Attachment N COI Acknowledgement Form_1.docx
DOCX document 41 KB Posted
- Solicitation number
- SFGOV-0000011940
- Issued by
- California
About this file
This is a Conflict of Interest and Acknowledgement Form for the Department of Public Health's Institutional Master Plan Consulting Services solicitation (SFGOV-0000011940) in San Francisco, California. The RFP seeks qualified firms to provide professional health planning services to support the City's review of hospital Institutional Master Plans submitted by specified facilities including Chinese Hospital, Sutter Health California Pacific Medical Center (with locations at Van Ness, Mission, Bernal, and Davies), and Kaiser Permanente San Francisco. The pre-proposal conference is scheduled for September 18, 2026, with a deadline for questions on September 25, 2026 and a Q&A addendum expected to be posted by October 2, 2026. Proposals are due by 2:00 PM PT on October 13, 2026, with an estimated award announcement in November 2026, a Health Commission presentation anticipated in May 2027, and a contract start date of June 1, 2027.
The form requires all proposers to disclose any current or past economic, financial, or other relevant relationships with the listed healthcare facilities to identify potential conflicts of interest. Proposers must demonstrate sufficient independence from the entities submitting IMPs and certify their ability to render objective and unbiased evaluation. The Procurement Officer and/or City Attorney will review any disclosed conflicts to determine whether they preclude participation. All authorized representatives must sign the acknowledgement confirming their impartiality in the IMP evaluation process.
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Attachment N Conflict of Interest and Acknowledgement Form
SFGOV-0000011940
Institutional Master Plan Consulting Services
The undersigned does hereby acknowledge and agree to the following:
Conflict of Interest: Actual or Perceived Proposers are strongly encouraged to review the list of facilities included in this solicitation that may submit an Institutional Master Plan (IMP) for review. If you currently have, or previously had, an economic relationship with any of the listed facilities below, we recommend that you consult with your attorney to ensure there is no conflict of interest that would preclude you from submitting a proposal.
| Network/Chain |
| Hospital |
Chinese Hospital
| Sutter Health |
| California Pacific Medical Center (CPMC) Van Ness, Mission Bernal, Davies |
| Kaiser Permanente |
| Kaiser Permanente San Francisco |
A conflict of interest for purposes of this document is defined as any action by a proposer in the IMP evaluation process which would affect, or could appear to affect, the proposer’s financial interest (including any family members or domestic partner of the proposer), or would cause the proposer’s impartiality in the IMP evaluation process to be questioned. Proposers should be sufficiently independent of the entities submitting IMPs to the City and must be able to render an objective and unbiased evaluation.
If you have concerns that you may have a conflict, please specify the possible conflict below. The Procurement Officer and/or City Attorney will review the information and determine whether a conflict exists.
Conflict of Interest Disclosure Please describe any current or past economic, financial, or other relevant relationship you have had with any of the facilities listed above that may submit an IMP for review. Include dates and the nature of the relationship.
Disclosure (if applicable). If you have no potential conflicts to disclose, write “None”:
Click or tap here to enter text.
Acknowledgement I acknowledge that I can be fair and impartial in the IMP evaluation process and that I do not have a conflict of interest as stated above.
Authorized Representative’s Printed Name: Click or tap here to enter text.
Authorized Representative’s Title: Click or tap here to enter text.
Date: Click or tap here to enter text.
Authorized Representative’s Signature:
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