Fillable Implementation Council Fillable Nomination Form Nov 2016 (Commonwealth of Massachusetts)

Fill Online, Printable, Fillable, Blank Implementation Council Fillable Nomination Form Nov 2016 (Commonwealth of Massachusetts) Form

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Implementation Council Fillable Nomination Form Nov 2016 (Commonwealth of Massachusetts)

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The Implementation Council Fillable Nomination Form Nov 2016 (Commonwealth of Massachusetts) form is 3 pages long and contains:

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NOMINATION FORM
Implementation Council for One Care
ABOUT YOURSELF/THE NOMINEE
Name: Job Title (if applicable):
Organization (if applicable):
Address: City, State, ZIP code:
Telephone: E-mail:
Voice Videophone TTY
Preferred method of communication: E-mail Mail Phone
QUALIFICATIONS
INTEREST IN PARTICIPATING: Why do you want to serve on the Implementation Council?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
KNOWLEDGE/SKILLS
/EXPERIENCE HIGHLIGHTS: List three qualities that you have that will help
the Implementation Council achieve its goals and complete its work. This can include knowledge,
skills, work, education, or other lived experience. If applicable, include any relevant experience with or
knowledge of One Care.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PLEASE turn to next page and complete required information
TheImplementationCouncilisacommitteeconvenedbytheMassachusettsExecutiveOfficeofHealthandHuman
Services(EOHHS)toprovideinputtoandmonitoringoftheMassachusettsStateDemonstrationtoIntegrateCare
forDualEligibleIndividuals,alsoknownasOneCare.ThepurposeofOneCareistoimprovequalityofcareand
reducehealthdisparities,improvehealthandfunctionaloutcomes,andcontainhealthcarecostsforDual
Eligibles.TheCouncilwillmeetthroughDecember31,2019;however,EOHHSinitssolediscretionmayterminate
thetermsofImplementationCouncilmemberssooneriftheDemonstrationends.EOHHShassolediscretionto
extendthecontractsforImplementationCouncilmembersforuptoanadditional2yearsforanyincrementof
time.
Formoreinformation,see“FrequentlyAskedQuestionsabouttheImplementationCouncil,”at
www.mass.gov/masshealth/dualsunderRelatedInformationoronCOMMBUYS(www.commbuys.com).
[DirectionsforaccessingthedocumentsthroughCOMMBUYS:(1)ScrolldowntothebottomoftheCOMMBUYS
homepageandclickon“ContractandBidsearch.”(2)OnthenextpageclickonBids.(3)OntheAdvancedSearch
pageenterthekeyword“Implementation”intheBidDescriptionfield;fromthedropdownmenuinthe
Organizationfieldselect1039‐ExecutiveOfficeofHealthandHumanServices;clickon“findit.”(4)Thelinkfor
therelevantdocumentsshouldbeatorverynearthetopofthelist.Clickonthatlink.]
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OUTREACH EXPERIENCE: Describe your experience/skills in this area.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DIVERSITY EXPERIENCE: Describe your experience with people with disabilities or with people of
different social, racial and cultural backgrounds, including deaf and LGBTQ communities, or any
experience that shows a commitment to diversity.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
COMPOSITION OF THE IMPLEMENTATION COUNCIL
INDICATE YOUR AFFILIATION(S)
Complete all applicable sections.
Section 1
I am a MassHealth member with a disability. (Check applicable population(s) below that apply to
you)
I am a family member or guardian of a MassHealth member with a disability. (Check applicable
population(s) below.)
POPULATIONS (check all areas that apply):
adults with physical disabilities adults with intellectual/developmental disabilities
adults with serious mental illness adults with substance use disorders
adults with disabilities with multiple chronic illnesses or functional and cognitive limitations
adults with disabilities who are homeless
Section 2
I represent a community-based or consumer advocacy organization.
Specify organization and populations representing or serving: ___________________
I represent a provider/trade association (check service type below)
Medical Behavioral Health Long-Term Services and Supports
I represent a union. Union name: ____________________________________________
POPULATIONS SERVED BY ORGANIZATION, ASSOCIATION, OR UNION (check all areas
that apply):
adults with physical disabilities adults with intellectual/developmental disabilities
adults with serious mental illness adults with substance use disorders
adults with disabilities with multiple chronic illness or functional and cognitive limitations
adults with disabilities who are homeless or have been homeless
Page3of3
Do you receive pay or a salary from the organization, association, or union that you will be
representing? Yes No
Section 3
I live/work in and am familiar with communities in the following county/ies (Check all that apply):
Barnstable Berkshire Bristol Dukes Essex
Franklin Hampden Hampshire Middlesex Nantucket
Norfolk Plymouth Suffolk Worcester
LETTER OF REFERENCE (1-2 pages total)
Attach one letter of reference from an individual, business or organization that can support your
candidacy for this position. If you completed section 2 above and are applying to serve as an
individual that represents an organization, association, or union, include a letter of reference from that
entity.
SUBMISSION INSTRUCTIONS
Return a signed and complete copy of this nomination form (with requested accommodations, as
needed) with one letter of reference by e-mail, mail, or fax to:
E-mail: Gerry.sobkowicz@state.ma.us
Mail: Executive Office of Health and Human Services
Attn: Geraldine Sobkowicz, Procurement Coordinator
One Ashburton Place, 11
th
Floor
Boston, MA 02108
Office Phone: (617) 573-1714 Fax: (617) 573-1893
Please put “Implementation Council Nomination Form” in the subject line of your e-mail or fax or on
the envelope if submitting by mail.
Public Records Notice: In submitting this nomination form, you understand that any information contained
within in it, including voluntary self-identification as a recipient of MassHealth or Medicare coverage, may be
made public. All responses and information submitted in response to this nomination form are subject to the
Massachusetts Public Records Law, M.G.L. c. 66, § 10, and M.G.L. c. 4, § 7, subsection 26.
_______________________________ _______________________
Applicant’s Signature Date
Nominations are due no later than Tuesday, January 10, 2017, at 5:00 PM.
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Implementation Council Fillable Nomination Form Nov 2016 (Commonwealth of Massachusetts)

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Completed 27 July 2020

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