5-RFP Certification of Non-Debarment - Separate for upload to Bonfire.pdf
PDF 183 KB Posted
- Attached to
- Check Stock Services State and local contract opportunity
- Solicitation number
- 25-06650
- Issued by
- San Bernardino County, California
About this file
This document is a Certification form from the Inland Empire Health Plan (IEHP) Procurement Department. The certification requires an authorized representative to attest that their firm is not excluded, ineligible, or terminated from participation in State or Federal health care programs. The document lists four specific databases and websites that must be checked to verify the firm's eligibility:
- Department of Health & Human Services (DHHS) Office of Inspector General's List of Excluded Individuals and Entities (LEIE)
- General Services Administration (GSA) System for Award Management (SAM.gov)
- California Department of Health Care Services (DHCS) Medi-Cal Suspended and Ineligible Provider List
- Medicare Opt-Out List
The certification also requires the firm to conduct monthly regulatory sanction and exclusion screenings of subcontracted entities, with the understanding that any exclusion or termination from State and Federal health care programs will result in immediate contract termination with IEHP. The document provides space for the RFI name/number, signature, date, and title of the authorized agent or officer.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 3-Non-Collusion Declaration 5-14-18.pdf | ||
| 4-PROFESSIONAL SERVICES AGREEMENT.pdf | ||
| 1-RFP Bidder Terms and Conditions 05-14-18.pdf | ||
| 7-iRFP 25-06650 Check Stock Services Final 09092025 POSTED.pdf | ||
| 6-Local Preference Affidavit 1-25-22.pdf | ||
| 2-RFP Principal Certification Page Binding Bidders Response.pdf |
On GovTribe
Work with this file on GovTribe
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Inland Empire Health Plan Procurement Department
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.
RFI 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
File details come from the government source that posted it. Updated .