LCA DQ Appendix B, PII Cert.pdf

This is a Personal Identifying Information (PII) Certification form for the Colorado Department of Health Care Policy and Financing (HCPF) Solicitation #DQ UHAA 2026000469, which pertains to a Local Contact Agency for In-Reach Counseling services. The certification document requires an authorized representative of any third-party entity or organization seeking to access PII through a database or automated network to certify under penalty of perjury that the organization will not use or disclose Personal Identifying Information as defined by Colorado Revised Statutes 24-74-102(1) for the purpose of investigating, participating in, cooperating with, or assisting Federal Immigration Enforcement, including enforcement of civil immigration laws and the Illegal Immigration and Immigrant Responsibility Act (8 U.S.C. § 1325 and 1326), unless required by Federal or State law or to comply with a court-issued subpoena, warrant, or order.

The certification requires the signatory to represent that they possess full legal authority to execute the certification on behalf of the organization. Required signature fields include the authorized representative's signature, printed name, title, and date of execution. This is a mandatory compliance document for any entity participating in the Local Contact Agency – In-Reach Counseling contract opportunity with the State of Colorado, ensuring adherence to state privacy and immigration enforcement restrictions.