1-Certification of Non-Debarment 03-14-24.pdf
PDF 166 KB Posted
- Solicitation number
- IEHP-RFI-26-07137
- Issued by
- San Bernardino County, California
About this file
This is a Certification of Non-Debarment form dated March 14, 2024, required for participation in a state and local contract opportunity with the Inland Empire Health Plan (IEHP) in California. The certification requires authorized representatives of bidding firms, companies, or sole proprietorships to attest that their entity is not excluded, ineligible, or terminated from participation in State or Federal health care programs. Bidders must verify their status against four specific exclusion lists: the Department of Health & Human Services Office of Inspector General List of Excluded Individuals and Entities (LEIE), the General Services Administration System for Award Management (SAM.gov), the California Department of Health Care Services Medi-Cal Suspended and Ineligible Provider List (S&I List), and the Medicare Opt-Out List. The form requires the signature, date, and title of an authorized agent or officer of the bidding entity and includes a statement confirming the undersigned's understanding of the terms and conditions.
The certification mandates that selected firms conduct regulatory sanction and exclusion screenings of all subcontracted entities prior to engagement and monthly thereafter. The form explicitly states that failure to maintain non-debarred status will result in immediate termination of any contracts held with IEHP for cause. This certification requirement applies to the Hospital Relations Software Request for Information opportunity in California, which seeks a software platform to streamline patient transitions across the care continuum, including discharge planning, post-acute care placement, and coordination with community-based providers. Bidders must complete and submit this certification as part of their proposal response.
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Other files
| File | Type | Posted |
|---|---|---|
| 2-RFI - Hospital Relations Software.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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