Attachment 3 Sample Work Order Final.docx

Attachment 3 Work Order Contract [CSTAT# - WOC#]

STATE OF OREGON

WORK ORDER CONTRACT

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This Work Order Contract (“WOC”) is executed as evidenced in Section 6. “Signatures” below, against Price Agreement # [CSTAT NUMBER], by and between Oregon Health Authority acting by and through its Behavioral Health Division (“BHD”) and [LEGAL ENTITY] (“Provider”). The terms of this WOC along with all terms and conditions of the Price Agreement constitute the entire Contract.

1. WOC TERM. This WOC is effective upon the date signed by both parties and all applicable approvals have been obtained (“WOC Effective Date”). The WOC expires on [MM/DD/YYYY]

2. COMPENSATION: BHD will make payment to the Provider for accepted and approved Work or Services of Provider named herein, under this WOC according to the following:

The maximum not to exceed compensation payable to Provider under this WOC is $[NTE AMOUNT]. BHD will pay $[HOURLY RATE] per hour, as set forth in the Price Agreement # [CSTAT NUMBER] for a maximum of [NUMBER] Forensic Evaluation services performed by Provider under this WOC.

3. AUTHORIZED REPRESENTATIVES: Defined as the individuals with express authority to bind their organization, under the Price Agreement or this WOC, by affixing their signature in Section 6. “Signatures.”.

4. STATEMENT OF WORK.

Provider shall provide Forensic Evaluations (“Services”), as identified in the Statement of Work in Price Agreement # [CSTAT NUMBER]. The Provider shall conduct no more than [NUMBER] Forensic Evaluation(s) during the term of this WOC. Each Forensic Evaluation shall be initiated by request from BHD to Provider for each Individual and location identified in BHD’s request to Provider.

5. Certification. Without limiting the generality of the foregoing, by signature on this Contract, the undersigned hereby certifies under penalty of perjury that:

a. Provider is in compliance with all insurance requirements in Exhibit B of the Price Agreement and notwithstanding any provision to the contrary, Provider shall deliver to the BHD Agreement Administrator (named on the face page of the Price Agreement) the required Certificate(s) of Insurance within 30 days of execution of this Contract. By certifying compliance with all insurance as required by this Contract, Provider acknowledges it may be found in breach of the Contract for failure to obtain required insurance. Provider may also be in breach of the Contract for failure to provide Certificate(s) of Insurance as required and to maintain required coverage for the duration of the Contract.

b. Provider acknowledges that the Oregon False Claims Act, ORS 180.750 to 180.785, applies to any “claim” (as defined by ORS 180.750) that is made by (or caused by) the Provider and that pertains to this Contract or to the project for which the Contract work is being performed. Provider certifies that no claim described in the previous sentence is or will be a “false claim” (as defined by ORS 180.750) or an act prohibited by ORS 180.755. Provider further acknowledges that in addition to the remedies under this Contract, if it makes (or causes to be made) a false claim or performs (or causes to be performed) an act prohibited under the Oregon False Claims Act, the Oregon Attorney General may enforce the liabilities and penalties provided by the Oregon False Claims Act against the Provider.

c. The undersigned is authorized to act on behalf of Provider and that Provider has complied with the tax laws of the State of Oregon and the applicable tax laws of any political subdivision of Oregon. Provider shall, throughout the duration of this Contract and any extensions, comply with all tax laws of this state and all applicable tax laws of any political subdivision of Oregon. For the purposes of this Section, “tax laws” includes: (i) All tax laws of Oregon, including but not limited to ORS 305.620 and ORS chapters 316, 317, and 318; (ii) Any tax provisions imposed by a political subdivision of Oregon that applied to Provider, to Provider’s property, operations, receipts, or income, or to Provider’s performance of or compensation for any work performed by Provider; (iii) Any tax provisions imposed by a political subdivision of Oregon that applied to Provider, or to goods, services, or property, whether tangible or intangible, provided by Provider; and (iv) Any rules, regulations, charter provisions, or ordinances that implemented or enforced any of the foregoing tax laws or provisions.

The Provider acknowledges that the Oregon Department of Administrative Services will report this Contract to the Oregon Department of Revenue (ODOR). The ODOR may take any and all actions permitted by law relative to the collection of taxes due to the State of Oregon or a political subdivision, including (i) garnishing the Provider’s compensation under this Contract or (ii) exercising a right of setoff against Provider’s compensation under this Contract for any amounts that may be due and unpaid to the State of Oregon or its political subdivisions for which the ODOR collects debts;

d. [Reserved];

e. To the best of the undersigned’s knowledge, Provider has not discriminated against and will not discriminate against minority, women or emerging small business enterprises certified under ORS 200.055 in obtaining any required subcontracts;

f. Provider and Provider’s employees and agents are not included on the list titled “Specially Designated Nationals” maintained by the Office of Foreign Assets Control of the United States Department of the Treasury and currently found at: https://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx;

g. Provider is not listed on the non-procurement portion of the General Service Administration’s “List of Parties Excluded from Federal procurement or Non-procurement Programs” currently found at: https://www.sam.gov/portal/public/SAM/;

h. Provider is not subject to backup withholding because:

(1) Provider is exempt from backup withholding;

(2) Provider has not been notified by the IRS that Provider is subject to backup withholding as a result of a failure to report all interest or dividends; or

(3) The IRS has notified Provider that Provider is no longer subject to backup withholding; and

i. Provider Federal Identification Number (FEIN) or Social Security Number (SSN) provided is true and accurate. If this information changes, Provider shall provide BHD with the new FEIN or SSN within 10 days.

PROVIDER, BY EXECUTION OF THIS CONTRACT, HEREBY ACKNOWLEDGES THAT PROVIDER HAS READ THIS CONTRACT, UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND CONDITIONS.

PROVIDER: YOU WILL NOT BE PAID FOR SERVICES RENDERED PRIOR TO NECESSARY STATE APPROVALS

6. Signatures. This Contract and any subsequent amendments may be executed in several counterparts, all of which when taken together shall constitute one agreement binding on all parties, notwithstanding that all parties are not signatories to the same counterpart. Each copy of the Contract and any amendments so executed shall constitute an original.

[LEGAL ENTITY NAME]

By:

Authorized Signature Printed Name

Title Date State of Oregon, acting by and through its Oregon Health Authority By:

Authorized Signature Printed Name

Title Date Approved for Legal Sufficiency:

Exempt per OAR 137-045-0050(15).

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