1-VENDOR CERTIFICATION OF ELIGIBILITY.pdf

VENDOR CERTIFICATION OF ELIGIBILITY TO PARTICIPATE

IN FEDERAL AND STATE HEALTH CARE PROGRAMS

Background

The Harris County Hospital District d/b/a Harris Health System (“Harris Health”) participates in Federal and State health care programs. As conditions of participation, neither Harris Health nor its vendors may be excluded from participation in any Federal or State health care program, and both Harris Health and its vendors must comply with all rules and regulations regarding the programs.

Harris Health screens all vendors upon engagement, and at least annually thereafter, against the General Services Administration’s List of Parties Excluded from Federal Programs and the HHS/OIG List of Excluded Individuals/Entities (“LEIE/EPLS”) (collectively referred to as “exclusion lists”) to ensure that they are not listed on the exclusion lists. In addition, all vendors must disclose to Harris Health’s Corporate Compliance Office whether they or any of their owners, officers, directors, employees, or principals (collectively, “Principals”) are listed on the exclusion lists.

The contact information for Harris Health’s Corporate Compliance Office is:

Harris Health System Corporate Compliance Office P.O. Box 300033 Houston, Texas 77230-0033

(346) 426-1505 (Phone)

Harris Health has a disclosure policy that emphasizes a no-retribution, no-retaliation policy and includes a reporting mechanism for anonymous communications for which confidentiality is maintained. Harris Health has also arranged for a hotline service with an outside agency. The hotline’s phone number is 1-800-500-0333.

Certification

I hereby certify that neither the vendor who is listed below, nor any of its Principals, is on the exclusion lists. I further certify that the vendor will report immediately to Harris Health’s Corporate Compliance Office if either the vendor or any of its Principals becomes placed on the exclusion lists at any time in the future while the vendor is associated with Harris Health. I understand that if the vendor is now or subsequently become placed on the exclusion lists, Harris Health will terminate its contract(s) with vendor.

I further understand that if the vendor fails to immediately terminate any of its Principals who become placed on the exclusion lists, Harris Health will terminate its contract(s) with vendor.

I further certify that the vendor understands that its Principals are expected to disclose or report to Harris Health’s Corporate Compliance Office, or other appropriate Harris Health designated individual, any suspected violation of any Federal or State health care program requirement or of Harris Health’s own policies and procedures.

Vendor Name

Address

City State Zip Code

Signature

Print Name

Title Phone Number

Email Address Date