Addendum No. 2 - Fillable Forms~1.docx

DOCX document 308 KB Posted Sep 10, 2026

Attached to: Children's Residential Intensive Services Program (ChRIS)
Solicitation number: DBHE26-ADMN-6420
Issued by: California

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Written by GovTribe AI · Oct 5, 2026

Addendum No. 2 Summary

This is an Addendum No. 2 to the Request for Qualifications (RFQ) #25-99 issued by the California Department of Behavioral Health (DBH) for the Children's Residential Intensive Services Program (ChRIS). The addendum provides fillable forms and supplementary documentation to support bidders' submissions for residential intensive services to children. The document contains standardized forms designed to facilitate uniform proposal submissions from qualified providers. Specific details regarding response deadlines, site visit requirements, bidders' conferences, and award timelines are referenced within the original RFQ documentation and any previous addenda. The contract term and any renewal options are established in the primary RFQ materials.

The addendum focuses on administrative and procedural requirements through the provision of standardized templates and forms. Pricing structures, set-asides, incumbent provider information, and funding details are addressed in the primary RFQ documentation. Bidders are directed to reference the complete RFQ package and all associated addenda for comprehensive information regarding contract terms, financial requirements, and submission protocols.

View the file

Other files

File	Type	Posted
DBH RFQ 25-99 Proposer Conference for ChRIS.9.17.26.pdf	PDF	Sep 10, 2026
Addendum No. 1 - Questions and Answers.docx	DOCX document	Sep 10, 2026
ChRIS CalAim Budget Schedule FY 29-30.xlsx	XLSX spreadsheet	Sep 10, 2026
ChRIS CalAim Budget Schedule FY 27-28.xlsx	XLSX spreadsheet	Sep 10, 2026
ChRIS CalAim Budget Schedule FY 30-31.xlsx	XLSX spreadsheet	Sep 10, 2026
ChRIS CalAim Budget Schedule FY 26-27~1.xlsx	XLSX spreadsheet	Sep 10, 2026
RFQ 25-99 ChRIS.pdf	PDF	Sep 10, 2026
ChRIS CalAim Budget Schedule FY 28-29.xlsx	XLSX spreadsheet	Sep 10, 2026

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Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services		RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420
	ATTACHMENT A

ROUND 1 PROPOSAL SUBMISSION CHECKLIST AND TABLE OF CONTENTS

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

Proposer Legal Business Name:

→

Address:

→

City, State Zip Code:

→

Phone Number:

→

Federal Tax ID:

→

RFQ Contact Name and Title:

→

Contact Phone Number:

→

Contact Email:

→

Authorized Representative/ Signatory Name and Title:

→

Representative Phone Number:

→

Representative Email:

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Items Completed

Page Number

	1. Cover Page
	Submit a letter, on letterhead stationery, signed by a duly authorized officer, employee, or agent of the organization/agency submitting the Proposal that includes the following information: Submit three statements:
□	a. A statement that the Proposal is submitted in response to the Request for Qualifications for Children’s Residential Intensive Services - RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420.
□	b. A statement indicating which individuals, by name, title, address, and phone number, are authorized to negotiate with the County on behalf of the organization or agency.
□	c. A statement certifying that the undersigned, under penalty of perjury, is an agent authorized to submit Proposals on behalf of the organization/agency. The individual acknowledges that he/she has read and understands the RFQ, the contents of the Proposal and the Attachments, and attests to the accuracy of the information submitted therein.

2. Proposal Submission Checklist and Table of Contents
□	Complete and include Attachment A to ensure that all requested items have been included with respective page numbers

3. ChRIS Supplemental Application
□	Complete and include Attachment B to ensure that all supplemental information has been included in your Agency’s Proposal.

	4.Statements of Certification, Reportable Conditions, Disclosures, and Exceptions
	□	Complete and include Attachment C – Statements of Certification in this section of the Proposal; also attach a concise statement of the services proposed.
□	Complete and include Attachment D – Reportable Conditions in this section of the Proposal.
□	If necessary, complete and include Attachment E – Disclosures, Exceptions, and Public Records Act Exemptions to RFQ.

	5. Proposal Narrative/ Description
	Proposal should address, but is not limited to addressing, all items in Section IV, Paragraph C - Program Description and the following items:
□	a. A brief synopsis of the Proposer’s understanding of the County’s needs and how the Proposer plans to meet these needs given the intensive behavioral and emotional needs of some of the youth at this highest level of care. This should provide a broad understanding of the Proposer’s entire Proposal.
□	b. Proposer (also referred to as “Agency” herein) should include copies of:
□	1) Current or Provisional STRTP License for each site proposed
		AND
□	2a) Accreditation Certificate for agency
		OR
□	2b) Accreditation application email response
□	c. A narrative description of the proposed plan to achieve the program objective and requirements addressing the following elements:
□	1) Describe the program plan to provide required services to the target population inclusive of children and youth with high acuity. Outline the service approach in terms of general treatment intensity, frequency, and array of service and expected length of service.
□	2) Describe program services and strategies to be employed to ensure stability and continuity of care for the clients, and the Agency’s ability to be flexible in meeting changing needs of the client.
□	3) Describe how the Agency will collaborate with DBH clinics and programs, County and community agencies, law enforcement, and hospital inpatient and emergency departments to meet these needs.
□	4) Describe how the Agency will treat the intensive behavioral and emotional needs of the youth requiring services at this highest level of care.
□	5) Describe how the Agency will utilize formal and informal supports provided by professionals and non-professionals in the provision of services.
□	6) Describe the process of transitioning to a lower level of treatment and discharge planning.
□	7) Describe the Agency’s experience providing Specialty Mental Health Services to children and youth.
□	8) Describe staffing for the program, including basic level of responsibilities, duties, supervisory structure, level of authority and experience of staff members, and licensure.
□	9) Describe how the Agency will meet all training, licensing, and certification requirements as stipulated in the RFQ.
□	10) State the address of the facility and explain why it is appropriate for this contract (clinical environment, size of facility, provided floor plan with room designations, facility(ies) exterior, etc.).
□	11) Provide some examples of the outcomes expected and utilization of outcome measurement tools (i.e., CANS).
□	12) Total amount requested.
□	13) Estimate the number of unique or unduplicated clients expected to be served and how that number will be generated and/or affected (i.e. community outreach, etc.).
□	14) Estimate the anticipated cost per participant.
□	d. Describe your Agency’s state of readiness to enroll participants, which shall include:
□	1) A Detailed Implementation Plan.
□	2) Your timeline for participant enrollment and hiring staff during the first program year.
□	3) Explanation of any assumptions and/or constraints

	6.Statements of Experience
	Include the following in this section of the Proposal:
□	a. Business name of the Proposer and type of legal entity such as corporation, partnership, etc., as well as all related prior business names and years each was active. If the Proposer is a business entity, the Proposer must be registered with the CA Secretary of State.
□	b. Number of years the Proposer has been in business providing Residential Services to youth under the present business name.
□	c. A statement that the prospective Proposer has a demonstrated capacity to perform the required services.
□	d. List all applicable licenses, permits, and/or certifications presently held, including issuance/effective dates and expiration dates, and indicate ability to obtain any additional licenses, permits, and/or certifications that may be required.
□	1) Provide copies of all applicable licenses, permits, and/or certifications for Agency.
□	2) Provide copies of all applicable licenses, permits, and/or certifications for Clinical Staff.
□	e. A statement that the Proposer has an organization that is adequately staffed and trained to perform the required services or demonstrate the capability for recruiting such staff.
□	f. Experience of principal individuals of the prospective Proposer's present organization in the areas of financial and management responsibility, including names of principal individuals, current position or office and their years of service experience, including capacity, magnitude and type of work.
□	Attach copies of current Resumes for all staff acting as Administrator, Head of Service (HOS), and/or Clinical Director.
□	g. Experience with medical insurance, eligibility verification and process for managing beneficiary insurance status.
□	h. Experience working with Medi-Cal Managed Care Plans, the coordination of Medi-Cal and Medicare, and transitional care planning for beneficiaries who change insurances during the course of care.
□	i. With respect to contracts completed during the last five years which involve similar type projects, for each contract show:
□	1) Date of completion and duration of each contract.
□	2) Type of service.
□	3) Total dollar amount contracted for and amount received.
□	4) Location of area served.
□	5) Name and address of agency with which contracted and agency person administering the contract.
□	6) If none, so state.
□	j. If any contract with any other government entity (including San Bernardino County) was terminated prior to the original termination date during the last five years, for each contract show:
□	1) Date of termination and duration of each contract.
□	2) Type of service.
□	3) Total dollar amount contracted for and amount received.
□	4) Location of area served.
□	5) Name and address of agency with which contracted and agency person administering the contract.
□	6) Reason for termination.
□	7) If none, so state.
□	k. With respect to contracts currently in effect, for each contract show:
□	1) Contract start date and date due for completion.
□	2) Type of service.
□	3) Total contract amount.
□	4) Location of area served.
□	5) Name and address of agency with which the organization is currently contracting and agency person administering the contract.
□	6) If none, so state.
□	l. A statement that the Proposer does not have any commitments or potential commitments which may impact on the Proposer’s assets, lines of credit, guarantor letters, or ability to perform the Contract.

7. Subcontractor Information *Psychiatric services for the purpose of Medication Support is the only service allowed to be subcontracted for ChRIS.

	If Proposer plans to subcontract any portion of the service delivery described in the RFQ, include a written justification for subcontracting.
□	a. Complete and include Attachment F.
□	b. Attach the MOU with original signatures that includes:
□	1) The name of the subcontracting agency.
□	2) The amount (units, minutes, etc.) and types of services to be rendered under this MOU.
□	3) The amount of funding to be paid to the subcontracting agency.
□	4) A description of the subcontracting agency’s role and responsibilities as it relates to this Contract.
□	5) A detailed description of the methods by which the Primary Agency will insure that all subcontracting agencies meet the monitoring requirements associated with funding regulations.
□	6) A budget sheet outlining how the subcontracting agency will spend the allocation.
□	7) Additionally, each MOU shall contain the following requirements:
a)	Subcontractor shall comply with the Right to Monitor and Audit Performance and Records requirements, as referenced in the Performance Article.
b)	Subcontractor agrees to comply with Personnel Article related to the review of applicable Federal databases in accordance with Title 42 of the Code of Federal Regulations, Section 455.436, and applicable professional disciplines’ and licensing and/or certifying boards’ code of ethics and conduct.
c)	Subcontractor shall operate continuously throughout the term of the MOU with all licenses, certifications, and/or permits as are necessary to perform services and comply with Licensing, Certification, and Accreditation Article related to excluded and ineligible status.
d)	Subcontractor agrees to perform work under this MOU in compliance with confidentiality requirements, as referenced in the Confidentiality and Laws and Regulations Articles.
e)	MOU is governed by, and construed in accordance with, all laws and regulations, and all contractual obligations of the Contractor under the primary contract.
f)	Subcontractor’s delegated activities and reporting responsibilities follow the Contractor’s obligations in the primary contract.
g)	Subcontractor shall be knowledgeable in and adhere to primary contractor’s program integrity requirements and compliance program, as referenced in the Laws and Regulations Article.
h)	Subcontractor agrees to not engage in unlawful discriminatory practices, as referenced in the Nondiscrimination Article.
□	c. Any subcontracting agency must be approved in writing by DBH and shall be subject to all applicable provisions of any agreement “awarded” to the Primary Agency as a result of the RFQ process. The Primary Agency will be fully responsible for any performance of a subcontracting agency.
NOTE:	DBH will not reimburse contractor or subcontractor for any expenses rendered by a subcontractor NOT approved in writing by DBH.

	8. Audited Financial Statements
	Such statements shall be the most recent and complete audited financial statements available and shall be for a fiscal period not more than eighteen (18) months old at time of submission (see Attachment G).
□	1a. In accordance with CDSS MPP Section 23-610(L), submit the three most recent and complete annual audited financial statements; the most recent must be completed within the past 18 months.

-OR-

□	1b. If the business has been in existence for less than three years, provide the most recent financial statements. These statements shall be audited by an independent, certified public accountant.
NOTE: □	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).
□	2) In accordance with CDSS MPP Section 23-610(M), submit 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.

9. Insurance
□	Complete and sign Attachment H - Indemnification and Insurance Requirements Affidavit.

10. Complaint and Grievance Procedures
□	A statement that the Proposer will ensure that any complaints made by service recipients will be referred to the County in accordance with the County procedure.

	11. Program Budget
	□	Submit complete Budget Proposal (Schedule A’s and B’s) for each program, for each fiscal year and for each site (if applicable) for cost analysis purposes (see ChRIS CalAim Budget Schedule and Attachment J – Cover Page). Electronic version will be emailed to each agency upon request, as appropriate.
□	Proposer’s budget should be consistent with the cost structure of the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards as well as other budget guidelines applicable to the type of organization.

NOTE: Failure to submit Budget sheets for each program, for each year and for each proposed site as required WILL result in the elimination of the entire submitted Proposal; it will not move forward in the evaluation process.

12. References
□	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 RFQ. Provide Contact Name, Address, Phone Number, and dates Services were provided. (Attachment K).

13. Local Vendor Preference
□	Self-Certification that Vendor meets all requirements for eligibility to Local Vendor Preference. (Attachment M, if applicable)

14. Federal Contracting Provisions
□	Certification that no federal funds have been used for undue influence or Lobbying.(Attachment Q)

NOTE: PLEASE DO NOT INCLUDE COPIES OF SOCIAL SECURITY CARDS OR NUMBERS, AND/OR COPIES OF DRIVER’S LICENSES OR NUMBERS, OR HOME ADDRESSES UNLESS IT IS THE FACILITY ADDRESS.

By signing below, the individual acknowledges that he/she has the authority to bind the Proposer to the terms of the Proposal. All costs for developing and completing the Proposal and supporting documents are the responsibility of the applicant or agency/organization and will not be chargeable to the County of San Bernardino. The individual further acknowledges that he/she has read and understands the RFQ, the contents of the Proposal and the Attachments, and attests to the accuracy of the information submitted therein.

Signature (Authorized Signer)

Date

Print/Type Name

Agency

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

ATTACHMENT B

ChRIS SUPPLEMENTAL APPLICATION

RFQ 25-99 (ROUND 1)

In order to qualify for the provision of this service, the facility must meet the following criteria:

*Please check all that apply and include a copy of the license or certification noted.

1.	☐ a) Currently Licensed as a Short Term Residential Therapeutic Program (STRTP)
		OR
	☐ b) Currently have a Provisional License as a STRTP
		AND
2.	☐ Nationally accredited by one of the CCR approved accreditation agencies:

☐ a) Council of Accreditation (COA) ☐ b) Commission on Accreditation of Rehabilitation Facilities ☐ c) The Joint Commission ☐ d) Agency has applied for Accreditation and is pending a Survey Date (include written confirmation from accreditation agency in response.

3.	☐ Agrees to provide San Bernardino County CFS and Probation first opportunity for placement for any vacancies within the STRTP,
		AND
4.	☐ Physically located in California

Please answer the following questions completely. If a question does not apply to you, please indicate with Not Applicable (N/A).

5.	Does the applicant or agency/organization have experience providing Treatment Services for individuals with:
	Mental Illness	☐ Yes ☐ No
	Substance Abuse	☐ Yes ☐ No

6.	Please indicate whether applicant or agency/organization would like to participate in the Children’s Crisis Continuum Program.
	☐ Yes ☐ No

7. Describe the trauma-informed therapy model(s) that will be utilized in your clinical program.

8 Having a Licensed Head of Service (HOS) or a Licensed Clinical Supervisor is a requirement for this program. Describe the steps that the agency has taken to ensure that they have licensed staff to provide services. Or, include steps taken in the current effort to recruit such staff.

9. State the physical address of the STRTP facility(ies) and explain why it is appropriate for this service (Clinical appropriateness, facility layout, facility size, etc.). Include a floorplan of the facility with specific information about facility layout, including room designations for individual clinical work, group therapy, and private Child and Family Team meetings with technical provisions for remote interface with other CFT members.

10. Describe the facilities exterior (front and rear yard); include what the agency has done to make these areas comfortable and welcoming to clients; a home-like atmosphere.

11. Transporting clients for necessary program services, school, etc. will be required by your agency. Describe the Agency’s readiness to transport clients; include make, model, and year of agency vehicles and include information on any accidents with agency vehicles in the last three (3) years.

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

ATTACHMENT C

STATEMENTS OF CERTIFICATION

Statement

Agree (Initial)

Agree but with exceptions

(initial and explain in E- Exceptions)

Services will be provided as described in the Request for Proposals, beginning on one of the following: January 1, 2027; date of execution; or date of youth placement; and continuing through June 30, 2031.

Gender: Male Both Programs Age Range:

Child/Youth Referrals from:

Children and Family Services (CFS) Juvenile Probation Department (Probation) Both

The offer made in the Proposal is firm and binding for nine (9) months from the date the Proposal is opened and recorded.

All declarations in the Proposal and any attachments are true and shall constitute a warranty, the falsity of which shall entitle the County to pursue any remedy by law.

All aspects of the Proposal, including cost, have been determined independently, without consultation with any other prospective Proposer or competitor for the purpose of restricting competition.

Proposer agrees that all aspects of the RFQ and the Proposal submitted shall be binding if the Proposal is selected and a Contract is awarded.

Proposer will provide the County with any other information that the County determines is necessary for an accurate determination of the Proposer’s ability to perform services as proposed.

If selected, the Proposer agrees to comply with all applicable rules, laws, and regulations.

If selected, the Proposer agrees to submit verification of exclusion checks; in addition, verification of necessary licensure would be required prior to contract execution.

Proposer agrees to the right of the County, State and Federal governments to audit the Proposer’s financial and other records.

10.

If applicable and selected, the Proposer agrees to be Medi-Cal certified in accordance with State and San Bernardino County Department of Behavioral Health requirements.

11.

If selected, the Proposer agrees to comply with the County’s Grievance and Complaint Procedure.

12.

The RFQ has been reviewed in its entirety and Proposer has no exceptions to any requirements, terms, or conditions, except as noted in Attachment E.

Signature (Authorized Signer)

Date

Print/Type Name

Agency

ATTACHMENT D

REPORTABLE CONDITIONS

Statement

None to Disclose (Initial)

Disclosures

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

Former County Officials

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

Similar Contracts

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

Terminated Contracts

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

Current Contracts

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

Controlling Interest

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

Financial Interest

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

Pending Litigation

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?

Convictions or Adverse Court Rulings

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?

Tax Delinquencies

Is the agency/organization currently delinquent in paying its State/Federal payroll taxes?

10.

Debarment or Suspension

Proposer certifies that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in transactions with federal departments or agencies. Refer to Attachment P.

Signature (Authorized Signer)

Date

Print/Type Name

Agency

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

ATTACHMENT E

DISCLOSURES, EXCEPTIONS, AND PUBLIC RECORDS ACT EXEMPTIONS TO RFQ

DISCLOSURES

Proposer reports the following:

EXCEPTIONS

Proposer has reviewed the RFQ 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 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.

Signature (Authorized Signer)

Date

Print/Type Name

Agency

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

ATTACHMENT F

SUBCONTRACTOR INFORMATION

* Psychiatric services for the purpose of Medication Support is the only subcontracted service allowed with ChRIS contracts.

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. Program Requirements for Children’s Residential Intensive Services (ChRIS), RFQ DBH #25-99/ePro Bid # DBHE26-ADMN-6420.

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

Signature: Date:

Print/Type Name: Title:

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

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 RFQ:

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.

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

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 Qualifications (RFQ). 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 RFQ 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 Article V, 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 RFQ with your email question(s)).

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

ATTACHMENT I

Reserved

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

ATTACHMENT J

BUDGETS

Use this page as a cover sheet when submitting budgets.

Submit complete Budgets (Schedule A’s and B’s) for each program, for each fiscal year and for each site (if applicable) for cost analysis purposes (see ChRIS CalAim Budget Schedule).

NOTE: Failure to submit the Budget sheets for each program, for each year and for each proposed site as required WILL result in the elimination of the entire submitted Proposal; it will not move forward in the evaluation process.

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

ATTACHMENT K

REFERENCES

Agency Name And Address

Contact Name and Title

Email Address

Phone 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 RFQ. Provide Contact Name, Address, Phone Number, and dates Services were provided.

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

Signature (Authorized Signer)

Date

Print/Type Name

Agency

Request for Qualifications	San Bernardino County Department of Behavioral Health
Title: Children’s Residential Intensive Services	RFQ DBH # 25-99/ePro #DBHE26-ADMN-6420

ATTACHMENT L

BUSINESS ASSOCIATE AGREEMENT

This Business Associate Agreement (Agreement) supplements and is made a part of the contract (Contract) by and between the San Bernardino County Department of Behavioral Health (hereinafter Covered Entity) and [INSERT CONTRACTOR NAME HERE] (hereinafter Business Associate). This Agreement is effective as of the effective date of the Contract.

RECITALS

WHEREAS, Covered Entity (CE) wishes to disclose certain information to Business Associate (BA) pursuant to the terms of the Contract, which may include Protected Health Information (PHI); and

WHEREAS, CE and BA intend to protect the privacy and provide for the security of the PHI disclosed to BA pursuant to the Contract in compliance with the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA), the Health Information Technology for Economic and Clinical Health Act, Public Law 111-005 (HITECH Act), their implementing regulations, and other applicable laws; and

WHEREAS, The Privacy Rule and the Security Rule require CE to enter into a contract containing specific requirements with BA prior to the disclosure of PHI, as set forth in, but not limited to, Title 45, sections 164.314, subdivision (a), 164.502, subdivision (e), and 164.504, subdivision (e) of the Code of Federal Regulations (C.F.R.) and contained in this Agreement; and

WHEREAS, Pursuant to HIPAA and the HITECH Act, BA shall fulfill the responsibilities of this Agreement by being in compliance with the applicable provisions of the HIPAA Standards for Privacy of PHI set forth at 45 C.F.R. sections 164.308 (Administrative Safeguards), 164.310 (Physical Safeguards), 164.312 (Technical Safeguards), 164.316 (Policies and Procedures and Documentation Requirements), and, 164.400, et seq. and 42 United States Code (U.S.C.) section 17932 (Breach Notification Rule), in the same manner as they apply to a CE under HIPAA;

NOW THEREFORE, in consideration of the mutual promises below and the exchange of information pursuant to this Agreement, the parties agree as follows:

I. Definitions Unless otherwise specified herein, capitalized terms used in this Agreement shall have the same meanings as given in the Privacy Rule, the Security Rule, the Breach Notification Rule, and HITECH Act, as and when amended from time to time.

a. Breach shall have the same meaning given to such term under the HIPAA Regulations [45 C.F.R. §164.402] and the HITECH Act [42 U.S.C. §§17921 et seq.], and as further described in California Civil Code section 1798.82.

b. Business Associate (BA) shall have the same meaning given to such term under the Privacy Rule, the Security Rule, and the HITECH Act, including but not limited to 42 U.S.C. section 17921 and 45 C.F.R. section 160.103.

c. Covered Entity (CE) shall have the same meaning given to such term as under the Privacy Rule and Security Rule, including, but not limited to 45 C.F.R. section 160.103.

d. Designated Record Set shall have the same meaning given to such term under 45 C.F.R. section 164.501.

e. Electronic Protected Health Information (ePHI) means PHI that is maintained in or transmitted by electronic media as defined in the Security Rule, 45 C.F.R. section 164.103.

f. Individual shall have the same meaning given to such term under 45 C.F.R. section 160.103.

g. Privacy Rule means the regulations promulgated under HIPAA by the United States Department of Health and Human Services (HHS) to protect the privacy of Protected Health Information, including, but not limited to, 45 C.F.R. Parts 160 and 164, subparts A and E.

h. Protected Health Information (PHI) shall have the same meaning given to such term under 45 C.F.R. section 160.103, limited to the information received from, or created or received by Business Associate from or on behalf of, CE.

i. Security Rule means the regulations promulgated under HIPAA by HHS to protect the security of ePHI, including, but not limited to, 45 C.F.R. Part 160 and 45 C.F.R. Part 164, subparts A and C.

j. Unsecured PHI shall have the same meaning given to such term under the HITECH Act and any guidance issued pursuant to such Act, including, but not limited to 42 U.S.C. section 17932, subdivision (h).

II. Obligations and Activities of BA

a. Permitted Uses and Disclosures BA may disclose PHI: (i) for the proper management and administration of BA; (ii) to carry out the legal responsibilities of BA; (iii) for purposes of Treatment, Payment and Operations (TPO); (iv) as required by law; or (v) for Data Aggregation purposes for the Health Care Operations of CE. Prior to making any other disclosures, BA must obtain a written authorization from the Individual.

If BA discloses PHI to a third party, BA must obtain, prior to making any such disclosure, (i) reasonable written assurances from such third party that such PHI will be held confidential as provided pursuant to this Agreement and only disclosed as required by law or for the purposes for which it was disclosed to such third party, and (ii) a written agreement from such third party to immediately notify BA of any breaches of confidentiality of the PHI, to the extent it has obtained knowledge of such breach. [42 U.S.C. section 17932; 45 C.F.R. sections 164.504(e)(2)(i), 164.504(e)(2)(i)(B), 164.504(e)(2)(ii)(A) and 164.504(e)(4)(ii)]

b. Prohibited Uses and Disclosures

i. BA shall not use, access or further disclose PHI other than as permitted or required by this Agreement and as specified in the attached Contract or as required by law. Further, BA shall not use PHI in any manner that would constitute a violation of the Privacy Rule or the HITECH Act. BA shall disclose to its employees, subcontractors, agents, or other third parties, and request from CE, only the minimum PHI necessary to perform or fulfill a specific function required or permitted hereunder.

ii. BA shall not use or disclose PHI for fundraising or marketing purposes.

iii. BA shall not disclose PHI to a health plan for payment or health care operations purposes if the patient has requested this special restriction, and has paid out of pocket in full for the health care item or service to which the PHI solely relates. (42 U.S.C. section 17935(a) and 45 C.F.R. section 164.522(a)(1)(i)(A).)

iv. BA shall not directly or indirectly receive remuneration in exchange for PHI, except with the prior written consent of CE and as permitted by the HITECH Act (42 U.S.C. section 17935(d)(2); and 45 C.F.R. section 164.508); however, this prohibition shall not affect payment by CE to BA for services provided pursuant to this Agreement.

c. Appropriate Safeguards

i. BA shall implement appropriate safeguards to prevent the unauthorized use or disclosure of PHI, including, but not limited to, administrative, physical and technical safeguards that reasonably protect the confidentiality, integrity and availability of the PHI BA creates, receives, maintains, or transmits on behalf of the CE, in accordance with 45 C.F.R. sections 164.308, 164.310, 164.312 and 164.316. [45 C.F.R. sections 164.504(e)(2)(ii)(b) and 164.308(b).]

ii. In accordance with 45 C.F.R. section 164.316, BA shall maintain reasonable and appropriate written policies and procedures for its privacy and security program in order to comply with the standards, implementation specifications, or any other requirements of the Privacy Rule and applicable provisions of the Security Rule.

iii. BA shall provide appropriate training for its workforce on the requirements of the Privacy Rule and Security Rule as those regulations affect the proper handling, use confidentiality and disclosure of the CE’s PHI.

Such training will include specific guidance relating to sanctions against workforce members who fail to comply with privacy and security policies and procedures and the obligations of the BA under this Agreement.

d. Subcontractors BA shall enter into written agreements with agents and subcontractors to whom BA provides CE’s PHI that impose the same restrictions and conditions on such agents and subcontractors that apply to BA with respect to such PHI, and that require compliance with all appropriate safeguards as found in this Agreement.

e. Reporting of Improper Access, Use or Disclosure or Breach Every suspected and actual Breach shall be reported immediately, but no later than one (1) business day upon discovery, to CE’s Office of Compliance, consistent with the regulations under HITECH Act. Upon discovery of a Breach or suspected Breach, BA shall complete the following actions:

i. Provide CE’s Office of Compliance with the following information to include but not limited to:

1. Date the Breach or suspected Breach occurred;

2. Date the Breach or suspected Breach was discovered;

3. Number of staff, employees, subcontractors, agents or other third parties and the names and titles of each person allegedly involved;

4. Number of potentially affected Individual(s) with contact information; and

5. Description of how the Breach or suspected Breach allegedly occurred.

ii. Conduct and document a risk assessment by investigating without unreasonable delay and in no case later than five (5) calendar days of discovery of the Breach or suspected Breach to determine the following:

1. The nature and extent of the PHI involved, including the types of identifiers and likelihood of re-identification;

2. The unauthorized person who had access to the PHI;

3. Whether the PHI was actually acquired or viewed; and

4. The extent to which the risk to PHI has been mitigated.

iii. Provide a completed risk assessment and investigation documentation to CE’s Office of Compliance within ten (10) calendar days of discovery of the Breach or suspected Breach with a determination as to whether a Breach has occurred. At the discretion of CE, additional information may be requested.

1. If BA and CE agree that a Breach has not occurred, notification to Individual(s) is not required.

2. If a Breach has occurred, notification to the Individual(s) is required and BA must provide CE with affected Individual(s) name and contact information so that CE can provide notification.

iv. Make available to CE and governing State and Federal agencies in a time and manner designated by CE or governing State and Federal agencies, any policies, procedures, internal practices and records relating to a Breach or suspected Breach for the purposes of audit or should the CE reserve the right to conduct its own investigation and analysis.

f. Access to PHI To the extent BA maintains a Designated Record Set on behalf of CE, BA shall make PHI maintained by BA or its agents or subcontractors in Designated Record Sets available to CE for inspection and copying within ten (10) days of a request by CE to enable CE to fulfill its obligations under the Privacy Rule. If BA maintains ePHI, BA shall provide such information in electronic format to enable CE to fulfill its obligations under the HITECH Act. If BA receives a request from an Individual for access to PHI, BA shall immediately forward such request to CE.

g. Amendment of PHI If BA maintains a Designated Record Set on behalf of the CE, BA shall make any amendment(s) to PHI in a Designated Record Set that the CE directs or agrees to, pursuant to 45 C.F.R. section 164.526, or take other measures as necessary to satisfy CE’s obligations under 45 C.F.R. section 164.526, in the time and manner designated by the CE.

h. Access to Records BA shall make internal practices, books, and records, including policies and procedures, relating to the use, access and disclosure of PHI received from, or created or received by BA on behalf of, CE available to the Secretary of HHS, in a time and manner designated by the Secretary, for purposes of the Secretary determining CE’s compliance with the Privacy Rule and Security Rule and patient confidentiality regulations. Any documentation provided to the Secretary shall also be provided to the CE upon request.

i. Accounting for Disclosures BA, its agents and subcontractors shall document disclosures of PHI and information related to such disclosures as required by HIPAA. This requirement does not apply to disclosures made for purposes of TPO. BA shall provide an accounting of disclosures to CE or an Individual, in the time and manner designated by the CE. BA agrees to implement a process that allows for an accounting to be collected and maintained by BA and its agents or subcontractors for at least six (6) years prior to the request. At a minimum, the information collected and maintained shall include: (i) the date of disclosure; (ii) the name of the entity or person who received PHI and, if known, the address of the entity or person; (iii) a brief description of PHI disclosed; and (iv) a brief statement of purpose of the disclosure that reasonably informs the individual of the basis for the disclosure, or a copy of the Individual’s authorization, or a copy of the written request for disclosure.

j. Termination CE may immediately terminate this agreement, and any related agreements, if CE determines that BA has breached a material term of this agreement. CE may, at its sole discretion, provide BA an opportunity to cure the breach or end the violation within the time specified by the CE.

k. Return of PHI Upon termination of this Agreement, BA shall return all PHI required to be retained by the BA or its subcontractors, employees or agents on behalf of the CE. In the event the BA determines that returning the PHI is not feasible, the BA shall provide the CE with written notification of the conditions that make return not feasible. Additionally, the BA must follow established policies and procedures to ensure PHI is safeguarded and disposed of adequately in accordance with 45 C.F.R. section 164.310, and must submit to the CE a certification of destruction of PHI. For destruction of ePHI, the National Institute of Standards and Technology (NIST) guidelines must be followed. BA further agrees to extend any and all protections, limitations, and restrictions contained in this Agreement, to any PHI retained by BA or its subcontractors, employees or agents after the termination of this Agreement, and to limit any further use, access or disclosures.

l. Breach by the CE Pursuant to 42 U.S.C. section 17934, subdivision (b), if the BA is aware of any activity or practice by the CE that constitutes a material Breach or violation of the CE’s obligations under this Agreement, the BA must take reasonable steps to address the Breach and/or end eliminate the continued violation, if the BA has the capability of mitigating said violation. If the BA is unsuccessful in eliminating the violation and the CE continues with non-compliant activity, the BA must terminate the Agreement (if feasible) and report the violation to the Secretary of HHS.

m. Mitigation BA shall have procedures in place to mitigate, to the extent practicable, any harmful effect that is known to BA of a use, access or disclosure of PHI by BA, its agents or subcontractors in violation of the requirements of this Agreement.

n. Costs Associated to Breach BA shall be responsible for reasonable costs associated with a Breach. Costs shall be based upon the required notification type as deemed appropriate and necessary by the CE and shall not be reimbursable under the Agreement at any time. CE shall determine the method to invoice the BA for said costs. Costs shall incur at the current rates and may include, but are not limited to the following:

· Postage;

· Alternative means of notice;

· Media notification; and

· Credit monitoring services.

o. Direct Liability BA may be held directly liable under HIPAA for impermissible uses and disclosures of PHI; failure to provide breach notification to CE; failure to provide access to a copy of ePHI to CE or individual; failure to disclose PHI to the Secretary of HHS when investigating BA’s compliance with HIPAA; failure to provide an accounting of disclosures; and, failure to enter into a business associate agreement with subcontractors.

p. Indemnification BA agrees to indemnify, defend and hold harmless CE and its authorized officers, employees, agents and volunteers from any and all claims, actions, losses, damages, penalties, injuries, costs and expenses (including costs for reasonable attorney fees) that are caused by or result from the acts or omissions of BA, its officers, employees, agents and subcontractors, with respect to the use, access, maintenance or disclosure of CE’s PHI, including without limitation, any Breach of PHI or any expenses incurred by CE in providing required Breach notifications.

q. Judicial or Administrative Proceedings CE may terminate the Contract, effective immediately, if (i) BA is named as a defendant in a criminal proceeding for a violation of HIPAA, the HITECH Act, the Privacy Rule, Security Rule or other security or privacy laws or (ii) a finding or stipulation is made in any administrative or civil proceeding in which the BA has been joined that the BA has violated any standard or requirement of HIPAA, the HITECH Act, the Privacy Rule, Security Rule or other security or privacy laws.

r. Insurance In addition to any general and/or professional liability insurance coverage required of BA under the Contract for services, BA shall provide appropriate liability insurance coverage during the term of this Agreement to cover any and all claims, causes of action, and demands whatsoever made for loss, damage, or injury to any person arising from the breach of the security, privacy, or confidentiality obligations of BA, its agents or employees, under this Agreement and under HIPAA 45 C.F.R. Parts 160 and 164, Subparts A and E.

s. Assistance in Litigation or Administrative Proceedings BA shall make itself, and any subcontractors, employees, or agents assisting BA in the performance of its obligations under the Agreement, available to CE, at no cost to CE, to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being commenced against CE, its directors, officers, or employees based upon a claimed violation of HIPAA, the HITECH Act, the Privacy Rule, the Security Rule, or other laws relating to security and privacy, except where BA or its subcontractor, employee or agent is a named adverse party.

III. Obligations of CE

a. CE shall notify BA of any of the following, to the extent that such may affect BA’s use, access, maintenance or disclosure of PHI:

i. Any limitation(s) in CE’s notice of privacy practices in accordance with 45 C.F.R. section 164.520.

ii. Any changes in, or revocation of, permission by an individual to use, access or disclose PHI.

iii. Any restriction to the use, access or disclosure of PHI that CE has agreed to in accordance with 45 C.F.R. section 164.522.

IV. General Provisions

a. Remedies BA agrees that CE shall be entitled to seek immediate injunctive relief as well as to exercise all other rights and remedies which CE may have at law or in equity in the event of an unauthorized use, access or disclosure of PHI by BA or any agent or subcontractor of BA that received PHI from BA.

b. Ownership The PHI shall be and remain the property of the CE. BA agrees that it acquires no title or rights to the PHI.

c. Regulatory References A reference in this Agreement to a section in the Privacy Rule and Security Rule and patient confidentiality regulations means the section as in effect or as amended.

d. No Third-Party Beneficiaries Nothing express or implied in the Contract or this Agreement is intended to confer, nor shall anything herein confer, upon any person other than CE, BA and their respective successors or assigns, any rights, remedies, obligations or liabilities whatsoever.

e. Amendment The parties acknowledge that state and federal laws related to privacy and security of PHI are rapidly evolving and that amendment of the Contract or this Agreement may be required to ensure compliance with such developments. The parties shall negotiate in good faith to amend this Agreement when and as necessary to comply with applicable laws.

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File details come from the government source that posted it. Updated Oct 5, 2026.