5-Certification of Non-Debarment 03-14-24.pdf
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- Attached to
- Consent and Preference Management Software
- Solicitation number
- 25-06921
- Issued by
- San Bernardino County, California
About this file
This is a Certification of Non-Debarment document dated March 14, 2024, required for participation in a Consent and Preference Management Software contract opportunity with the Inland Empire Health Plan (IEHP) in California. The certification attests that the bidding firm, company, or sole proprietorship is not excluded, ineligible, or terminated from participation in state or federal health care programs and does not appear on relevant exclusion lists maintained by the Department of Health & Human Services Office of Inspector General, the General Services Administration System for Award Management, the California Department of Health Care Services Medi-Cal Suspended and Ineligible Provider List, or the Medicare Opt-Out List. The authorized representative executing the document commits to conducting regulatory sanction and exclusion screenings of any subcontracted entities prior to engagement and on a monthly basis thereafter.
The certification further establishes that failure to maintain eligibility status will result in immediate contract termination for cause with IEHP. The document requires the signature, date, and title of an authorized agent or officer of the bidding entity and serves as binding certification that the signatory has read and understands all terms and conditions and that the principal entity is fully committed to compliance with these requirements.
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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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