type in title of Position 11                                                                                                                                                                 $           -
           Type in title of Position 12                                                                                                                                                                 $           -
           Type in title of Position 13                                                                                                                                                                 $           -
           Type in title of Position 14                                                                                                                                                                 $           -
           Type in title of Position 15                                                                                                                                                                 $           -
Insurance (other than health)                                                                                                                                                                           $           -
Interest expense                                                                                                                                                                                        $           -
Materials and supplies                                                                                                                                                                                  $           -
Meals and entertainment                                                                                                                                                                                 $           -
Mortgage interest                                                                                                                                                                                       $           -
Office expense                                                                                                                                                                                          $           -
Rent or lease                                                                                                                                                                                           $           -
Rent or lease: vehicles, equipment                                                                                                                                                                      $           -
Repairs and maintenance                                                                                                                                                                                 $           -
Supplies                                                                                                                                                                                                $           -
Taxes and licenses                                                                                                                                                                                      $           -
Travel                                                                                                                                                                                                  $           -
Utilities                                                                                                                                                                                               $           -
Type in name of other expense 1                                                                                                                                                                         $           -
Type in name of other expense 2                                                                                                                                                                         $           -
Type in name of other expense 3                                                                                                                                                                         $           -
Type in name of other expense 4                                                                                                                                                                         $           -
Loan principal payment                                                                                                                                                                                  $           -
Capital purchases                                                                                                                                                                                       $           -

Total Budget by Revenue Source $                  -    $       -      $        -    $       -     $      -      $         -    $       -    $         -    $       -     $       -      $        -      $           -




                                                                                                                                                                                                                                        17
                                             Queen Anne's County Mental Health Clinic Revenue Flow Projection
                                                                           0
Form RFP-2c
Starting date                                              Place propsed clinic opening date here.
Fund balance alert minimum                   $        -             0            0           0            0          0           0            0          0          0           0          0          0

                                                 Startup    Jan-00        Feb-00      Mar-00      Apr-00      May-00     Jun-00      Jul-00       Aug-00     Sep-00     Oct-00      Nov-00     Dec-00     Total

Funds on hand (beginning of month)                                    0           0           0           0          0           0            0          0          0           0          0          0

REVENUE CATEGORIES
Community Partnerships Grant*                                                                                                                                                                                -
Fee for Service                                                                                                                                                                                              -
Third Party Payments                                                                                                                                                                                         -
Loan proceeds
Other Grant:
Other Grant:
Owner Contribution
Other:
Other:                                                                                                                                                                                                       -
Other:                                                                                                                                                                                                       -
TOTAL REVENUE RECEIPTS                                -           -           -           -           -          -           -           -           -          -           -          -          -          -
Total revenue available                               -           -           -           -           -          -           -           -           -          -           -          -          -

EXPENSES OUT
Advertising                                                                                                                                                                                                  -
Contractual                                           -           -           -           -           -          -           -           -           -          -           -          -          -          -
            Type in name of Contract 1                                                                                                                                                                       -
            Type in name of Contract 2                                                                                                                                                                       -
            Type in name of Contract 3                                                                                                                                                                       -
Employee Salaries                                     -           -           -           -                      -           -           -           -          -           -          -          -          -
               Type in title of Position 1                                                                                                                                                                   -
               Type in title of Position 2                                                                                                                                                                   -
               Type in title of Position 3                                                                                                                                                                   -
               Type in title of Position 4                                                                                                                                                                   -
               Type in title of Position 5                                                                                                                                                                   -
               Type in title of Position 6                                                                                                                                                                   -
               Type in title of Position 7                                                                                                                                                                   -
               Type in title of Position 8                                                                                                                                                                   -
               Type in title of Position 9                                                                                                                                                                   -
              Type in title of Position 10                                                                                                                                                                   -
              Type in title of Position 11                                                                                                                                                                   -
              Type in title of Position 12                                                                                                                                                                   -
              Type in title of Position 13                                                                                                                                                                   -
              Type in title of Position 14                                                                                                                                                                   -
              Type in title of Position 15                                                                                                                                                                   -
Employee Fringe Costs                                 -           -           -           -           -          -           -           -           -          -           -          -          -          -
               Type in title of Position 1                                                                                                                                                                   -
               Type in title of Position 2                                                                                                                                                                   -
               Type in title of Position 3                                                                                                                                                                   -
               Type in title of Position 4                                                                                                                                                                   -
               Type in title of Position 5                                                                                                                                                                   -
               Type in title of Position 6                                                                                                                                                                   -
               Type in title of Position 7                                                                                                                                                                   -
               Type in title of Position 8                                                                                                                                                                   -
               Type in title of Position 9                                                                                                                                                                   -
              Type in title of Position 10                                                                                                                                                                   -
              Type in title of Position 11                                                                                                                                                                   -
              Type in title of Position 12                                                                                                                                                                   -
              Type in title of Position 13                                                                                                                                                                   -
              Type in title of Position 14                                                                                                                                                                   -
              Type in title of Position 15                                                                                                                                                                   -
Insurance (other than health)                                                                                                                                                                                -
Interest expense                                                                                                                                                                                             -
Materials and supplies                                                                                                                                                                                       -
Meals and entertainment                                                                                                                                                                                      -
Mortgage interest                                                                                                                                                                                            -
Office expense                                                                                                                                                                                               -
Rent or lease                                                                                                                                                                                                -
Rent or lease: vehicles, equipment                                                                                                                                                                           -
Repairs and maintenance                                                                                                                                                                                      -
Supplies                                                                                                                                                                                                     -
Taxes and licenses                                                                                                                                                                                           -
Travel                                                                                                                                                                                                       -
Utilities                                                                                                                                                                                                    -
Type in name of other expense 1                                                                                                                                                                              -
Type in name of other expense 2                                                                                                                                                                              -
Type in name of other expense 3                                                                                                                                                                              -
Type in name of other expense 4                                                                                                                                                                              -
Loan principal payment
Capital purchases                                                                                                                                                                                            -
TOTAL EXPENSES OUT                                    -           -           -           -           -          -           -           -           -          -           -          -          -          -
Revenue on hand (end of month)                        -           -           -           -           -          -           -           -           -          -           -          -          -

OTHER OPERATING DATA
Number of Private Ins. Clients
Number of MA clients
Number of Clients no pay
Total Hours Reimbusable                                           -           -           -           -          -           -           -           -          -           -          -          -
                Reimbursement Type 1
                Reimbursement Type 2
                Reimbursement Type 3
                Reimbursement Type 4
                Reimbursement Type 5
                Reimbursement Type 6
                Reimbursement Type 7
Number of Private Ins. Panels
Bad debt balance
Number of Staff
Accounts payable balance



                                                                                                                                                                                                                 18
Form RFP-2d



                                                                       Cash Flow Projection
                                                                        <Company Name>
                          1

                          1

                          1
   Revenue Availabe




                          1
                                                                                                                              Cash Flow Projection
                          1                                                                                                   Cash on Hand Minimum Alert

                          1

                          0

                          0

                          0

                          0

                      -
                              Startup Jan-00 Feb-00 Mar-00 Apr-00 May-00 Period Jul-00
                                                                          Jun-00         Aug-00 Sep-00 Oct-00 Nov-00 Dec-00



Cash balance alert minimum                        $          -




                                                                                                                                                           19

								
To top