2024HCA15ExhibitA-Bidder Forms&Certifications.pdf

REQUEST FOR PROPOSALS (RFP)

RFP NO. 2024HCA15

EXHIBIT A:

BIDDER FORMS AND CERTIFICATIONS

HCA RFP No. 2024HCA15 Page 2 of 11 Exhibit A, Bidder Forms and Certifications (A)

A. BIDDER PROFILE & SUBMITTAL FORM

HCA reserves the right to request additional information or proof of documentation as referenced in this document.

1. MINIMUM QUALIFICATIONS

Bidder confirms they meet all requirements specified in the Minimum Qualifications section of the RFP as a prerequisite to submitting a proposal in response to this solicitation.

☐YES

If a Bidder selects “yes” and it is verified later that the Bidder does not meet the Minimum Qualifications, the Bidder’s Proposal will be considered non-responsive.

2. ORGANIZATION INFORMATION

(a)

Legal Name*

DBA (if any)

Street Address

Mailing Address:

City, State, ZIP

*HCA requires the legal name of Bidder’s organization as it is registered in the state of Washington or the state in which Bidder organization is registered.

(b)

Telephone Number

Area Code: Number: Extension:

(c) Email Address

(d)

Signatory Information (person with signature authority for the organization)

Name & Title:

Email Address:

HCA RFP No. 2024HCA15 Page 3 of 11

Telephone Number:

(e)

Primary Contact Information (for questions/contract negotiations)

Name & Title:

Email Address:

Telephone Number:

(f) WA State Unified Business Identification (UBI) Number:

If organization does not have a UBI Number to provide above, select the appropriate option below to show compliance with the licensing requirement:

Our organization will obtain a business license within 30 calendar days of being notified of its selection as an Apparent Successful Bidder.

OR

Our organization has been exempted from state licensing by the State of Washington. (Proof of such exemption may be required)

(g) If applicable, Unique Entity Identifier issued by SAM.gov:

A Unique Entity Identifier is required if the solicitation uses federal funds.

(h) If applicable, Washington State Office of Minority and Women’s Business Enterprises (OMWBE) Certification Number.

For more information: http://www.omwbe.wa.gov.

3. ADDITIONAL INFORMATION

IMPORTANT: If Bidder answers YES to any question in this Section 3, Bidder is required to submit the additional response materials as described below the question. A Bidder’s failure to provide this information may cause HCA to consider their Proposal non-responsive and reject it.

(a) Subcontractor(s)

Does Bidder’s Proposal include any Subcontractors?

☐YES ☐NO

http://www.omwbe.wa.gov/

HCA RFP No. 2024HCA15 Page 4 of 11

If yes, complete and provide an information sheet for each Subcontractor, providing information for items 2(a) – 2(h) shown above. If any Subcontractor is a minority owned, women owned, veteran owned, or disadvantaged business, include the percentage and dollar amount of their participation.

The substitution of one Subcontractor for another may be made only at the discretion and prior written approval of HCA. The contractor is liable and responsible for all Subcontractor work.

(b)

Procurement or Financial -Related Convictions

Indicate whether the Bidder, Subcontractor, or any of the Bidder or Subcontractor principal owners, officers or partners has been convicted within the last ten (10) years of any of the following:

1) Conviction for commission of a criminal offense as an incident to obtaining or attempting to obtain a public or private contract or subcontract, or in the performance of such contract or subcontract;

2) Conviction or a final determination in a civil action under state or federal statutes of fraud, embezzlement, theft, forgery, bribery, falsification or destruction of records, receiving stolen property, violation of the federal false claims act, 31 U.S.C. Sec. 3729 et seq., or the state Medicaid fraud false claims act, chapter 74.66 RCW, or any other offense indicating a lack of business integrity or business honesty that currently, seriously, and directly affects responsibility as a state contractor;

3) Conviction under state or federal antitrust statutes arising out of the submission of bids or proposals.

If yes, submit full details of the terms of the incident including the customer and/or other adverse party name, address, and telephone number. Present the Bidder’s position on the matter.

HCA reserves the right to contact the customer or other adverse party and their representatives for further investigation of the incident. HCA will evaluate the facts and may, at its sole discretion, reject the Proposal on the grounds of the past conviction.

(c)

Termination for Default

Has Bidder or Bidder’s Subcontractors had a contract terminated for default within the last five years?

☐YES ☐NO

If yes, submit full details including the other party’s name, address, and telephone number. The Bidder must specifically grant HCA permission to contact any and all involved parties and access to any and all information HCA determines is necessary to satisfy its investigation of the termination. HCA will evaluate the circumstances and may, at its sole discretion bar the participation of the Bidder from this solicitation.

If discovered post contract award, failure to disclose any termination for default may result in termination of the contract with liquidated damages.

http://apps.leg.wa.gov/rcw/default.aspx?cite=74.66

HCA RFP No. 2024HCA15 Page 5 of 11

(d)

Federal and State Debarment Certification

Is the Bidder, including any of its officers or holder of controlling interest; or proposed Subcontractors presently or been previously debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in any federal or state contracts or grants by any federal or state department or agency?

If yes, submit full details including reason for debarment and timeframe.

Wage Payment Requirement Violation

Has Bidder or Bidder’s Subcontractors, within the three (3) year period immediately preceding the date of the Proposal, been determined by a final and binding citation and notice of assessment issued by the Department of Labor and Industries or through a civil judgement entered by a court of limited or general jurisdiction to have willfully violated, as defined in RCW 49.48.082, any provision of RCW chapter 49.46 (Minimum Age Requirements and Labor Standards), 49.48 (Payment of Wages), or 49.52 (Wage Deductions)?

If yes, submit full details including the citation and/or judgement, the other party’s name, address, and telephone number. The Bidder specifically grants access to HCA to all information HCA determines necessary to satisfy its investigation of the citation and/or judgement. HCA will evaluate the circumstances and may, at its sole discretion bar the participation of the Bidder from this solicitation.

If discovered post contract award, failure to disclose any wage payment requirement violation may result in termination of the contract with liquidated damages.

(f) Conflict of Interest Information

(f)(1)

Specific restrictions apply to contracting with current or former state employees pursuant to chapter 42.52 of the Revised Code of Washington. Bidders should familiarize themselves with the requirements prior to submitting a proposal that includes current or former state employees.

Were any of Bidder’s employees, officers or Subcontractor’s employees or officers employed by the State of Washington during the last two (2) years?

If yes, state their positions within your organization, proposed duties under any resulting contract, their duties and position during their employment with the state, and the date of their separation from state employment. If

HCA RFP No. 2024HCA15 Page 6 of 11 applicable, indicate whether individual providing services retired using the 2008 Early Retirement Factors (ERF) or whether the organization is owned by an individual who retired under the ERF and receiving compensation as a result of the contracted service.

(f)(2)

Is any owner, key officer or key employee of the Bidder related by blood or marriage to an employee of HCA or has close personal relationship to same?

If yes, identify the parties, identify their current or proposed positions, and describe the nature of the relationship.

(f)(3)

In preparing this Proposal, has Bidder been assisted by any current or former employee of the state of Washington whose duties relate (or did relate) to this Proposal or prospective contract, and who was assisting in other than his or her official, public capacity?

If yes, please submit an explanation.

(f)(4) Is the Bidder aware of any other real or potential conflict of interest?

If yes, disclose the nature and circumstance of such potential conflict of interest.

If after review of the information provided and the situation, HCA determines that a potential conflict of interest exists, HCA may, at its sole discretion, disqualify the Bidder from participating in this solicitation. Failure to fully disclose any real or potential conflict of interest may result in disqualification of the Bidder or Termination for Default of any contract with the Bidder resulting from this solicitation if discovered post contract award.

(g)

Recent Washington State Contracts

Has the Bidder or any Subcontractor contracted with the state of Washington during the past 24 months?

If yes, provide the name of the agency, the contract number, and project description and/or any other information available to identify the contract.

(h)

Confidential Information and Public Disclosure

Does Bidder’s Proposal contain any proprietary or confidential information? Is Bidder claiming an exemption under chapter 42.56 RCW, the Public Records Act, or other state or federal law that provides for nondisclosure of a record?

If yes, provide an indexed list, identifying location of proprietary/confidential information by document name, page number, and location on page where the information is in the response. Each page claimed to be exempt from disclosure must reference either (1) the specific basis claimed under Chapter 42.56 RCW, the Public Records Act, or (2) a statement of why the information is designated proprietary/confidential or exempt from disclosure.

Additionally, each page claimed to be exempt from disclosure must be clearly identified by the word “Proprietary” http://apps.leg.wa.gov/rcw/default.aspx?cite=42.56

HCA RFP No. 2024HCA15 Page 7 of 11 printed on the lower right-hand corner of the page. Stating or marking the entire Proposal or entire sections as proprietary will not be honored.

4. CERTIFICATIONS AND ASSURANCES

Bidder makes the following certifications and assurances (4(a) – 4(j)) as a required element of the Proposal attached, understanding that the truthfulness of the facts affirmed here and the continuing compliance with these requirements are conditions precedent to the award or continuation of the related contract:

(a) Bidder’s answers and statements made in the Proposal are true and correct.

(b) Bidder’s prices and/or cost data have been determined independently, without consultation, communication, or agreement with others for the purpose of restricting competition?

Bidder may join with other persons or organizations for the purpose of presenting a single proposal.

(c)

Bidder’s attached Proposal is a firm offer for a period of 120 days from the due date for receipt of proposals, or up until the start date of the resulting contract, and it may be accepted by HCA without further negotiation (except where Bidder has identified exceptions to the Draft Contract below or where there is lack of certainty in key terms) at any time within this period.

(d)

Bidder understands that HCA will not be liable for any costs incurred by the Bidder in preparation of a proposal submitted in response to this RFP, in conduct of a presentation/product demonstration, or any activities related in any way to responding to this RFP. Funds are not obligated until a contract has been fully executed.

Bidder understands that its Proposal will become the property of HCA, and Bidder claims no proprietary rights to the ideas, writings, items, or samples, unless so stated in its response to the Confidential Information and Public Disclosure question above.

(f) Bidder confirms the prices and/or cost data submitted have not been knowingly disclosed by the Bidder and will not be knowingly disclosed by Bidder prior to announcement of ASB, directly or indirectly, to any other Bidder or to any competitor.

(g)

(1) Bidder agrees that submission of the attached Proposal constitutes acceptance of the solicitation contents and the attached Draft Contract terms and conditions. Additionally, if there are any exceptions to these terms, Bidder has described those exceptions in detail as redlines within Exhibit B, Draft Contract.

(2) Bidder is submitting exceptions to Exhibit B, Draft Contract with its Proposal. ☐YES ☐NO

(h) Bidder confirms it has made no attempt and will make no attempt to induce any other person or organization to submit or not to submit a proposal for the purpose of restricting competition.

HCA RFP No. 2024HCA15 Page 8 of 11

(i) Bidder grants HCA the right to contact references and others, who may have pertinent information regarding the ability of Bidder and the lead staff person(s) to perform the services contemplated by this solicitation.

AUTHORIZED SIGNATURE(S):

By signing below, you hereby certify that you are an authorized representative of your organization and empowered to negotiate, enter into, and execute, in the name and on behalf of your organization, any agreements or documents associated with this solicitation and to bind your organization to the obligations stipulated therein.

I declare under penalty of perjury under the law of Washington that the information provided in this Exhibit A is true and correct.

Name:

Title:

Signature:

Date:

Location: (city or other location, and state or country)

HCA RFP No. 2024HCA15 Page 9 of 11 Exhibit A, Bidder Forms and Certifications (B)

B. DIVERSE BUSINESS INCLUSION PLAN

1. Do you anticipate using, or is your organization, a State Certified Minority Business?

☐YES ☐NO

2. Do you anticipate using, or is your organization, a State Certified Women’s Business?

☐YES ☐NO

3. Do you anticipate using, or is your organization, a State Certified Veteran Business?

☐YES ☐NO

4. Do you anticipate using, or is your organization, a Washington State Small Business?

☐YES ☐NO

5. If you answered No to all the questions above, please explain:

6. Please list the approximate percentage of work to be accomplished by each group:

6.1 Minority [INSERT #]%

6.2 Women [INSERT #]%

6.3 Veteran [INSERT #]%

6.4 Small Business [INSERT #]%

7. Please identify the person in your organization to manage your Diverse Inclusion Plan responsibility.

7.1 Name:

7.2 Phone:

7.3 E-Mail:

HCA RFP No. 2024HCA15 Page 10 of 11 Exhibit A, Bidder Forms and Certifications (C)

C. EXECUTIVE ORDER 18-03 – WORKER’S RIGHTS

Pursuant to the Washington State Governor’s Executive Order 18-03 (dated June 12, 2018), the Washington State Health Care Authority is seeking to contract with qualified entities and business owners who certify that their employees are not, as a condition of employment, subject to mandatory individual arbitration clauses and class or collective action waivers.

HCA Solicitation No.: 2024HCA15-Health Technology Assessment

I hereby certify, on behalf of the organization identified below, as follows (check one):

☐ NO MANDATORY INDIVIDUAL ARBITRATION CLAUSES AND CLASS OR COLLECTIVE ACTION

WAIVERS FOR EMPLOYEES. This organization does NOT require its employees, as a condition of employment, to sign or agree to mandatory individual arbitration clauses or class or collective action waivers.

OR

☐ MANDATORY INDIVIDUAL ARBITRATION CLAUSES AND CLASS OR COLLECTIVE ACTION

WAIVERS FOR EMPLOYEES. This organization requires its employees, as a condition of employment, to sign or agree to mandatory individual arbitration clauses or class or collective action waivers.

I hereby certify, under penalty of perjury under the laws of the state of Washington, that the certifications herein are true and correct and that I am authorized to make these certifications on behalf of the organization listed herein.

ORGANIZATION NAME: _____________________________________________________

Name of Bidder – Print full legal entity name of organization

By: ______________________________ Signature of authorized person

Title: ______________________________ Title of person signing certificate

Date: ______________________________

Print Name of person making certifications for organization

Place: ________________________________ Print city and state where signed

HCA RFP No. 2024HCA15 Page 11 of 11 Exhibit A, Bidder Forms and Certifications (D)

D. REFERENCES

BIDDER REFERENCE #1

Organization Legal Name:

Contact Name:

Contact Title:

Contact's Phone Number:

Contact Email Address:

Time Frame of Services Provided: Names and Titles for Bidder Team Members Who Provided the Services:

Description of Services Performed:

BIDDER REFERENCE #2

BIDDER REFERENCE #3