5-Certification of Non-Debarment 03-14-24.pdf
PDF 166 KB Posted
- Attached to
- Clinical Review Services
- Solicitation number
- 25-06803
- Issued by
- San Bernardino County, California
About this file
This is a Certification of Non-Debarment form dated March 14, 2024, submitted to the Inland Empire Health Plan (IEHP), a California health plan organization. The certification serves as an attestation by an authorized representative of a bidding firm, company, or sole proprietorship that the entity is not excluded, ineligible, or terminated from participation in state or federal health care programs. The bidder confirms that its organization does not appear on the Department of Health & Human Services Office of Inspector General's List of Excluded Individuals and Entities (LEIE), the General Services Administration's System for Award Management (SAM.gov), the California Department of Health Care Services' Medi-Cal Suspended and Ineligible Provider List, or the Medicare Opt-Out List. The form is associated with the Clinical Review Services contract opportunity for IEHP in California.
The certification requires the bidder to commit to conducting regulatory sanction and exclusion screenings of any subcontracted entities prior to engagement and monthly thereafter. The bidder acknowledges that any contracts held with IEHP will be subject to immediate termination for cause if the firm becomes excluded, ineligible, or terminated from participation in state or federal health care programs. The form must be signed and dated by an authorized agent or officer of the bidding organization, with the signature serving as certification that the undersigned has read and understood the terms and conditions and that the principal is fully bound and committed to the attestation.
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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: |
File details come from the government source that posted it. Updated .