BHTRP RFRMandatory Response Forms.docx

RFR for Behavioral Treatment and Referral Platform: Required Forms Bidder Name:

Certification of Non-Collusion Form

The undersigned certifies under penalties of perjury that this bid or response has been made and submitted in good faith and without collusion or fraud with any other person. As used in this certification, the word “person” shall mean any natural person, business, partnership, corporation, union, committee, club, or other organization, entity, or group of individuals.

(Name of person signing Response)

(Name of business)

Certification Regarding Debarment and Suspension The undersigned (authorized official signing for Bidder) certifies to the best of his or her knowledge and belief, that Bidder and its principals:

(a) are not presently debarred, suspended, proposed for debarment, declared ineligible, under any federal, state, or local law or regulation, including Executive Order 147; G.L. c. 29, s. 29F G.L. c.30, § 39R, G.L. c.149, § 27C, G.L. c.149, § 44C, G.L. c.149, § 148B and G.L. c. 152, s. 25C or voluntarily excluded from contracting with or being a contractor of a government entity (federal, state or local);

(b) have not received a notice from any government entity regarding a proposed suspension or investigation of a violation of any federal or state law that could result in debarment from contracting with or being a contractor of any federal or state agency;

(c) have not within the last 3-years been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

(d) are not presently indicted or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and

(e) have not within the last 3 years had one or more public transactions (federal, state, or local) terminated for cause or default.

Bidder:

Signed (by authorized signatory):

Print name:

Title:

Date:

RFR for Behavioral Treatment and Referral Platform: Required Forms

Disclosures

Name of Bidder:

I. Please provide the following information below or attach a separate sheet:

1. Does the Bidder currently have contracts with Massachusetts health care providers or companies that provide health information technology related services in Massachusetts?

1. If so, for each of these current contracts exceeding $20,000, please provide the legal name of the health care provider or health information technology company and a description of the services provided.

1. Please state whether the contract, combined with any other contracts the Bidder has had with the same provider or company in the past 5 years, exceeds $100,000 in total.

II. Please provide the following information for each subcontractor (if any) below or attach a separate sheet:

1. Does the subcontractor currently have contracts with Massachusetts health care providers or companies that provide health information technology related services in Massachusetts?

1. If so, for each of these current contracts exceeding $20,000, please provide the legal name of the health care provider or health information technology company and a description of the services provided.

1. Please state whether the contract, combined with any other contracts the Bidder has had with the same provider or company in the past 5 years, exceeds $100,000 in total.

EOHHS reserves the right to request additional disclosures from Bidders.

RFR for Behavioral Treatment and Referral Platform: Required Forms Certification with Regard to Financial Condition Name of Bidder:

Certification:

A check in the box to the right of each item indicates an affirmative response to the certification.

If one or more of the above boxes are not checked, please explain in the space provided below or attach a clearly labeled separate sheet.

Signature

Printed Name of Signatory

Title

Date

AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER FORM

All Bidders responding to this RFR must agree to participate in EOHHS EFT program for receiving payments, unless the Bidder can provide compelling proof that it would be unduly burdensome (see RFR Section 5.11).