1-Certification of Non-Debarment 03-14-24.pdf
PDF 166 KB Posted
- Attached to
- RFI Hospital Referral Management
- Solicitation number
- RFI-26-07036
- Issued by
- San Bernardino County, California
About this file
This is a Certification of Non-Debarment document dated March 14, 2024, required by Inland Empire Health Plan (IEHP) in California for participation in a state and local contract opportunity related to hospital referral management software. The certification requires authorized representatives of bidding firms to attest that their organization is not excluded, ineligible, or terminated from participation in State or Federal health care programs and does not appear on exclusion lists maintained by the Department of Health & Human Services Office of Inspector General, General Services Administration System for Award Management, California Department of Health Care Services Medi-Cal Suspended and Ineligible Provider List, or Medicare Opt-Out List. Bidders must conduct regulatory sanction and exclusion screenings of any subcontracted entities prior to engagement and continue such screenings monthly thereafter.
The document specifies that any firm becoming excluded, ineligible, or terminated from participation in State and Federal health care programs will be subject to immediate contract termination for cause with IEHP. The certification requires signature, date, and title of the authorized agent or officer, and serves as binding acknowledgment that the signatory has read and understands the terms and conditions and that their principal is fully committed to compliance with the debarment requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| 2-RFI HOSPITAL REFERRAL MANAGEMENT.pdf |
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Certification of Non-Debarment 03-14-2024
CERTIFICATION
As an authorized representative of my Firm/Company/Sole Proprietorship, I hereby attest that my Firm/Company/Sole Proprietorship is not excluded, ineligible, or terminated from participation in State or Federal health care programs and does not appear on any of the following lists:
a. The Department of Health & Human Services (DHHS), Office of Inspector General (OIG), and List of Excluded Individuals and Entities (LEIE). Please visit https://exclusions.oig.hhs.gov.
b. General Services Administration (GSA), and the System for Award Management (SAM.gov). Please visit https://www.sam.gov.
c. California Department of Health Care Services (DHCS), and Medi-Cal Suspended and Ineligible Provider List (S&I List). Please visit http://files.medical.ca.gov/pubsdoco/SandILanding.asp.
d. Medicare Opt-Out List. Please visit https://data.cms.gov/dataset/Opt-Out- Affidavits/7yuw-754z.
I further attest that if selected, my Firm/Company/Sole Proprietorship will conduct regulatory sanction and exclusion screenings of subcontracted entities prior to engagement with said entities and monthly thereafter.
I understand that if my Firm/Company/Sole Proprietorship becomes excluded, ineligible, or terminated from participation in State and Federal health care programs, any contracts held with IEHP will be subject to immediate termination for cause.
RFP Name/Number:
Signature: Date:
Title of Agent/Officer:
"Execution hereof is certification that the undersigned has read and understands the terms and conditions hereof, and that the undersigned's principal is fully bound and committed."
https://exclusions.oig.hhs.gov/ https://www.sam.gov/ http://files.medical.ca.gov/pubsdoco/SandILanding.asp https://data.cms.gov/dataset/Opt-Out-Affidavits/7yuw-754z https://data.cms.gov/dataset/Opt-Out-Affidavits/7yuw-754z
| RFP NameNumber: |
| Date: |
| Title of AgentOfficer: |
| Signature2_es_:signer:signature: |
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