AIDS FOUNDATION OF CHICAGO

FY 2016 Request for Proposals for

Ryan White HIV/AIDS Treatment Modernization CARE Act

Ambulatory Outpatient Medical Care & Case Management Services

Cook & Collar Counties

Issued: Monday, October 12th, 2015

Submission Date: Friday, November 20th, 2015 by 4:00 p.m. CST

RFP Forms Workbook

AIDS Foundation of Chicago

200 West Jackson Blvd., Suite 2100

Chicago, IL 60606

(312)-334-0951

(312) 922-2916 fax

RFP Forms Workbook Instructions

AFC provided a separate MS Word file “RFP Narrative Workbook” and “RFP Forms Workbook”. Use these documents to format your proposal submission. Download these workbooksfrom the AFC website aidschicago.org/RyanWhite2016.

Workbook Formatting

Delete the Workbook title and instruction pages included in this workbook. DO NOT submit these pages. Section Breaks are included at the end of each form. Page numbers were not inserted.

Proposal Formatting

The following table lists required forms and appendices for this RFP. Be sure to follow the formatting guidelines on pages 11 of the RFP.

Required Documents Checklist

Sections / Proposal Section Order
Section 1 / Proposal Title Page (Include this in the RFP Narrative Workbook as the 1st page)
Table of Contents / Table of Contents
Section 2 / Agency Experience
Section 3 / Target Populations
Section 4 / Cultural & Linguistic Capacity
Section 5 / Client Eligibility
Section 6 / Program Description/Scope of Services
Section 7 / Ambulatory Outpatient Medical Care
Section 8 / Payer of Last Resort
Section 9 / Agency Collaborations
Section 10 / Quality Management
Section 11 / Technology & Systems Capacity
Section 12 / Unit Costs (non-case management funded services only)
Section 13 / Budget Justification (case management funded services only)
Appendix 1 / Internal Revenue Service 501(c)3
Appendix 2 / Articles of Incorporation
Appendix 3 / Executive Director Resume; List of Board of Directors including employment and contact information
Appendix 4 / Organizational Chart
Appendix 5 / Relevant agency certifications and licenses (if applicable or leave blank)
Appendix 6 / Client Demographics Template
Appendix 7 / Program Work Plan Template
Appendix 8 / Resumes & Job Descriptions for Key Staff; Relevant staff certifications and licenses
Appendix 9 / Payer of Last Resort Policy & Procedures
Appendix 10 / Medicaid Certification (if applicable or leave blank)
Appendix 11 / Memorandum of Agreement Matrix (for joint proposals and agency linkages)
Appendix 12 / Quality Assurance Team Resumes
Appendix 13 / Unit Cost Template
Appendix 14 / Most recent financial statement or independent audit, OMB Circular A-133 Audit

AIDS Foundation of Chicago

FY 2016 Request for Proposals for

Ryan White HIV/AIDS Treatment Modernization CARE Act

Ambulatory Outpatient Medical Care

Intent to Apply

Organizations interested in applying for funding under the AFC Ryan White CARE Act Request for Proposals are required to submit this “Intent to Apply” form. The submission of the Intent to Apply does not guarantee funding, nor does it require the agency to submit a proposal.

Due Date: Friday October 16th, 2015, by 4:00 p.m.

This form must be submitted via mail or fax to:
AIDS Foundation of Chicago
200 West Jackson Blvd., Suite 2100
Attn: 2015 Ryan White RFP
Chicago, Illinois 60606
(312) 784-9052 fax

Organization Name:
Corporate Name if Different:
Administrative Address:
Primary Contact for this RFP:
Email Address:
Phone Number:
Executive Director’s Name: /
Executive Director’s Signature: /

AIDS Foundation of Chicago

FY 2016 Request for Proposals for

Ryan White HIV/AIDS Treatment Modernization CARE Act

Ambulatory Outpatient Medical Care

Proposal Title Page

Organization Name:
Corporate Name if Different:
Administrative Address:
Primary Contact Name:
Email Address:
Phone Number:
Tax ID Number:
DUNS Number:

Service Categories

Select the Core or Essential Service category your organization is requesting to submit a proposal for. If you are applying for multiple service categories, complete a separate Title Page for each proposal.

Category / Category / “X” / Target Population(s) / Estimated FTE’s
Ambulatory Outpatient Medical Care / Core

Counties Served

Selectwhich counties your facility is located in and/or where services will be delivered. Select all that apply.

X / County / X / County
Suburban Cook / Kendall
DeKalb / Lake
DuPage / McHenry
Grundy / Will
Kane

Letter of Commitment:

This signature certifies that the Executive Director and/or Board of Directors has reviewed and approved the enclosed proposal in consideration under the Ryan White CARE Act funding.

Executive Director’s Name: /
Executive Director’s Signature: /

AIDS Foundation of Chicago

FY 2016 Request for Proposals for

Ryan White HIV/AIDS Treatment Modernization CARE Act

Ambulatory Outpatient Medical Care

Client Demographics Template

Narrative Section: Target Populations

Organization Name:
Service Category:
Projected Units of Service:
Total Projected Number of Unduplicated Clients:
Total Units of Service per Client:
Percentage of Clients are: / Client Profile / HIV/AIDS / Affected
Hispanic/Latino / % / %
Non-Hispanic / % / %
White Non-Hispanic / % / %
Black Non-Hispanic / % / %
Asian / % / %
Pacific Islander/Native Hawaiian / % / %
Native American/Native Alaskan / % / %
Percentage of Clients are: / Male / % / %
Female / % / %
Transgender / % / %
Percentage of Clients are: / Less than 2 years / % / %
Children (2-12) / % / %
Youth (13-24) / % / %
Adult (25-64) / % / %
Adult 65 and over / % / %
Percentage of Clients whose mode of transmission is: / Men who have sex with men (MSM) / % / %
Injection Drug User (IDU) / % / %
Men who have sex with men (MSM)/Injection Drug User (IDU) / % / %
Heterosexual / % / %
Perinatal Transmission / % / %
Hemophilia/Coagulation Disorder / % / %
Recipient of a blood transfusion, blood components or tissue / % / %
Unknown/unreported / % / %
Other: / % / %
Other: / % / %
Percentage of clients presenting with other co-factors / Mental Health / % / %
Food/Nutrition / % / %
Housing / % / %
Legal / % / %

AIDS Foundation of Chicago

FY 2016 Request for Proposals for

Ryan White HIV/AIDS Treatment Modernization CARE Act

Ambulatory Outpatient Medical Care

Program Work Plan Template

Narrative Section: Program Workplan

Organization Name:
Service Category:

Document the primary goals and objectives in this section. Ensure that this template is aligned with and supports narrative descriptions.

Goal A:
Objectives / Target Dates / Lead
1
2
3
4
5
Goal B:
Objectives / Target Dates / Lead
1
2
3
4
5

AIDS Foundation of Chicago

FY 2016 Request for Proposals for

Ryan White HIV/AIDS Treatment Modernization CARE Act

Ambulatory Outpatient Medical Care

Scope of Services Template

Narrative Section: Program Work Plan (continued)

Goal C:
Objectives / Target Dates / Lead
1
2
3
4
5
Goal D:
Objectives / Target Dates / Lead
1
2
3
4
5
Goal E:
Objectives / Target Dates / Lead
1
2
3
4
5

AIDS Foundation of Chicago

FY 2016 Request for Proposals for

Ryan White HIV/AIDS Treatment Modernization CARE Act

Ambulatory Outpatient Medical Care

Memorandum of Agreement Matrix

Narrative Section: Collaborations

Organization Name:
Service Category:

Use additional sheets as necessary:

Collaborating Agency / Services Coordinated / Number of Years in Partnership / Lead Staff / Priority Areas Addressed

AIDS Foundation of Chicago

FY 2016 Request for Proposals for

Ryan White HIV/AIDS Treatment Modernization CARE Act

Ambulatory Outpatient Medical Care

Unit Cost Template for Non-Case Management Services

Narrative Section: Unit Cost Calculation

Organization Name:
Service Category:

Unit cost is the cost to produce or deliver one unit or product or service. Unit costs have many uses. They can provide the basis for cost comparisons across services, providers or geographic areas and they provide a benchmark for performance measurement. They are the basis for contract payment where reimbursement is based on units of service delivered.

Agencies may not choose to use this form. This Unit Cost template is not required. If an agency chooses not use this form, provide your calculated unit costs. If you choose not to use the template provided, refer to the following link to calculate unit costs.

Instructions: There are five basic steps to determining unit costs for a 12-month time period.

  1. Define the exact units of service for each activity.
  2. Count the total number of units in a given time period
  3. Determine all the direct and indirect costs of producing the units of service
  4. Add these components of full cost for the same time period
  5. Divide the full cost by the total number of service units to arrive at the average unit cost during a particular time period

Average Unit Cost Calculator

Calculation / Activity 1 / Activity 2 / Activity 3 / Activity 4 / Activity 5
Units of Service
12-Month Time Period
Direct Costs
Non-Allocated ProgrammaticCosts
Total Cost
Divide Total Number of Service Units
Average 12-Month Unit Cost

Total Average 12-Month Unit Cost for All Activities

Average Unit Cost Per Activity
Activity 1
Activity 2
Activity 3
Activity 4
Activity 5
Total Average 12 Month Unit Cost