GEOGRAPHIC MAP OF NEW MEXICO This map provides a visual representation of the five (5) separate geographic regions within the State of New Mexico, served by the BISF Program. Brain Injury services through RFP # 15-630-8000-2000, provided statewide. APPENDIX G COST RESPONSE FORM and FUNDING RFP # 15-630-8000-2000 Brain Injury Services – New Mexico Human Services Department - Brain Injury Program Cost Response Form - Home and Community-Based Brain Injury Services This form must be submitted as part of the response to Mandatory Specifications in Section IV, Letter C, Factor III. Offeror Name BISF Service Component Funding Request (Complete A or B and Total; See Funding Table for Available Funding) BISF Service Region Projected Total Yearly Total Yearly Number of Funding Funding for Participants Requested Administrative (served annually) Costs A* $ $ Service METRO Coordination $ $ NE / $ $ NW Life Skills $ $ SE Independence $ $ SW Coaching* B** Crisis Interim Statewide $ $ Fiscal Intermediary** $ $ TOTAL FUNDING REQUESTED *See Funding Table: Column C **See Funding Table: Column D Please indicate other funding your agency is currently receiving Number Yearly Funding Serving/ Projected Received/ Projected $ C Medicaid $ D Medicare $ Other Federal Funds E (Specify) $ $ Other HSD Funds F (Specify) $ Other State Funds $
GEOGRAPHIC MAP OF NEW MEXICO This map provides a visual representation of the five (5) separate geographic regions within the State of New Mexico, served by the BISF Program. Brain Injury services through RFP # 15-630-8000-2000, provided statewide. APPENDIX G COST RESPONSE FORM and FUNDING RFP # 15-630-8000-2000 – Brain Injury Services New Mexico Human Services Department - Brain Injury Program Cost Response Form - Home and Community-Based Brain Injury Services This form must be submitted as part of the response to Mandatory Specifications in Section IV, Letter C, Factor III. Offeror Name BISF Service Component Funding Request (Complete A or B and Total; See Funding Table for Available Funding) BISF Service Region Projected Number of Participants (served annually) Total Yearly Funding Requested Total Yearly Funding for Administrative Costs A* Service Coordination / Life Skills Independence Coaching* METRO $ $ NE $ $ NW $ $ SE $ $ SW $ $ B** Crisis Interim Fiscal Intermediary** Statewide $ $ TOTAL FUNDING REQUESTED $ $ *See Funding Table: Column C **See Funding Table: Column D Please indicate other funding your agency is currently receiving Number Serving/ Projected Yearly Funding Received/ Projected C Medicaid $ D Medicare $ E Other Federal Funds (Specify) $ $ F Other HSD Funds (Specify) $ $ Other State Funds $