1-DHHS26149 Attachment F Past Perfomance.docx

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Attached to
Residential Treatment Services
Solicitation number
DHHS26149
Issued by
Utah

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This is a Past Performance Minimum Requirements Form for DHHS26149, a residential treatment services contract with the Utah Department of Health and Human Services. The form establishes eligibility criteria that offerors must satisfy to be considered responsible bidders for providing residential treatment programs, including an 8-bed facility for male youth with problematic sexual behaviors at a moderate level and a 12-bed facility for females requiring high-level mental and behavioral health services.

The form contains three mandatory screening questions that determine offeror responsibility and eligibility. Offerors must disclose whether they have had any DHHS or equivalent state licenses suspended, revoked, or denied for health or safety reasons within the past five years; whether any State of Utah contracts have been terminated for cause due to health or safety reasons within the same period; and whether they have been placed on a moratorium by DHHS for health or safety reasons. Offerors answering affirmatively to license suspension/revocation/denial or to contract termination for cause will be determined non-responsible and eliminated from further consideration. Those who experienced a moratorium resulting in contract termination will also be eliminated, though offerors whose mortariums were resolved may continue in the bidding process. The form requires offerors to list all relevant licenses, contracts, and provide required signatures with printed name and title, with evaluators verifying all responses through issuing entities and DHHS monitoring records.

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Other files

File Type Posted
6-DHHS26149 Document Submission Checklist.docx DOCX document
4-DHHS26149 Form 4 - Mandatory Minimum Requirements.docx DOCX document
13-DHHS26149 Attachment C Established Rates.docx DOCX document
7-DHHS26149 Attachment D Facility Service Selection.docx DOCX document
5-DHHS26149 Attachment E Facility Org Chart.docx DOCX document
3-DHHS26149 RFP Template Residential 9.29.26.docx DOCX document
8-DHHS26149 Form 1 - DHHS Data Sheet.pdf PDF
12-DHHS26149 Attachment A DHHS Client Service Terms.docx DOCX document
14-26089 Form 2 W-9.pdf PDF
11-DHHS26149 Attachment B Scope of Work 9.29.26.docx DOCX document
9-DHHS26149 Score Sheet.xlsx XLSX spreadsheet
2-DHHS26149 Attachment G Medicaid Services Attachment.docx DOCX document
10-DHHS26149 Form 3 Conflict of Interest Disclosure Statement.pdf PDF
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ATTACHMENT F

PAST PERFORMANCE MINIMUM REQUIREMENTS FORM DHHS26149

1. Within the past 5 years, has the Offeror had any DHHS/OL licenses, or equivalent licenses in another state suspended, revoked, or denied for health or safety reasons?

· Yes, there have been licenses, including facility licenses that have been suspended, revoked, denied for health or safety reasons within the past 5 years.

· No, continue completing list of licenses below.

Evaluator will verify Offeror’s answer through the issuing entity. Offerors who have had a license suspended, revoked, or denied for health or safety issues within the past 5 years will be determined non-responsible and will be eliminated from further consideration.

List all DHHS/OL licenses, or equivalent licenses in another state issued to the Offeror within the past 5 years (attach additional sheet if necessary):

Issuing Entity and State
Type of License
License Number
Effective Dates

2. Within the past 5 years, has the Offeror had any State of Utah contract terminated for cause due to health or safety reasons?

· Yes, the Offeror has had contracts with the State of Utah terminated for cause due to health or safety reasons within the past 5 years.

· No, continue completing list of contracts below.

Evaluator will verify Offeror’s answer through the contracting agency. Offerors who have had a contract with the State of Utah terminated for cause due to health or safety reasons within the past 5 years will be determined non-responsible and will be eliminated from further consideration.

List all contracts the Offeror has had with the State of Utah within the past 5 years (attach additional sheet if necessary):

Contracting Agency
Contract Number
Effective Dates

ATTACHMENT F

PAST PERFORMANCE MINIMUM REQUIREMENTS FORM DHHS26149

3. Within the past 5 years, has the Offeror been placed on a moratorium by DHHS for health or safety reasons?

· Yes, and the Offeror’s contract was terminated.

· Yes, but the moratorium was resolved so that the Offeror could continue contracting OR the moratorium has not yet been resolved.

· No.

Evaluator will verify Offeror’s answer through DHHS monitoring records. Offerors who have had a moratorium for health or safety reasons resulting in a contract termination, within the past 5 years, will be determined non- responsible and will be eliminated from further consideration.

REQUIRED SIGNATURE:

Signature:
Date:

Print Name and Title:

File details come from the government source that posted it. Updated .