Minnesota Department of Health
MIIC Regional Services RFP
Notice of Intent Form
Instructions
Complete the Notice of Intent Form and submit to MDH by 4:00 p.m., October 1, 2015. Options for
submission include:
 Mail to: Jenevera Wolfe, MIIC Operations Unit, Minnesota Department of Health, 625 Robert
Street North, P.O. Box 64975, St. Paul, Minnesota 55164-0975, or
 Submit electronically to: Jenevera Wolfe at jenevera.wolfe@state.mn.us and Sudha Setty at
sudha.setty@state.mn.us. Indicate “MIIC RFP Notice of Intent” in the subject line and attach
completed form.
Applicant Information
Agency Name:
Address:
Contact:
Title:
Phone:
Email:
Fax:
Agency Eligibility
Applicants must be able to check “yes” to all of the following to be eligible.
1. Applicant is a Minnesota Community Health Board.
 Yes
 No
2. Applicant applying on behalf of at least two contiguous counties if operating within the 7county metro and at least four contiguous counties if operation outside the 7-county metro.
 Yes
 No
3. Applicant is willing to act as a lead and fiscal agent for administering eventual grant
agreement on behalf of member counties.
 Yes
 No
4. Applicant is willing to provide services as outlined in eventual grant agreement without
requiring financial contributions from member counties.
 Yes
 No
1|P a g e
Minnesota Department of Health
MIIC Regional Services RFP
Member Counties
List all counties committed to working with this applicant as the MIIC regional lead and fiscal agent.
1
16
2
17
3
18
4
19
5
20
6
21
7
22
8
23
9
24
10
25
11
26
12
27
13
28
14
29
15
30
2|P a g e