Addendum No. 1 - Fillable Forms~3.docx

Request for Proposal for Inpatient Concurrent Review

Georgina Yoshioka, Director Department of Behavioral Health

San Bernardino County Department of Behavioral Health Contracts Administration 303 East Vanderbilt Way San Bernardino, CA 92415-0026

Addendum No. 1 to RFP DBH 25-61 ePro Document ID # DBHE26-ADMN-6093

ATTACHMENT A

PROPOSAL SUBMISSION CHECKLIST

Use this checklist to ensure that all items have been included. This form is to be completed and included in the proposal.

ATTACHMENT B

TABLE OF CONTENTS

Item Page Number

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

ATTACHMENT C

STATEMENTS OF CERTIFICATION

(initial and explain in E- Exceptions)

Signature (Authorized Signer) Date

Print/Type Name

Company/Agency

Address

ATTACHMENT D

REPORTABLE CONDITIONS

(Initial and explain in Attachment E- Disclosures/Exceptions)

Does the Proposer or agency/organization have any former county administrative officials who are employees or representatives?

Has the Proposer or agency/organization had completed similar contracts or projects during the last five years?

Has the Proposer or agency/organization had any contracts terminated prior to the original termination date?

Does the Proposer or agency/organization have similar contracts currently in place?

Does the Proposer or agency/organization have controlling interest in any agencies providing equivalent or similar services?

Does the Proposer or agency/organization have any financial interest in other lines of business?

Does the Proposer or agency/organization have any pending litigation regarding crimes or offenses, financial misconduct, or fraud involving the Proposer’s business, or any of its officers, employees, and/or consultants thereof, in connection with contracts?

Does the Proposer or agency/organization have any convictions or adverse court rulings involving fraud and/or related acts of all officers, consultants, and employees?

Signature (Authorized Signer) Date

Print/Type Name

Company/Agency

Address

Address

ATTACHMENT E

DISCLOSURES, EXCEPTIONS, AND PUBLIC RECORDS ACT EXEMPTIONS TO RFP

DISCLOSURES

Proposer reports the following:

EXCEPTIONS

Proposer has reviewed the RFP and General Contract Terms in their entirety and has the following exceptions. (Please list your exceptions by indicating the section or paragraph number, and page number, as applicable. Be specific about your objections to content, language, or omissions. Add as many pages as required.)

PUBLIC RECORDS ACT EXEMPTIONS

Proposer requests that specific portions of the contents of this proposal be held confidential and not subject to public disclosure pursuant to the Public Records Act. The specific portions are detailed below: (Please identify and list your exemptions by indicating the Section or Paragraph number, and Page number, of the proposal where the content is contained.) Each stated exemption must include a citation to the supporting legal authority, including statutory authority or case law, to support exemption from the Public Records Act. Requested exemptions that do not meet the requirements of this section will not be considered.

Name of Authorized Representative:

Signature of Authorized Representative:

Title: Date:

ATTACHMENT F

SUBCONTRACTOR INFORMATION

SUBCONTRACTOR NAME (name of agency, entity or organization):

Name and Title of Proposer’s Contact Person:

Mailing Address:

Telephone Number:

Fax Number:

E-mail Address:

Federal Employer Identification Number:

Number of Years under Current Name:

Justification for Subcontracting: (Work)

Capacity to Perform the Required Services Statement:

Subcontractor’s Authorized Signature:

The undersigned hereby certifies that the information above is correct and agrees to serve as a subcontractor on and perform all work as indicated above and will comply with all items as indicated in Section IV of Inpatient Concurrent Review, RFP DBH 25-61.

I have attached an MOU with original signatures to this sheet for DBH review.

Signature: Date:

Print/Type Name: Title:

ATTACHMENT G

PROPOSER’S FINANCIAL CAPABILITY

Use this page as a cover sheet for financial documents.

Per Section XI, Sub-Section C, Item #8 of this RFP:

Proposer must provide the Company’s three most recent and complete annual audited financial statements; the most recent must be completed within the past 18 months.

If business has been in existence less than three years, and audited financial statements are not available, you must provide the most recent financial statements that have been audited by an independent, certified public accountant.

If you do not have audited financial statements, please submit unaudited financial statements for the three most current years (including balance sheet, income statement, and statement of cash flow).

You must also provide an unaudited financial statement to cover the period from the last audited statement to present, ending no more than 120 days prior to the date of submission of this proposal.

ATTACHMENT H

Indemnification and Insurance Requirements Affidavit

THE PROPOSER’S INSURANCE COMPANY(S) OR INSURANCE AGENT MUST COMPLETE THIS FORM

AND

THE PROPOSER MUST SUBMIT THIS COMPLETED AFFIDAVIT WITH THE PROPOSAL.

I, the undersigned (Please check one box) underwriter agent/broker, certify that I and the Proposer listed below have jointly reviewed the “Insurance Requirements” in this Request for Proposal (RFP). If the San Bernardino County (“County”) awards the Proposer the Contract for this project, I will be able—within fourteen (14) calendar days after the Proposer is notified of the Contract’s award—to furnish the County with all the required, insurance certificate(s) and endorsement(s) as specified in Section V, Paragraph B. Indemnification and Insurance Requirements.

Insurance Broker / Agency Name Date

Insurance Broker’s / Agent’s Name (Printed) Insurance Broker’s / Agent’s Name (signature)

Address City State Zip Code

Telephone Number FAX Number Email Address

Proposer’s Name County RFP Name and Number Below State the Name of Insurance Company Providing Coverage:

DO NOT write “Will Provide,” “To Be Determined,” “When required,” or similar phrases.

Commercial/General Liability Automobile Liability

Workers’ Compensation Liability Professional Liability

Cyber Liability

Sexual Abuse Liability

[NOTE TO PROPOSER: See Section X, Paragraph B. Indemnification and Insurance Requirements, for details on the basic requirements and types of insurance for this agreement.]

NOTE TO THE UNDERWRITER / AGENT-BROKER: If the insurance forms that the Proposer submits to the County do not fully comply with the Insurance Requirements, and/or if the Proposer fails to submit the forms within the 14-day time limit, the County may: (1) declare the Proposer’s Proposal non-responsive, and (2) award the Contract to the next highest ranked Proposer.

If you have any questions about the Insurance Requirements, please contact County - Risk Management Department, via e-mail Insurance.Questions@RM.sbcounty.gov (Please provide name of RFP with your email question(s)).

ATTACHMENT J

RATES

Use this page as a cover sheet when submitting rates.

Submit complete Rate Sheets for each fiscal year for cost analysis purposes (see Attachment I- Sample). Electronic version will be e-mailed to each agency upon verification of proposal conference attendance or upon request, as appropriate.

NOTE: Failure to submit the Rates Sheets for each year as required WILL result in the elimination of the entire submitted proposal; it will not move forward in the evaluation process.

ATTACHMENT K

REFERENCES

Number Dates services provided (begin/end*)

Provide three (3) references from other entities, preferably public agencies, of same or similar size as the County, with whom you have established a contract on a project of the same nature as this RFP. Provide Contact Name, Address, Email Address, Phone Number, and dates Services were provided.

*Enter “Present” if still providing the services (Example: 10/08/03-Present).

Name of Authorized Representative:

Signature of Authorized Representative:

Title: Date:

ATTACHMENT N

LOCAL VENDOR PREFERENCE SELF-CERTIFICATION

To be certified as a local vendor, eligible for Local Vendor Preference (any vendor, contractor or consultant, hereafter “vendor”) I certify under penalty of perjury that Agency Name meets all of the following requirements:

· The main office (headquarters) or a major regional office is located within the boundaries of San Bernardino County;

· Twenty-five percent (25%) of full-time management employees and twenty-five percent (25%) of full-time regular employees work from locations in the County;

· Employ at least one full-time or two part-time employees with primary residence in the County;

· Point of sale” for purposes of reporting sales tax to the State Board of Equalization (if applicable) is within the boundaries of the County and payment of any local share of sales tax goes to the County or a city within the County. (If the local business has more than one sales office in the State of California, the office located in the County shall be the point of sale for sales tax calculation);

· Not delinquent in any taxes or other payments to the County;

· Possess a valid and verifiable business license in Locations (if required);

· Have been open and established since Date

· Have had on-going business activity in the field of Nature of business since Date (which is at least six months prior to the issuance of the solicitation);

· Have not, within five years prior to the date this form is signed, admitted guilt or been found guilty by any court or state or federal regulatory enforcement agency of violation of any criminal law or any law or regulation regarding fraud and not federally debarred; and

· Not suspended or debarred from participation in the County, in the scope of work that is the subject of the solicitation.

Further, I acknowledge by initiating the following boxes that I understand:

If any time after being certified as a local vendor, a change in status occurs rendering a vendor no longer eligible for such status, the vendor must notify the Purchasing Agent prior to responding to a solicitation or accepting an award. Self certification is good for a period of five years, then must be renewed.

False Certifications shall be immediate grounds for rejection of any proposal or bid or if the proposal or bid is awarded, grounds for voiding the proposal or bid, terminating any agreement, and seeking damages thereto. Failure to certify the above information shall result in the proposal or bid being considered by the County without any adjustment for a local vendor.

Self-certification provided by the vendor requesting a local preference shall be submitted to the Contact Person under penalty of perjury. No person or business shall make a false representation to a County official or employee for the purpose of influencing the certification or denial of certification of any local vendor.

Any vendor that falsely obtains certification shall be ineligible to transact business with the County for not less than one year and not more than three years, at the discretion of the County. This penalty shall also apply to any vendor that previously obtained proper certification and, because of a change in its status would no longer be eligible for certification, and fails to notify the County of this information prior to responding to a solicitation or accepting an award.

I am an authorized representative of Agency Name and can be legally bind the company.

Name of Authorized Representative:

Signature of Authorized Representative:

Title: Date:

image1.png