Atch H - IHS IEE Representation Form.pdf
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- Solicitation number
- RFP-22-PHX-08
About this file
This document contains a request for proposal for family practice physician services at the Hopi Health Care Center in Polacca, Arizona. The solicitation is set aside for Native American firms under the Buy Indian Act of 1910. The Indian Health Service is seeking a firm fixed price contract for non-personal professional family practice physician services at the Hopi Health Care Center located in Polacca, Arizona. The period of performance is an estimated base period from July 15, 2022 through July 14, 2023 with four option years. There are no opportunities for joint ventures, teaming arrangements, or subcontracting. Proposals are due electronically by email no later than the date specified in Attachment F. The contractor must be registered in the System for Award Management prior to award. The solicitation incorporates provisions and clauses from FAC 2022-06 effective May 1, 2022. The North American Industry Classification System code is 621111 for offices of physicians and the size standard is $12 million.
The request for proposal includes rate schedules, statements of work, forms for contract services and representations. Offerors must meet the definition of an Indian Economic Enterprise and be 51% owned by a federally recognized tribal entity. The government will award a firm fixed price contract to the responsible and responsive offeror whose proposal provides the best value based on price and other factors.
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Text version
DEPARTMENT OF HEALTH & HUMAN SERVICES
Indian Health Service
Office of Management Services Division of Acquisition Policy (DAP)
5600 Fishers Lane Rockville, MD 20857
INDIAN HEALTH SERVICE
BUY INDIAN ACT
INDIAN ECONOMIC ENTERPRISE
REPRESENTATION FORM
SOLICITATION/SOURCES SOUGHT/RFI #: _________________________________________________
PROJECT TITLE: ________________________________________________________
DATE: ___________________________________________________________________
In accordance with 25 U.S.C. 47 the Buy Indian Act, the signature below constitutes self-certification that the Offeror meets the definition of an “Indian Economic Enterprise” (HHSAR 326.601) in response to this Sources Sought Notice, Request for Information (RFI) or Solicitation and resultant contract.
The enterprise must meet the definition of “Indian Economic Enterprise” throughout the following time periods:
(1) At the time an offer is made in response to this solicitation;
(2) At the time of contract award; and
(3) During the full term of the contract performance period. At any point during these periods, if the Contractor no longer meets the eligibility requirements, the contractor must provide immediate written notification to the Contracting Officer.
Individual Contracting Officers may require documentation of eligibility before awarding a set-aside or sole source contracts under the Buy Indian Act and awards may be subject to protest if the eligibility of the successful Offeror is in question. In addition to the self-certification requirements, successful Offerors must also be registered with the System of Award Management (SAM).
Any false or misleading information submitted by an enterprise when submitting an offer in consideration of an award set-aside under the authority of the Buy Indian Act is a violation of the law and punishable under 18 U.S.C. 1001.
False claims submitted as part of contract performance are subject to the penalties enumerated in 31 U.S.C. 3729 to 3731 and 18 U.S.C. 287.
REPRESENTATION
The Offeror represents as part of its offer that it does _____, does not _____ meet the definition of an “Indian Economic Enterprise” with “Indian Ownership” under the authority of the Buy Indian Act.
Name of the 51% owner of IEE Firm
Certifying Signature
Print Name
Name of Federally Recognized Tribal Entity
Business Name
DUNS Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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