2026HCA4-ExhibitA-BidderFormsandCertification.docx

REQUEST FOR PROPOSALS (RFP)

RFP NO. 2026HCA4

EXHIBIT A:

BIDDER FORMS AND CERTIFICATIONS

HCA RFP No. 2026HCA4 Page 28 of 38 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

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

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.

Name & Title:

Email Address:

Telephone Number:

Name & Title:

Email Address:

Telephone 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

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

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.

Does Bidder’s Proposal include any Subcontractors?

☐YES ☐NO

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.

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.

☐YES ☐NO

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.

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.

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?

☐YES ☐NO

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

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)?

☐YES ☐NO

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.

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?

☐YES ☐NO

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 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.

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

If yes, please submit an explanation.

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.

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

☐YES ☐NO

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

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?

☐YES ☐NO

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” 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:

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

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)

B.

C. DIVERSE BUSINESS INCLUSION PLAN

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

☐YES ☐NO

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

☐YES ☐NO

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

☐YES ☐NO

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

☐YES ☐NO

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

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

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

Name:

Phone:

E-Mail:

HCA RFP No. 2026XHCA4X Page 28 of 38 Exhibit A, Bidder Forms and Certifications (B)

D. 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.

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.

Print Name of person making certifications for organization

HCA RFP No. Page 1 of 37 Exhibit H

HCA RFP No. 2026XHCA4X Page 28 of 38 Exhibit A, Bidder Forms and Certifications (C)

E. REFERENCES

BIDDER REFERENCE #1

Organization Legal Name:

Contact Name:

Contact Title:

Contact's Phone Number:

Contact Email Address:

Description of Services Performed:

BIDDER REFERENCE #2

Organization Legal Name:

Contact Name:

Contact Title:

Contact's Phone Number:

Contact Email Address:

Description of Services Performed:

BIDDER REFERENCE #3

Organization Legal Name:

Contact Name:

Contact Title:

Contact's Phone Number:

Contact Email Address:

Description of Services Performed:

HCA RFP No. 2026XHCA4X Page 28 of 38 Exhibit A, Bidder Forms and Certifications (D)

F. WASHINGTON SMALL AND/OR CERTIFIED VETERAN OWNED BUSINESS CERTIFICATION

1. WASHINGTON SMALL BUSINESS.

Bidder certifies as follows (Bidder must check all applicable boxes):

☐ WASHINGTON SMALL BUSINESS. Bidder is a Washington Small Business as defined in RCW 39.26.010(13) and (22)(a). To qualify as a Washington Small Business, Bidder must meet three (3) requirements:

a. Location. Bidder’s principal office/place of business must be located in and identified as being in the State of Washington. A principal office or principal place of business is a firm’s headquarters where business decisions are made and the location for the firm’s books and records as well as the firm’s senior management personnel.

b. Size. Bidder must be owned and operated independently from all other businesses and qualify as one of the following:

i. Bidder Qualifies as a Small Business – i.e.,

1) Bidder has fifty (50) or fewer employees; or

2) Bidder has an annual gross revenue of less than $7,000,000 as reported on Bidder’s federal income tax return or its return filed with the Washington State Department of Revenue over the previous three (3) consecutive years.

ii. Bidder Qualifies as a Minibusiness – i.e., Bidder has an annual gross revenue of less than $3,000,000, but $1,000,000 or more, as reported on Bidder’s federal income tax return its return filed with the Washington State Department of Revenue.

iii. Bidder Qualifies as a Microbusiness – i.e., Bidder has an annual gross revenue of less than $1,000,000 as reported on Bidder’s federal income tax return or its return filed with the Washington State Department of Revenue.

c. WEBS Certification. Bidder must have certified its Washington Small Business status in Washington’s Electronic Business Solution (WEBS).

OR

☐ NOT A WASHINGTON SMALL BUSINESS. Bidder does not qualify as a Washington Small Business as set forth above.

2. CERTIFIED VETERAN-OWNED BUSINESS. Bidder certifies as follows (Bidder must check one and, if stating that Bidder is a Certified Veteran-Owned Business, provide Bidder’s Washington Department of Veteran Affairs (WDVA) certification number in the space provided below):

☐ CERTIFIED VETERAN-OWNED BUSINESS. Bidder is a Certified Veteran-Owned Business under RCW 43.60A.190. To qualify as a Certified Veteran-Owned Business, Bidder must meet four (4) requirements:

a. 51% Ownership. Bidder must be at least fifty-one percent (51%) owned and controlled by:

i. A veteran as defined as every person who at the time he or she seeks certification has received a discharge with an honorable characterization or received a discharge for medical reasons with an honorable record, where applicable, and who has served in at least one of the capacities listed in RCW 41.04.007;

ii. A person who is in receipt of disability compensation or pension from the department of veterans affairs; or

iii. An active or reserve member in any branch of the armed forces of the United States, including the national guard, coast guard, and armed forces reserves.

b. Washington Incorporation/Location. Bidder must be either an entity that is incorporated in the State of Washington as a Washington domestic corporation or, if not incorporated, an entity whose principal place of business is located within the State of Washington.

c. WEBS Certification. Bidder must have certified its Veteran-Owned Business status in Washington’s Electronic Business Solution (WEBS).

d. WDVA Certification. Bidder must have provided certification documentation to the Washington Department of Veterans’ Affairs (WDVA) and be certified by WDVA and listed as such on WDVA’s website (WDVA – Veteran-Owned Businesses). Bidder’s WDVA certification no.: _____________

OR

☐ NOT A CERTIFIED VETERAN-OWNED BUSINESS. Bidder does not qualify as a Certified Veteran-Owned Business as set forth above.