6-Certification of Non-Debarment 03-14-24.pdf
PDF 166 KB Posted
- Solicitation number
- 25-06606
- Issued by
- San Bernardino County, California
About this file
This document is a Certification of Non-Debarment form from Inland Empire Health Plan (IEHP), a California-based health care organization. The certification requires potential vendors or contractors to attest that they are not excluded, ineligible, or terminated from participating in State or Federal health care programs, and do not appear on specific exclusionary lists including the HHS 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 (DHCS) Medi-Cal Suspended and Ineligible Provider List, and the Medicare Opt-Out List.
The vendor must commit to conducting monthly regulatory sanction and exclusion screenings of subcontracted entities and understand that if they become excluded from State or Federal health care programs, any contracts with IEHP will be immediately terminated. The document is dated 03-14-2024 and is part of IEHP's procurement process, with blank spaces for the RFP name/number, signature, date, and title of the agent or officer completing the certification. The form includes a statement that execution of the document certifies the undersigned has read and understands the terms and conditions, and that their principal is fully bound and committed.
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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 .