EOHHS Required Bidder Certifications Form~5.docx
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- Solicitation number
- BD-26-1039-EHS01-ASHWA-129810
- Issued by
- Massachusetts
About this file
This is a Required Bidder Certifications Form issued by the Massachusetts Executive Office of Health and Human Services (EOHHS) for organizations responding to the MassHealth Personal Care Attendant (PCA) Program Personal Care Management (PCM) Functions Request for Responses (RFR). Bidders must complete and submit this form as a mandatory element of their business response, with failure to submit resulting in rejection as non-responsive. The form requires certification by both the Chief Executive Officer and Chief Financial Officer, with signatures made under the pains and penalties of perjury. Bidders must certify readiness to begin performance by the Operational Start Date of July 1, 2026, and confirm acceptance of all provisions in the PCM Model Contract, including Commonwealth Terms and Conditions, key personnel requirements, reporting obligations, site visit participation, and performance measures tied to new rates effective July 1, 2026, as specified in 101 CMR 309.00.
The certifications require bidders to affirm sound financial condition with unqualified audit opinions, absence of outstanding liabilities to the Internal Revenue Service or other government agencies, absence of current or past litigation or non-compliance findings, freedom from conflicts of interest, compliance with privacy and security obligations under M.G.L. c. 93H and c. 66A, and non-debarment status for all directors, officers, partners, and persons with beneficial ownership exceeding five percent. Bidders must also certify the availability and non-reassignment of identified Key Personnel, full responsibility for Material Subcontractors' performance, submission of MassHealth Federally Required Disclosure Forms for the bidder and all proposed Material Subcontractors, and obligation to notify EOHHS of any changes to submitted statements. Each Material Subcontractor must separately complete and sign a Certification with Regard to Material Subcontractor, attesting to readiness for performance by July 1, 2026, absence of conflicts of interest, and submission of required disclosure forms.
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EOHHS-REQUIRED BIDDER CERTIFICATIONS
Completion of these Certifications is a required element of the Bidder’s Business Response as described in Section 6 of the RFR. Failure to submit this form may result in a Bidder’s response being rejected as non-responsive.
Name of Bidder: (hereinafter, “Bidder”) Chief Executive Officer: Enter name of CEO here By my signature below, I certify that the information below, and any attached statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I sign under the pains and penalties of perjury, and may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
Chief Financial Officer: Enter name of CFO here By my signature below, I certify that the information below in response to Certification with Regard to Bidder Financial Condition and Certification with Regard to Bidder’s Parent Company Financial Condition and any attached statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I sign under the pains and penalties of perjury, and may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
A check in the box of each item, below, indicates an affirmative response to the certification. If one or more of the boxes are not checked, please provide an explanation on a clearly labeled separate sheet.
1. Bidder’s Qualifications and Contract Readiness
| ☐ | The undersigned certifies that the Bidder meets all Bidder Qualifications set forth in Section 1.3 of this RFR |
| ☐ | The undersigned certifies that the Bidder will be ready to begin performance of responsibilities described in this RFR and Attachment A, PCM Model Contract by the Operational Start Date set forth in Attachment A. |
2. Acceptance of MassHealth Contract for Personal Care Management Functions (PCM Model Contract) and Rates ☐ The undersigned accepts all of the provisions of Attachment A, PCM Model Contract, including the Commonwealth Terms and Conditions, Standard Contract Form Instructions and Contractor Certifications, and the Commonwealth of Massachusetts Standard Contract, in their entirety and without modification, and including but not limited to provisions relating to
· Key Personnel;
· Maintaining sufficient administrative staff;
· Satisfying EOHHS’ reporting requirements;
· Preparing for and attending EOHHS’ site visits and other performance review meetings; and,
· Performance measures, quality measures, and performance evaluations.
☐ The undersigned certifies that it understands the new rates effective July 1, 2026 set forth in the Appendix 5 of the Contract and subsequently 101 CMR 309.00: Rates for Certain Services for the Personal Care Attendant Program
3. Interests
| ☐ | The undersigned certifies that the Bidder’s interest will not conflict in any manner or degree with the performance of services required under the Contract. |
| ☐ | The undersigned certifies that the Bidder has submitted all of the information required under Section 6 of this RFR. The undersigned certifies that such information is complete, truthful, and accurately reflects the Bidder’s business. The undersigned certifies that they will provide any additional information required by EOHHS pursuant to Section 6 of this RFR. |
| ☐ | The undersigned certifies that the Bidder does not now, and shall not for the duration of the Contract term, knowingly having a director, officer, partner, or person with a beneficial ownership of more than 5 percent of the Bidder’s equity, or affiliate of any of the above, who is debarred, suspended, or excluded, or from having an employment, consulting, or other agreement with an individual or entity for the provision of items and services that are significant and material to the Bidder’s obligations under the Contract. |
4. Privacy and Security Certification ☐ The undersigned certifies that the Bidder will adhere to all applicable obligations regarding the protection of personal information, as defined in M.G.L. c. 93H, and personal data, as defined in M.G.L. c. 66A, owned or controlled by EOHHS that the Bidder may access in connection with its performance under the Contract.
5. Certification of Key Personnel ☐ The undersigned certifies that the Key Personnel identified in the Bidder’s Response to this RFR are employees, consultants, or under obligation to the Bidder such that they will be available to work on this Contract, and that they shall not be reassigned without the prior written approval of EOHHS.
6. Certification with Regard to Subcontractors
| ☐ | The undersigned certifies that the Bidder acknowledges its understanding that the Bidder will not be relieved of any legal obligations under any Contract resulting from this RFR as a result of any contracts with Material Subcontractors or subcontractors, that the Bidder shall be fully responsible for the Material Subcontractor’s or subcontractor’s performance, and that all Material Subcontractor agreements, subcontracts, and other agreements or arrangements for reimbursement will be in writing and will contain terms consistent with all terms and conditions of the Contract. |
| ☐ | The undersigned further has signed and obtained the signatures of each and every Material Subcontractor, if any, on a separate Certification with Regard to Material Subcontractor, which is attached hereto. |
7. Certification with Regard to Bidder Financial Condition (If one or more of the boxes in this section are not checked, please attach an explanation on a clearly labeled separate sheet.)
The undersigned certifies that the Bidder (please check one of the boxes below):
| ☐ | Is in sound financial condition, meets financial stability requirements set forth in the appropriate Model Contract, and has received an unqualified audit opinion for the latest audit of its financial statements. Specify the date of the last audit ; OR |
| ☐ | The Bidder is in sound financial condition, meets financial stability requirements set forth in the appropriate Model Contract, and will have received an unqualified audit opinion for the latest audit of its financial statements, prior to Contract execution. |
| ☐ | The undersigned certifies that the Bidder has no outstanding liabilities to the Internal Revenue Service or other government agencies. |
| ☐ | The undersigned certifies that the Bidder is not the subject of any current litigation or findings of non-compliance under federal or state law. |
| ☐ | The undersigned certifies that the Bidder has not been the subject of any past litigation or findings of non-compliance under federal or state law. |
8. Certification with Regard to Bidder’s Parent Company Financial Condition (If Applicable)
| ☐ | The undersigned certifies that Name of Parent Company is in sound financial condition and has received an unqualified audit opinion for the latest audit of its financial statements. Specify the date of the last audit ; |
| ☐ | The undersigned certifies that Name of Parent Company has no outstanding liabilities to the Internal Revenue Service or other government agencies. |
| ☐ | The undersigned certifies that Name of Parent Company is not the subject of any current litigation or findings of non-compliance under federal or state law. |
| ☐ | The undersigned certifies that Name of Parent Company has not been the subject of any past litigation or findings of non-compliance under federal or state law. |
| ☐ | The undersigned certifies that Name of Parent Company will provide an unconditional guarantee, in a form acceptable to EOHHS, of all financial and other obligations under the Contract. |
9. MassHealth Federally Required Disclosure Form ☐ The undersigned certifies that the Bidder has submitted a completed MassHealth Federally Required Disclosure Form for itself, and also submitted a separate completed form from each of the Bidder’s proposed Material Subcontractor(s).
10. Changes to Statements ☐ The undersigned acknowledges the Bidder’s obligation to notify EOHHS of any changes in the statements made herein.
11. Signatures Signature and date stamps, or the signature of anyone other than the provider/fiscal agent, or in the case of a legal entity, person legally authorized to sign on behalf of the entity, are not acceptable.
Signed under the pains and penalties of perjury this day of , 2026 Signature of the Chief Executive Officer
Printed Name of Signatory
Date
Signed under the pains and penalties of perjury this day of , 2026 Signature of the Chief Financial Officer
Printed Name of Signatory
Date
Certification with Regard to Material Subcontractor To be completed by the Bidder and each and every Material Subcontractor. A separate certification shall be submitted by each Material Subcontractor.
| ☐ | We the undersigned certify that Material Subcontractor Name will be ready to begin performance of responsibilities described in this RFR, explicitly subcontracted by the Bidder to us by July 1, 2026, and that Material Subcontractor Name is able to perform all services and responsibilities that include: Insert description of services and responsibilities. |
| ☐ | We the undersigned certify that Material Subcontractor Name’s interest does not now, and at no time will, conflict in any manner or degree with the performance of services required under the Contract. |
| ☐ | We the undersigned further certify that Material Subcontractor Name does not now, and shall not for the duration of their subcontracted term, knowingly having a director, officer, partner, or person with a beneficial ownership of more than 5 percent of Material Subcontractor Name’s equity, or affiliate of any of the above, who is debarred, suspended, or excluded, or from having an employment, consulting, or other agreement with an individual or entity for the provision of items and services that are significant and material to their subcontracted obligations under the Contract. |
| ☐ | The undersigned certifies that such information, as Material Subcontractor Name submitted to the Bidder is complete, truthful, and accurately reflects Material Subcontractor Name’s business regarding the services and responsibilities subcontracted by the Bidder to us. |
| ☐ | The undersigned certify that Material Subcontractor Name has completed and submitted a MassHealth Federally Required Disclosure Form. |
| ☐ | The undersigned certify that the Bidder and Material Subcontractor Name will provide any additional information required by EOHHS pursuant to Section 6 of this RFR. |
Bidder Signature
Printed Name of Signatory
Title
Date
Material Subcontractor Signature
Printed Name of Signatory
Title
Date
EOHHS-Required Bidders’ Certifications
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