Appendix A.docx

Santa Clara County –Behavioral Health Services Department RFP-BHS-FYXX-XXXX: RFP Title

APPENDIX A

County of Santa Clara – Behavioral Health Services Department RFSQ-BHS-FY23-0108: Substance Use Residential Withdrawal Management Services

COVER SHEET

Agency or Name:

Mailing Address:

City, State, and Zip Code:

Telephone Number: Fax Number:

Name & Title of Contact Person:

Telephone Number: Fax Number:

Email Address:

1. Do you wish to claim LOCAL PREFERENCE status? YES ☐ NO ☐

If yes, please refer to Appendix E, “Declaration Submittal Form” and complete the section entitled “Declaration of Local Business” (mark applicable check boxes under Declaration of Local Business section). If you fail to submit the proper information with your response, you will be denied consideration for local preference. The information cannot be submitted at a later date.

2. Select geographic locations within Santa Clara County (including clinic locations) where services would be provided:

☐ Southern ☐ Central ☐ Eastern ☐ Northern

3. Select Department of Health Care Services (DHCS) Certification status[footnoteRef:1]. [1: Refer to pages 5-6 of the RFSQ for more information relating to DHCS Facility Certification Status and tier system for contract negotiations upon qualification. Offerors who select “Active DHCS Licensure” or “Pending DHCS Licensure” shall provide any form of DHCS official documentation or correspondence as supplemental information following this form.]

☐ Active DHCS Licensure ☐ Pending DHCS Licensure ☐ Intent to begin DHCS Licensure process ☐ No intention to begin Licensure process

4. The County anticipates an estimated number of 15-20 additional beds are required for clients. Indicate a summary of the packet response below:

Initials

Substance Use Residential Withdrawal Management Services

· Years of Experience:

· Total Number of Beds proposing:

· Daily rate proposed per bed:

5. Offeror understands, agrees, and warrants:

A. That Offeror has carefully read and fully understands the information that was provided by the County to serve as the basis for submission of this response;

B. That Offeror has the capability to successfully undertake and complete the responsibilities and obligations of the response being submitted;

C. That all information contained in the response is true and correct to the best of Offeror’s knowledge;

D. That Offeror signed a non-collusion affidavit herewith attached with the response;

E. That Offeror did not receive unauthorized information from any County staff or consultant during the response period except as provided for in the RFSQ packet, addenda thereto, or the pre-proposal conference;

F. That by submission of this response, the Offeror acknowledges that the County has the right to make any inquiry it deems appropriate to substantiate or supplement information supplied by the Offeror, and Offeror hereby grants the County permission to make said inquiries, and to provide any and all requested documentation in a timely manner; and

G. That Offeror offers and agrees to furnish the goods and services specified in the response.

No response shall be accepted which has not been signed in ink in the appropriate space below.

I hereby certify that I am an authorized representative of the above agency and to the best of my knowledge and belief that:

The data in this response is true and accurate; the Offeror has investigated all aspects of the eRFP; the Offeror is aware of the applicable facts pertaining to the RFSQ process, procedures, and requirements; the Offeror has read and understands the RFSQ; the Offeror has the capability to successfully undertake and complete the responsibilities and obligations of their response being submitted; the agency will be able to meet all of the minimum response requirements as specified in this RFSQ; and the Offeror will comply with the necessary certifications and assurances if a contract is awarded.

This shall constitute a warranty, the falsity of which entitles the County to pursue any remedy authorized by law, including the right to declare any contract made as a result thereof to be void.

By signing below, the submission of a response shall be deemed a representation and certification by the Offeror that it has investigated all aspects of the RFSQ; that it is aware of the applicable facts pertaining to the RFSQ process, its procedures and requirements; and that it has read and understands the RFSQ. No request for modification of the response shall be considered after its submission on the grounds that the Offeror was not fully informed as to any fact or condition.

1. If Offeror is an INDIVIDUAL, sign here:

Date Offeror’s Signature

Offeror's Typed Name and Title

2. If Offeror is a CORPORATION, the duly authorized officer(s) shall sign here:

The undersigned certify that they are respectively:

and

Title

Title of the CORPORATION named below; that they are designated to sign this response form by resolution or by the Secretary of State's certificate of authorization, for and on behalf of the below named CORPORATION, and that they are authorized to execute same for and on behalf of said CORPORATION.

Corporation Name (type or print)

By:

Date:

Title:

By:

Date:

Title: