Appendix L.docx

APPENDIX L

County of Santa Clara – Behavioral Health Services Department RFSQ-BHS-FY23-0225: Behavioral Health Treatment Facility Continuum of Care

OFFEROR’S FEIN AND LICENSE INFORMATION FORM

All information requested in the Form shall be furnished by the Offeror and shall be submitted with the response to this Request for Statement of Qualifications (RFSQ). Information shall be complete, accurate, and in the form requested. Any omissions, inaccuracies, or misstatements may be cause for the rejection of a response in whole or part.

1. Legal name and Federal Employer Identification Number (FEIN) of Offeror exactly as it appears on the W9 (include DBA, if applicable): ___________________________________________________________

2. What is your business name under the California Secretary of State: ___________________________________________________________

3. Do you have a license with the Medical Board of California?

☐ Yes License Type: _________________________ License Number: _______________________ ☐ No, I am an individual without a license with the Medical Board of California ☐ Not applicable (contracting with an organization)

4. Do you have a license with the Board of Behavioral Sciences?

☐ Yes License Number: ________________________ ☐ No, I am an individual without a license with the Board of Behavioral Sciences ☐ Not applicable (contracting with an organization)

5. Are you a Care Facility Provider (licensed through the California Department of Social Services)?

☐ Yes Facility Number (must contain 9 digits): ________________________ Licensed Bed Count: ________________________________________ ☐ No

6. Are you a Substance Use Treatment Facility Provider (licensed or certified by California Department of Health Care Services)?

☐ Yes License/Certification Type: ________________________________ License Status: _________________________________________ Licensed Bed Count: _____________________________________ ☐ No

7. Are you a Healthcare Facility Provider (licensed through the California Department of Public Health)?

☐ Yes License Number: ___________________________ License Facility ID: __________________________ License Status: ____________________________ Licensed Bed Count: ________________________ ☐ No

The undersigned hereby declares under penalty of perjury that all statements, answers and representations made in this form are true and accurate.

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Last Reviewed and Approved by Counsel on 12/04/2024