Service Provision Form 650-25-75-05-05

(Revised 10/1/10 ML#3242)

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The Department of Human Services, Aging Services Division, requires the completion and submission of a Service Provision Form (applicable to nutrition, outreach, and health services). The form(s) outlines communities, sites, frequency, etc., for the specific funded service.

 

Through the procurement process, Aging Services Division will forward the Service Provision Form to entities for completion and submission to Aging Services Division. Throughout the contract term, contract entities are responsible for updating and resubmission of any information contained on the Service Provision Form. The contract entity must submit the following: Identifying Data Form that indicates the reason for resubmission; and the updated Service Provision Form(s).

 

The new form(s) will become a part of the contract.