Attachment_II_-_Forms_A-E.xlsx

XLSX spreadsheet 49 KB Posted Feb 5, 2024

Attached to: Pharmacy Benefits Management Services
Solicitation number: 042-1616186-LM
Issued by: Orange County, San Francisco City, California

About this file

Written by GovTribe AI · May 12, 2025

The document is an Excel spreadsheet containing Attachment II Forms A-E for a Pharmacy Benefits Management Services Request for Proposal (RFP No. 042-1616186-JFC) issued by the Orange County Health Care Agency in California. The RFP seeks qualified organizations to provide medication distribution services to Orange County residents of all ages who meet medical necessity criteria and lack financial resources for medications. The proposal requires comprehensive documentation including agency descriptions, bidder certifications, board of directors information, and detailed submission requirements. Bidders must submit a valid proposal for at least 365 calendar days and provide extensive organizational documentation such as articles of incorporation, by-laws, financial statements, and corporate organizational charts.

The RFP includes specific forms for bidders to complete, covering areas like organizational background, contract authority, operating budget, and related service experience. Bidders must disclose financial information, including current annual operating budget broken down by contract types, and provide details about their organization's conflict of interest procedures. The proposal emphasizes transparency, requiring disclosure of financial relationships, current clients, and potential conflicts of interest. While specific budget amounts are not clearly defined in the document, the forms indicate that bidders must provide comprehensive financial and operational information to be considered for the pharmacy benefits management services contract.

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Other files

File	Type	Posted
042-1616186-LM_-_Pharmacy_Benefits_Management_Services.pdf	PDF	Feb 5, 2024
Attachment_C_-_Campaign_Contribution_Disclosure_Form.docx	DOCX document	Feb 5, 2024
Attachment_III_-_Budget_Forms_(ACTUAL_COSTS).xlsx	XLSX spreadsheet	Feb 5, 2024
Attachment_I_–_Contract_Template.pdf	PDF	Feb 5, 2024

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Cover Page Attachment II

Forms A-E

RFP No.: 042-1616186-JFC Pharmacy Benefits Management Services

Form A - Checklist

Use this checklist to identify whether or not all items requested have been included. This form is to be completed and included in each uploaded BidSync file, and must be located with the proposal's Table of Contents.

Organization Name:

	Upload File I - Agency Description				Item(s) Enclosed/
Completed		Page and Section Number
	A.	Cover Page/Executive Summary
	B.	Agency Description (Form B - Attachment II)
	C.	Bidder Certifications (Form C - Attachment II)
	D.	Board of Directors (Form D - Attachment II)
	E.	Campaign Contribution Form
	F.	Reference Letters
	G.	Documentation
		1.	If incorporated:
			a.	Articles of Incorporation
			b.	By-Laws
			c.	Resolution empowering a Corporate Officer
		2.	If not incorporated: Documentation empowering

an Authorized Representative

	3.	Fictitious Business Name Statement and Proof of Publication
	4.	Partnership Papers and/or Joint Venture Agreements
	5.	Evidence of Federal/State tax status
	6.	IRS W-9 Form
	7.	Business License/Certifications/CUP (as applicable)
	8.	Table of Contents from P&P manual
	9.	Corporate Organizational Chart
	10.	Unique Entity Identifier (UEI)
H.	Recent Financial Statement
I	Audits/Reviews/Inspection Reports
J.	Active Litigation,Resolution, and Performance Issues
K	Past/Current/Threatened Litigation, Liens, and Claims

	Upload File II - Proposal			Item(s) Enclosed/
Completed		Page and Section Number
	A.	Provider Experience and Qualifications
		1.	Related Service Experience (Form E - Attachment II)

B. Services

C. Performance Objectives

D. Staffing

E. Facility

F. Budget (Attachment III)

FORM A - PROPOSAL PREPARATION CHECKLIST

Form B - Agency Description

1.	Organization Legal Name:
		(As Specified in The Articles of Incorporation or State License)
	Business Address:

2.	Contract Signature Authority - Identify below the person empowered to sign a contract:
	Corporate Officer or Authorized Representative Name and Title:
	Corporate Officer or Authorized Representative

Email address:

	Corporate Officer or Authorized Representative
Telephone:		Fax:

3. Date Organization Established:

4. Type of Business (Check One)

Nonprofit Corporation Other (Specify):

5. Self-insured: Yes No

6. Current Annual Operating Budget:

	Operating Budget Generated From:
	Non-Orange County
Government Contracts:		$			ERROR:#DIV/0!
	Orange County
Government Contracts:		$			ERROR:#DIV/0!
	Non-Governmental Contracts:		$			ERROR:#DIV/0!
	Donations:		$			ERROR:#DIV/0!
	Participant Fees:		$			ERROR:#DIV/0!
	Other (Specify): _______________		$			ERROR:#DIV/0!
	Other (Specify): _______________		$			ERROR:#DIV/0!
	TOTAL:		$	0.00		ERROR:#DIV/0!

7.	Solicitation Contact Person - Identify below the person who will represent the organization during the solicitation evaluation process:
	Solicitation Contact Name and Title:
	Solicitation Contact Email Address:
	Solicitation Contact Telephone:

Solicitation Submittal Authority:

The undersigned hereby acknowledges: "I have read and understand the contents of, and have authority to submit the attached proposal/application on behalf of the above-named organization. It is correct to the best of my knowledge and represents the organization's proposal/application for the provision of the requested services."

Corporate Office or Authorized Representative Date Telephone

FORM B - AGENCY DESCRIPTION

Form C - Bidder Certifications Organization Name:

Validity of Proposal

The County requires that all proposals be valid for at least 365 calendar days from the proposal due date. Submissions not valid for at least 365 calendar days from the proposal due date will be considered non-responsive. The Bidder shall state the length of time for which the submitted proposal shall remain valid below:

Validity of RFP (in days) (Signature Required)

Certification of Understanding

The County assumes no responsibillity for any understanding or representation made by any of its officers, employees or agents during or prior to the execution of any Contract resulting from this solicitation unless:

1.	Such understanding or representations are expressly stated in the Contract, and;
2.	The Contract expressly provides that the County therefore assumes the responsibility.

Representations made but not expressly stated and for which liability is not expressly assumed by the County in the Contract shall be deemed only for the information of the Bidder.

By signing below, Respondent certifies that such understanding has been considered in this response.

(Signature Required)

Certificate of Insurance

The Respondent shall certify its willingness and ability to provide the required insurance coverage and certificates as set forth in Section I.O of the Request for Proposals (RFP) by signing below.

(Signature Required)

In order to comply with this County requirement, within 10 days of notification of selection of award of Contract but prior to official award of the Contract, the selected Contractor agrees to furnish to the Contract Administrator, the County Procurement Officer, or the agency/department DPA the required W-9 or W-8.

(Signature Required)

Conflict of Interest

Attach the following on a separate piece of paper and include with Form C:

Description of your organization’s conflict of interest systems and procedures that are in place and their application to the services to be provided to the County.

Disclosure of any financial, business or other relationship with the County, any other entity that the County Board of Supervisors governs or with the city and county in which the service locations are located, which may have an impact, effect or influence on the outcome of the services you propose to provide. Provide a list of current clients, employees, principals or shareholders (including family members) who may have a financial interest in the outcome of the services you propose to provide (if applicable).

Disclosure of any financial, business or other relationship within the last three (3) years with any company or member of any company who may have a financial interest in the outcome of the work. If you believe that no conflict of interest exists or would exist, sign below.

(Signature Required)

Minimum Submission Requirements Statement

Bidder shall certify that it meets all minimum submission requirements set forth above in the RFP by signing below.

(Signature Required)

Statement of Compliance

A statement of compliance with all parts of the RFP or a listing of exceptions and suggested changes must be submitted in response to this RFP:

1. This response is in strict compliance with said RFP, including the terms and conditions set forth in the Contract and its Attachment(s), and no exceptions thereto are proposed.

(Signature Required)

2. This response is in strict compliance with said RFP, including the terms and conditions set forth in the Contract and its Attachment(s), except for those proposed exceptions listed in a separate attachment hereto.

(Signature Required)

Attachment for each proposed exception must include

1) The RFP page number and section of the provision Bidder is taking exception to;

2) The complete provision Respondent is taking exception to;

3) The Respondent’s suggested rewording;

4) Reason(s) for submitting the proposed exception; and,

5) Any impact the proposed exception may have on cost, scheduling, or other areas.

FORM C - BIDDER'S CERTIFICATION

Form D - Board of Directors

Organization Name:
Provide the following information about your Board of Directors
Number of Members:	Term Length:	Meeting Dates:
Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

FORM D - BOARD OF DIRECTORS

Form E - Related Services Exp.

Organization Name:

Describe past and current experience in providing services related to those requested in this solicitation.

	Description of Related Services		Length of Time in Business		Cities/Counties/Area Where Services are Provided	Funding/
Contract Amount		Funding Source(s)
			Start	End*
	1
	Contact Person/Title/Telephone/E-mail:
	2
	Contact Person/Title/Telephone/E-mail:
	3
	Contact Person/Title/Telephone/E-mail:
	4
	Contact Person/Title/Telephone/E-mail:
	5
	Contact Person/Title/Telephone/E-mail:
	6
	Contact Person/Title/Telephone/E-mail:
	7
	Contact Person/Title/Telephone/E-mail:
	8
	Contact Person/Title/Telephone/E-mail:
	9
	Contact Person/Title/Telephone/E-mail:
	10
	Contact Person/Title/Telephone/E-mail:

* Enter "Present" if still providing the identified services.

* Contact Persons listed above must be the organization's direct contact for which you provide/provided services.

FORM E - RELATED SERVICES EXPERIENCE

File details come from the government source that posted it. Updated May 12, 2025.