Attachment-F.PUR-7801-Vendor-Certification-Form.docx
DOCX document 57 KB Posted
- Attached to
- ITN NO. DMS-2425-258 COMPREHENSIVE SURGICAL AND MEDICAL BUNDLED SERVICES AND CANCER CARE COORDINATIO
- Solicitation number
- ITN-12526
- Issued by
- Leon County, Florida
About this file
This document is a Vendor Certification Form (Attachment F PUR-7801) for the State of Florida's Department of Management Services (DMS), Division of State Group Insurance, related to Invitation to Negotiate (ITN) No. DMS-24/25-258 for Comprehensive Surgical and Medical Bundled Services and Cancer Care Coordination. The procurement seeks a single contractor for a four-year contract with up to four optional one-year renewals, commencing January 1, 2026, serving 388,313 state group insurance members. The critical response deadline is May 30, 2025, at 2:00 PM Eastern Time, with a public opening at 3:00 PM the same day. The selected vendor will develop a Bundled Services Program allowing members to access surgical and medical procedures, establish a high-quality healthcare provider network, create a member website, maintain a customer service unit, and implement cancer care coordination with oncology nurse coordinator access.
The estimated annual contract amount is $4,400,000.00, subject to legislative appropriation, with vendors required to comply with various state statutory requirements including E-Verify usage and non-discrimination practices. The evaluation will assess vendors across ten comprehensive sections, totaling 50 raw points and 125 weighted points. Vendors must demonstrate capabilities in healthcare service delivery, including evidence-based provider selection, data security protocols, and transparent reporting. The contract includes rigorous requirements for data protection, mandating vendors maintain multiple insurance policies totaling at least $5 million per annual aggregate and potentially provide a performance bond or irrevocable letter of credit not exceeding 20% of the annual contract amount. The certification form specifically requires vendors to attest to various compliance measures, including non-participation in boycotts, adherence to state vendor lists, and compliance with labor and international business conduct regulations.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Q&A.pdf | ||
| Attachment-A.Statment-of-Work.docx | DOCX document | |
| Attachment-F.PUR-7801-Vendor-Certification-Form.docx | DOCX document | |
| Attachment-B.Cost-Reply.xlsx | XLSX spreadsheet | |
| ITN-DMS-2425-258.Comprehensive-Med-Surgical-Bundled-Srvc-and-Cancer-Care-Coord.docx | DOCX document | |
| Addendum No.1.pdf | ||
| Attachment-E.Business-Associate-Agreement.docx | DOCX document | |
| attachment-D.technical-reply-with-weight.xlsx | XLSX spreadsheet | |
| Attachment-C.Contract-Draft.docx | DOCX document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Attachment F PUR7801 – Vendor Certification Form
I hereby certify the following on behalf of the vendor identified below:
| Customer Indicator (Required, N/A, Determined by Vendor) |
| Vendor Indicator (Certified, N/A) |
| Certification |
| Required | |
| Choose an item. | Regardless of the dollar value of the goods or services provided, in accordance with the requirements of section 287.135(5), F.S., the vendor is not participating in a boycott of Israel and is not on the State Board of Administration’s “Quarterly List of Scrutinized Companies that Boycott Israel,” available at https://www.sbafla.com/governance/global-governance-mandates/ |
| Required | |
| Choose an item. | If the goods or services to be provided are $1 million or more, in accordance with the requirements of section 287.135, F.S., the vendor is not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Terrorism Sectors List (collectively, “Scrutinized List of Prohibited Companies”); does not have business operations in Cuba or Syria; and is not on the State Board of Administration’s “Scrutinized List of Prohibited Companies” available under the quarterly reports section at https://www.sbafla.com/reporting/ |
| Required | |
| Choose an item. | The vendor is not on the Suspended Vendor List; it and its suppliers, subcontractors, or consultants to be utilized under the contract are not on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists; and there is no pending or threatened action, proceeding, or investigation, or any other legal or financial condition, that would in any way prohibit, restrain, or diminish the vendor’s ability to satisfy the contract obligations. |
The vendor is hereby informed of the provisions of sections 287.133(2)(a), 287.134(2)(a), and 287.137(2)(a), F.S., that identify the impacts to the vendor's ability or its affiliates’ ability to respond to the competitive solicitations of a public entity; to be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a public entity; or to transact business with a public entity if it, or its affiliates, are placed on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists of the Department of Management Services. The vendor is hereby further informed of the provisions of section 287.1351, F.S., that identify the impacts to the vendor’s ability to enter into or renew a contract with an agency, as defined in section 287.012, F.S., if it is placed on the Suspended Vendor List of the Department of Management Services.
| Required | |
| Choose an item. | If the contract grants the vendor access to an individual’s personal identifying information, the vendor is not prohibited from entering into the contract pursuant to section 287.138, F.S., and has completed the Form PUR 1355, “Foreign Country of Concern Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15843, and attached it hereto. |
| Determined by Vendor | |
| Choose an item. | If the vendor is a common carrier, as defined in section 908.111, F.S., or a contracted carrier, it is not prohibited from entering into the contract pursuant to section 908.111, F.S., and has completed the Form PUR 1808, “Common Carrier or Contracted Carrier Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14614, and attached it hereto. |
| Required | |
| Choose an item. | The vendor is registered with, and uses, the E-Verify system for all newly hired employees in accordance with section 448.095, F.S.; and has not, within the last year, had a contract terminated under section 448.095(5)(c), F.S., by a public employer, contractor, or subcontractor, as defined by section 448.095(1), F.S. |
| Required | |
| Choose an item. | The vendor is in compliance with all applicable disclosure requirements set forth in section 286.101, F.S., and has not been deemed ineligible for a grant or contract funded by a state agency pursuant to section 286.101(7), F.S. |
| Required | |
| Choose an item. | If the contract is between a nongovernmental entity and a governmental entity, in accordance with section 787.06, F.S., the vendor has completed an affidavit signed by an officer or a representative of the vendor under penalty of perjury attesting that the vendor does not use coercion for labor or services as defined in section 787.06, F.S. |
| N/A | |
| Choose an item. | If the Contract is for the provision of commodities, in accordance with section 287.1346, F.S., the vendor, and any entity under the control of vendor, has not been placed on the Forced Labor Vendor List within the past 365 days or, if placed on the Forced Labor Vendor List, has been removed pursuant to section 287.1346(5)(d), F.S. |
If the Contract is for the provision of commodities, the Contractor will submit, prior to entering into or renewing the Contract, a written certification from senior management, as defined in section 287.1346(1)(c), F.S., which certifies to the best of their knowledge the commodities being offered pursuant to this solicitation have not been produced, in whole or in part, by forced labor.
The vendor is hereby informed of the provisions of section 287.1346, F.S., that identify the impacts to a vendor’s ability to respond to the competitive solicitations of a state agency; to be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a state agency; or to transact business for the provision of commodities with a state agency if it, or entities under the control of the vendor, is placed on the forced labor list in accordance with section 287.1346, F.S.
By signing below, I certify that I am authorized to complete and submit this Vendor Certification Form on behalf of the vendor.
Vendor Information Signatory
Name Signature Date
FEIN Typed or Printed Name
Title Form PUR 7801 (07/2024) Rule 60A-1.002, F.A.C.
File details come from the government source that posted it. Updated .