6-Certification of Non-Debarment 03-14-24.pdf
PDF 166 KB Posted
- Attached to
- Janitorial Services Staffing Augmentation
- Solicitation number
- 26-07128
- Issued by
- San Bernardino County, California
About this file
This is a Certification of Non-Debarment form dated March 14, 2024, required for participation in a Janitorial Services Staffing Augmentation contract opportunity with the Inland Empire Health Plan (IEHP) in California. As an authorized representative executing this certification, the bidder attests that their 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 any exclusion lists maintained by the Department of Health & Human Services Office of Inspector General (LEIE), the General Services Administration (SAM.gov), the California Department of Health Care Services (Medi-Cal Suspended and Ineligible Provider List), or the Medicare Opt-Out List. The signatory acknowledges understanding that failure to meet these requirements or any subsequent exclusion from State and Federal health care programs will result in immediate termination of any contracts held with IEHP for cause.
The certification further obligates the selected vendor to conduct regulatory sanction and exclusion screenings of all subcontracted entities prior to engagement and on a monthly basis thereafter. This document serves as binding certification that the undersigned has read and understands all associated terms and conditions and that the principal is fully committed to compliance. The form requires completion of signature, date, RFP name/number, and title of the authorizing agent or officer before submission.
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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 .