Attachment_J.2_Contractors_Organizational_Conflict_of_Interest_Certif.pdf

Attachment J.2 – ORGANIZATIONAL CONFLICT OF INTEREST CERTIFICATE

MPAPA

HHSM-500-2013-RFP-0030

ORGANIZATIONAL CONFLICT OF INTEREST CERTIFICATE

INSTRUCTIONS TEMPLATE

The Contractor’s Organizational Conflict of Interest Certificate that includes the Contractor’s plan to mitigate all actual, apparent and potential conflicts of interest in accordance with Section H.4 of this solicitation identified during the term of the contract and certification that all work to be performed under this contract is free of unresolved conflicts of interest, is incorporated at Attachment J.4 and should contain the following, as applicable.

i. A description of all business or contractual relationships or activities that may be viewed by a prudent business person as a conflict of interest.

ii. A description of the methods the Offeror or Contractor will apply to mitigate any situations listed in the Certificate that could be identified as a conflict of interest.

iii. A description of the Offeror’s or Contractor's program to monitor its compliance and the compliance of its proposed and actual subcontractors with the conflict of interest requirements as identified in the relevant solicitation.

iv. An affirmation, using language provided below, signed and dated by an official authorized to bind the Contractor:

I, (Name and Title), certify that to the best of my knowledge and belief: 1) I am an official authorized to bind the entity; 2) the information contained in the Organizational Conflict of Interest Certificate is true and accurate as of (Date);

and 3) I understand that the Contracting Officer may consider any deception or omission in this Certificate to be grounds for non-consideration for contract award, modification or non-renewal or termination of the current contract, and/or other contract or legal action.

An Offeror shall submit an affirmation certifying the information to be true and accurate as of the date the proposal is submitted. Upon award, the Contractor shall submit an updated affirmation, if necessary, certifying the information to be accurate as of the date of contract award.

v. Corporate and organizational structure.

vi. Financial interests in other entities, including the following:

(1) Percentage of ownership in any other entity.

(2) Income generated from other sources.

Attachment J.2 – ORGANIZATIONAL CONFLICT OF INTEREST CERTIFICATE

MPAPA

HHSM-500-2013-RFP-0030

(3) A list of current or known future contracts or arrangements, regardless of size, with any suppliers furnishing health services for which payment may be made under the Medicare program.

(4) In the case of contracts or arrangements identified in accordance with paragraph vi (3) of this section, the dollar amount of the contracts or arrangements, the type of work performed, and the period of performance.

vii. The following information for all of the Offeror’s or Contractor’s officers, directors (including medical directors), and managers who would be, or are involved with, the performance of the contract:

(1) The information required under paragraphs i. and vi. of this section.