RFP 2022-25 Prior Authorization Services.pdf

REQUEST FOR PROPOSALS #2022-25

Prior Authorization Services Publish Date: December 8, 2022

CareOregon, Inc. (“CareOregon”) is inviting submission of proposals for the Prior Authorization Services project.

Closing Date/Time: January 9, 2023 - 2:00 PM, Pacific Time

Project Summary: Review of Prior Authorization Services to support internal clinical staff for requests that may include physical health, mental health, and durable medical equipment.

Contact Information: The sole point of contact for procurement process or technical questions is: Kim

Randall, Procurement Manager; randallk@careoregon.org

RFP Location: RFP Documents can be downloaded from OregonBuys at the following address:

https://oregonbuys.gov/bso/. Prospective Proposers will need to sign in to download the information and that information will be accumulated for a Plan Holder's List. Prospective Proposers are responsible for obtaining any Addenda, clarifying questions, and Notices of Award from OregonBuys.

Submission: All proposals must be emailed to Procurement@careoregon.org.

CareOregon encourages proposals from minority, women, service-disabled veteran, and emerging small businesses.

**NO PROPOSALS WILL BE RECEIVED OR CONSIDERED AFTER THE ABOVE

RFP CLOSING DATE/TIME**

SCHEDULE

Request for Proposals Issued…….................................................. December 8, 2022

Deadline to Submit Clarifying Questions....................................... December 29, 2022, 5:00 PM, Pacific Time

Request for Proposals Closing Date and Time (“Closing”)........... January 9, 2023, 2:00 PM, Pacific Time

Anticipated Contract Start Date……..............................................February/March 2023 mailto:randallk@careoregon.org https://oregonbuys.gov/bso/ mailto:Procurement@careoregon.org

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SECTION 2

INSTRUCTIONS TO PROPOSERS

2.1 Modification or Withdrawal of Proposal: Any Proposal may be modified or withdrawn at any time prior to the Closing deadline, provided that a written request is received by Procurement, prior to the Closing. The withdrawal of a Proposal will not prejudice the right of a Proposer to submit a new Proposal.

2.2 Requests for Clarification and Requests for Change: Proposers may submit questions regarding the specifications of the RFP until the deadline in the Schedule. Requests for changes must include the reason for the change and any proposed changes to the requirements. The purpose of this requirement is to permit CareOregon to correct, prior to the opening of Proposals, RFP terms or technical requirements that may be unlawful, improvident or which unjustifiably restrict competition. CareOregon will consider all requested changes and, if appropriate, amend the RFP. No oral or written instructions or information concerning this RFP from CareOregon employees or agents to prospective Proposers shall bind CareOregon unless included in an Addendum to the RFP.

2.3 Addenda: If any part of this RFP is changed, an addendum will be published on OregonBuys. It shall be Proposers responsibility to regularly check OregonBuys for any notices, published addenda, or response to clarifying questions.

2.4 Submission of Proposals: Proposals must be submitted in accordance with Section 5. All Proposals shall be legibly written in ink or typed and comply in all regards with the requirements of this RFP. All Proposals must include a signature that affirms the Proposer’s intent to be bound by the Proposal (this may be on cover letter, or on the Proposal). The Certification page must be signed as well. If a Proposal is submitted by a firm or partnership, the name and address of the firm or partnership shall be shown, together with the names and addresses of the members. If the Proposal is submitted by a corporation, it shall be signed in the name of such corporation by an official who is authorized to bind the contractor. No late Proposals will be accepted.

2.5 Notice of Award: CareOregon will name the apparent successful Proposer in a Notice of Intent to Award published on OregonBuys. Identification of the apparent successful Proposer is procedural only and creates no right of the named Proposer to award of the contract.

2.6 Acceptance of Contractual Requirements: Failure of the selected Proposer to execute a contract and deliver required insurance certificates within ten (10) calendar days after notification of an award may result in cancellation of the award. This time period may be extended at the option of CareOregon.

2.7 Investigation of References: CareOregon reserves the right to investigate all references in addition to those supplied references and investigate past performance of any Proposer with respect to its successful performance of similar services, its compliance with specifications and contractual obligations, its completion or delivery of a project on schedule, its lawful payment of subcontractors and workers, and any other factor relevant to this RFP. CareOregon may postpone the award or the execution of the contract after the announcement of the apparent successful Proposer in order to complete its investigation.

2.8 RFP Proposal Preparation Costs and Other Costs: Proposer costs of developing the Proposal, cost of attendance at an interview (if requested by CareOregon), or any other costs are entirely the responsibility of the Proposer, and will not be reimbursed in any manner by CareOregon.

2.9 Clarification and Clarity: CareOregon reserves the right to seek clarification of each Proposal, or to make an award without further discussion of Proposals received. Therefore, it is important that each Proposal be submitted initially in the most complete, clear, and favorable manner possible.

2.10 Right to Reject Proposals: CareOregon reserves the right to reject any or all Proposals or to withdraw any item from the award, if such rejection or withdrawal would be in CareOregon’s interest, as determined by CareOregon.

Proposals may be rejected in whole or in part if they attempt to limit or modify any of the terms, conditions, or specifications of the RFP or the Sample Contract.

RFP 2022-25 Prior Authorization Services Page 2

2.11 Proposal Terms: All Proposals, including any price quotations, will be valid and firm through a period of one hundred and eighty (180) calendar days following the Closing date. CareOregon may require an extension of this firm offer period. Proposers will be required to agree to the longer time frame in order to be further considered in the procurement process.

2.12 Oral Presentations: At CareOregon’s sole option, Proposers may be required to give an oral presentation of their Proposals to CareOregon, a process which would provide an opportunity for the Proposer to clarify or elaborate on the Proposal but will in no material way change Proposer’s original Proposal. Any costs of participating in such presentations will be borne solely by Proposer and will not be reimbursed by CareOregon. Note: Oral presentations are at the discretion of the evaluating committee and may not be conducted; therefore, written Proposals should be complete.

2.13 Review for Responsiveness: Upon receipt of all Proposals, the Procurement Department will determine the responsiveness of all Proposals before submitting them to the evaluation committee. If a Proposal is incomplete or non-responsive in significant part or in whole, it will be rejected and will not be submitted to the evaluation committee.

CareOregon reserves the right to determine if an inadvertent error is solely clerical or is a minor informality which may be waived, and then to determine if an error is grounds for disqualifying a Proposal. The Proposer’s contact person identified on the Proposal will be notified, identifying the reason(s) the Proposal is non-responsive.

2.14 Communication Blackout Period: Except as called for in this RFP, Proposers may not communicate with members of the Evaluation Committee or other CareOregon employees or representatives about the RFP during the procurement process until the apparent successful Proposer is selected. Communication in violation of this restriction may result in rejection of a Proposer.

2.15 Prohibition on Commissions and Subcontractors: CareOregon will contract directly with persons/entities capable of performing the requirements of this RFP. Contractors must be represented directly. Participation by brokers or commissioned agents will not be allowed during the Proposal process. Contractor shall not use subcontractors to perform the Work unless specifically proposed or authorized to do so by CareOregon. Contractor represents that any employees assigned to perform the Work, and any authorized subcontractors performing the Work, are fully qualified to perform the tasks assigned to them, and shall perform the Work in a competent and professional manner. Contractor shall not be permitted to add on any fee or charge for subcontractor Work. Contractor shall provide, if requested, any documents relating to subcontractor’s qualifications to perform required Work.

2.16 Collusion: By responding, the Proposer states that the Proposal is not made in connection with any competing Proposer submitting a separate response to the RFP, and is in all aspects fair and without collusion or fraud. Proposer also certifies that no officer, agent, or employee of CareOregon has a pecuniary interest in this Proposal.

2.17 Evaluation Committee: Proposals will be evaluated by a committee consisting of representatives from CareOregon and potentially external representatives. CareOregon reserves the right to modify the make-up in its sole discretion.

2.18 Nondiscrimination: The successful Proposer agrees that, in performing the Work called for by this RFP and in securing and supplying materials, contractor will not discriminate against or treat differently, any person on the basis of race, color, religious creed, political ideas, sex, age, marital status, sexual orientation, gender identity, veteran status, physical or mental disability, national origin or ancestry, or any other class protected by applicable law.

2.19 Best and Final Offer: CareOregon may request best and final offers from those Proposers determined by CareOregon to be reasonably viable for contract award. However, CareOregon reserves the right to award a contract on the basis of initial Proposal received. Therefore, each Proposal should contain the Proposer’s best terms from a price and technical standpoint. Following evaluation of the best and final offers, CareOregon may select for final contract negotiations/execution the offers that are most advantageous to CareOregon, considering cost and the evaluation criteria in this RFP.

2.20 PROPOSAL CONFIDENTIALITY: Submitted proposals will be treated as confidential and will only be shared internally with applicable staff for this project. Names of awarded proposers will be shared in the Notice of Intent to Award.

Proposer scores and evaluation notes shall remain private and confidential information for CareOregon purposes only.

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SECTION 3

SCOPE OF WORK

3.1 BACKGROUND

Founded in 1993, CareOregon is a 501(c)(3) public benefit nonprofit company that draws nearly all its revenue from public programs such as Medicaid (the Oregon Health Plan – “OHP”), Medicare and the State Children’s Health Insurance Program (“SCHIP”). Coordinated care organizations (“CCOs”) are an Oregon innovation that integrates physical, behavioral and oral health care, and treats the whole person.

Through partnerships with our CCOs, we provide integrated managed care services. We partner with Health Share of Oregon to serve the tri-county Portland metro area. We own Jackson Care Connect and Columbia Pacific CCO. In addition to Medicare plans and CareOregon Dental lines of business, Housecall Providers delivers primary, palliative and hospice care to home-bound patients.

Our mission is to inspire and partner to create quality and equity in individual and community health.

Our vision is healthy communities for all individuals, regardless of income or social circumstances.

We focus on the total health of our members, not just traditional health care. In teaming up with members, their families and their communities, we help Oregonians live better lives, prevent illness and respond effectively to health issues.

We care about people We serve Oregonians eligible for the OHP and Medicare Advantage members who have us as their health care option. But that’s not all. We are a managed health care company with an overarching goal: to make world-class, high-quality health care available to all Oregon residents, regardless of income.

We support our neighbors We know that some Oregonians are in need but don’t qualify for OHP benefits. We work to strengthen the health care safety net that these Oregonians rely upon, from local health departments and community clinics to rural and migrant health centers. We partner with policy makers and legislators to improve services and provide access to quality care throughout the state, from urban centers to rural neighborhoods.

We work with first-class providers CareOregon has built a health care delivery system that assures access to physicians and health care professionals who understand special needs and provide quality care regardless of a patient’s financial resources.

We work with policy makers to ensure access We provide OHP enrollees access to health care services in exchange for a per member, per month capitation rate. The Oregon Legislature sets this payment rate. The payments are subject to available state funding. CareOregon takes full financial risk for the health care services our members use. CareOregon, formed by safety net health care providers in the state, is a Safety Net Health Plan. Safety Net Health Plans are nonprofits that derive their revenue from public programs.

To put it simply, CareOregon ensures that members have timely access to high quality health care from a broad network of providers, and CareOregon works hard every day to keep people healthy and active in their homes and communities.

Equity, Diversity, and Inclusion:

CareOregon recognizes that to achieve the vision of “Healthy communities for all individuals, regardless of income or social circumstances,” it must intentionally cultivate authentic member engagement, RFP 2022-25 Prior Authorization Services Page 2 community partnerships, and recruit, retain and develop a staff as diverse as the communities it serves.

CareOregon has embarked on a continuous effort to understand the effects of historical, institutional and structural oppression on the various communities represented within its membership and personnel.

CareOregon strives to internally, and in partnership with other like-minded organizations across sectors, to redress policies, systems and health related environmental issues that affect health care disparities and inequities.

Equity, diversity, and inclusion is a cornerstone of CareOregon’s mission, vision and strategic objectives.

CareOregon’s priority is strengthening our communities by making health care work for everyone by ensuring access to a broader and more diverse network of physical, behavioral, and oral health services that address the individual needs and cultural values of our members and reduces barriers to getting needed care.

It is the intent of CareOregon, through issuance of this RFP, to collaborate with like-minded firms that share the same values and that will take actual steps to embody those values in the services provided to CareOregon and its providers, members and clients.

Project Background:

CareOregon is looking for a Contractor to assist with Prior Authorization Services for Medicaid (our CCO plans) and Medicare (our Dual Special Needs Plan (D-SNP)) that will assist and support staff in processing these services.

CareOregon has a responsibility to provide medically necessary covered services for Medicaid (Oregon Health Plan (OHP)) and Medicare Advantage (MA) eligible members. This responsibility is partially met through the prior authorization process. CareOregon performs prior authorization for services including planned inpatient, durable medical equipment, physical therapy, speech therapy, occupational therapy, orthotics, prosthetics, day surgery, and ambulatory surgery.

3.2 SCOPE OF WORK

Clinical teams, made up of Registered Nurses (“RNs”), review requests and make determinations using Oregon Health Plan (“OHP”) guidelines, Medicare National Coverage Determinations (“NCD”), Local Coverage Determinations (“LCD”), InterQual criteria, and organizational policies. RNs are supported by non-clinical staff who are responsible for non-clinical work including: setting up cases, confirmation of eligibility, initial review, provider outreach, and member communication. Prior authorization RNs are further supported by a team of Medical Directors who are responsible for medical necessity denials and act as a clinical resource providing clinical expertise and determinations. RNs provide denial language meeting regulatory requirements for member communication, including readability and completeness, and provide to the non-clinical teams for processing.

Duties to include:

• Process assigned prior authorization requests in aging order based on established workflow. This may include determination at the RN level or in consultation with CareOregon’s Medical Director.

• Review Prior Authorization requests for completeness of information to ensure established criteria or guidelines are met. Request necessary additional information from providers to complete review in accordance with organizational policy.

• Access and use CareOregon Prior Authorization systems and tools (i.e. QNXT, SharePoint, InterQual web-based criteria, RightFax, Outlook, OHP’s prioritized list, NCDs/LCDs.)

• Process Prior Authorization requests per CareOregon’s defined polices and procedure by accessing Prior Authorization no-authorization list, exclusion list, OHAs prioritized list, and job aids.

• Create letter denial language for the requesting provider and member meeting established criteria for completeness and regulatory requirements such as: effective date, requested services, applicable

RFP 2022-25 Prior Authorization Services Page 3 criteria used for denial and readability (at or below 6th grade reading level). CareOregon Staff will mail the letters.

• Contractor will perform self-internal audits on assigned staff work results to ensure adherence to policies and procedures.

• Develop escalation pathway for requests that the Contractor’s team is unable to complete.

• Final processing of Prior Authorization request includes case documentation, administrative determination, and tasking.

Deliverables:

• Meet agreed upon productivity standards.

• Meet agreed upon quality standards.

• Provide data and detail of performance audits no less than monthly (processing and communication audits).

• Quarterly Business Review with senior leadership.

• Complete interrater reliability assessment at least annually.

Milestones/Timeline:

• Training on organizational policies/procedures for prior authorization reviews completed within 2 weeks for assigned review types.

• Ramp-up period of up to 12 weeks to reach production and quality expectations with documented progression toward full production and quality.

• Monthly report of productivity and quality metrics; including corrective action plan for missed metrics following completion of ramp-up period.

• At least one weekly check-in meeting with CareOregon supervisor liaison to answer questions and resolve workflow issues - frequency dependent on need.

• Quarterly business review to include senior leadership to review accomplishments, barriers, needs, and planning.

• CareOregon will audit Contractor’s audit results no less than monthly to assure adherence to policy and process.

3.2.1 Term of Contract: The initial term of the awarded contract shall be from the effective date through December 31, 2024, with the option for two (2) additional two (2) year renewals thereafter subject to the mutual agreement of the parties.

3.2.2 Sample Contract: Submission of a Proposal in response to this RFP indicates Proposer’s willingness to enter into a contract containing substantially the same terms (including insurance requirements) of the sample contract identified below. No action or response to the sample contract is required under this RFP. Any objections to the sample contract terms should be raised in accordance with Paragraphs 2.2 of this RFP pertaining to requests for clarification of the RFP/specifications. This RFP and all supplemental information in response to this RFP will be a binding part of the final contract.

The applicable Sample Professional Services Contract for this RFP can be found at https://careoregon.org/contact-us/vendor-resources.

Professional Services Contract (unless checked, item does not apply) The following paragraphs of the Professional Services Contract will be applicable:

Article I, Paragraph 5 – Travel and Other Expense is Authorized Article II, Paragraph 29 – Protection of Patient Privacy and Security (PHI - BAA required) Article II, Paragraph 30 – Criminal Background Check Requirements Article II, Paragraph 31 – Key Persons https://careoregon.org/contact-us/vendor-resources

RFP 2022-25 Prior Authorization Services Page 4

Article II, Paragraph 32 – On-Call Contract Basis Article II, Paragraph 33 – CareOregon Data Security Requirements (Access to CO data) Article II, Paragraph 34 – Hosted Software

The following insurance requirements will be applicable:

Commercial General Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence, with an annual aggregate limit of $2,000,000 for Bodily Injury and Property Damage.

Professional Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence, with an annual aggregate limit of $2,000,000 for damages caused by error, omission, or negligent acts.

Automobile Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence for Bodily Injury and Property Damage.

Cyber Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence for network security (including data breach), privacy, interruption of business, media liability, and errors and omissions.

RFP 2022-25 Prior Authorization Services Page 5

SECTION 4

EVALUATION PROCEDURE

4.1 An evaluation committee will review all Proposals that are initially deemed responsive, and they shall rank the Proposals in accordance with the below criteria. The evaluation committee may recommend an award based solely on the written responses or may request Proposal interviews/presentations.

Interviews/presentations, if deemed beneficial by the evaluation committee, will consist of the highest scoring Proposers. The invited Proposers will be notified of the time, place, and format of the interview/presentation. Based on the interview/presentation, the evaluation committee may revise their scoring.

Written Proposals must be complete, and no additions, deletions, or substitutions will be permitted during the interview/presentation (if any). The evaluation committee will recommend award of a contract to the final CareOregon decision maker based on the highest scoring Proposal. The CareOregon decision maker reserves the right to accept the recommendation, award to a different Proposer, or reject all Proposals and cancel the RFP.

Proposers are not permitted to directly communicate with any member of the evaluation committee during the evaluation process. All communication must be facilitated through the assigned Procurement Analyst.

4.2 Evaluation Criteria

Category Points available:

Proposer’s General Background and Qualifications 0-30 Scope of Work 0-35 Equity, Diversity, and Inclusion Efforts 0-10 Fees 0-25

Available points 0-100

4.3 Once a selection has been made, CareOregon will enter into contract negotiations. During negotiation, CareOregon may require any additional information it deems necessary to clarify the approach and understanding of the requested services. Any changes agreed upon during contract negotiations will become part of the final contract. The negotiations will identify a level of Work and associated fee that best represents the efforts required. If CareOregon is unable to come to terms with the highest scoring Proposer, discussions shall be terminated, and negotiations will begin with the next highest scoring Proposer. If the resulting contract contemplates multiple phases and CareOregon deems it is in its interest to not authorize any particular phase, it reserves the right to return to this solicitation and commence negotiations with the next highest ranked Proposer to complete the remaining phases.

RFP 2022-25 Prior Authorization Services Page 6

SECTION 5

PROPOSAL CONTENTS

5.1 Vendors must adhere to submission instructions and be advised as follows:

1. Complete Proposals must be emailed to Procurement@careoregon.org. The subject line of the email must identify the RFP title. Proposers are encouraged to contact Procurement to confirm receipt of the Proposal.

2. CareOregon reserves the right to solicit additional information or Proposal clarification from the vendors, or any one vendor, should CareOregon deem such information necessary.

3. Proposal may not exceed a total of 25 pages (single-sided), inclusive of all exhibits, attachments or other information.

4. Proposers are required to structure Proposals following the below question outline. It is important for answers to be clear and concise.

5.2 Proposer’s General Background and Qualifications:

1. Description of the firm.

2. Credentials/experience of key individuals that would be assigned to this project.

3. Description of providing similar services to non-profit entities of similar size within the past five (5) years.

4. Describe your typical customer profile, such as size and service provided. What is your customer retention rates?

5. Description of the firm’s ability to meet the requirements in Section 3 above.

6. Description of what distinguishes the firm from other firms performing a similar service.

7. Describe if your firm is currently or potentially engaged in litigation.

8. Provide information demonstrating that your firm is financially stable.

9. Identify any issues or concerns in social media about your firm?

5.3 Scope of Work

1. Describe your experience performing clinical reviews and providing organizational determination using web-based criteria and customized criteria.

2. Provide information demonstrating your process for ensuring consistent application of clinical review policies? How do you ensure interrater reliability?

3. Describe your experience working with Medicaid requests, including Oregon Health Plan (or similar) prioritized list of covered services.

4. Describe your standard onboarding and training process, including ramp-up period to full production and quality metrics.

5. Provide information regarding productivity and quality standards for your teams.

6. Describe your experience providing member communication ensuring readability standards.

7. Describe your process for translating member communications into their chosen primary language.

5.4 Equity, Diversity and Inclusion Efforts

1. Describe your firm’s equity, diversity and inclusion values, policies, efforts, and successes. Include specific details of efforts and how they have shaped the composition and spirit of your firm.

2. Supplier diversity is the intentional inclusion of historically underutilized businesses in a firm’s supply base to achieve innovation, cost reduction, and building economic growth in our communities. If you plan to use subcontractors or other third-party services for the services proposed to CareOregon, describe your supplier diversity program.

3. Outline the specific elements of your proposed services that will support and advance CareOregon’s equity, diversity, and inclusion mission.

mailto:Procurement@careoregon.org

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5.5 Fees

Fees should be on a time and material with a not to exceed fee basis. Fees should be sufficiently descriptive to facilitate acceptance of a Proposal. Regarding time and material basis – Fees and fee schedules should outline all estimated expenses, hourly rates for all assigned individuals, anticipated travel (if allowed), and other reimbursable expenses. List the not-to-exceed amount you propose for the service for the initial term of the resulting contract. If services are extended past the initial contract term, provide a maximum escalator to the fee for additional optional terms.

5.6 References

Provide at least three (3) references from clients your firm has served similar to CareOregon in the past three (3) years, including one client that has newly engaged the firm in the past thirty-six (36) months and one (1) long-term client. Provide the name, address, email, and phone number of the references. Please note the required three references may not be from CareOregon staff, but additional references may be supplied. Points awarded for these criteria are based on both the providing of references as well as information gleaned from the provided contacts. Evaluation Committee members may contact references at their sole discretion.

5.7 Completed Proposal Certification (see the below form)

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PROPOSAL CERTIFICATION

RFP #2022-25

Submitted by:

(Must be entity’s full legal name, and State of Formation)

Each Proposer must read, complete and submit a copy of this Proposal Certification with their Proposal. Failure to do so may result in rejection of the Proposal. By signature on this Proposal Certification, the undersigned certifies that they are authorized to act on behalf of the Proposer and that under penalty of perjury, the undersigned will comply with the following:

SECTION I. NONDISCRIMINATION: That the Proposer has not and will not discriminate in its employment practices with regard to race, color, creed, age, religious affiliation, sex, marital status, disability, sexual orientation, gender identity, national origin, veteran status, or any other protected class. Nor has Proposer or will Proposer discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owns or an emerging small business that is certified under ORS 200.055.

SECTION II. CONFLICT OF INTEREST: The undersigned hereby certifies that no officer, agent or employee of CareOregon is personally interested, directly or indirectly, in any resulting contract from this RFP, or the compensation to be paid under such contract, and that no representation, statements (oral or in writing), of the CareOregon, its officers, agents, or employees had induced Proposer to submit this Proposal. In addition, the undersigned hereby certifies that this proposal is made without connection with any person, firm, or corporation submitting a proposal for the same material, and is in all respects fair and without collusion or fraud.

SECTION III. COMPLIANCE WITH SOLICITATION: The undersigned further agrees and certifies that they:

1. Have read, understand and agree to be bound by and comply with all requirements, instructions, specifications, terms and conditions of the RFP (including any attachments);

2. Are an authorized representative of the Proposer, that the information provided is true and accurate, and that providing incorrect or incomplete information may be cause for rejection of the Proposal or contract termination; and

3. Will furnish the designated item(s) and/or service(s) in accordance with the RFP and Proposal.

Name:_______________________________________ Date:______________________________________

Signature:____________________________________ Title:______________________________________

Email:_______________________________________ Phone:_____________________________________

Oregon Business Registry Number:________________ OR CCB # (if applicable):________________________

Proposer Primary Point of Contact (Coordination during process and for award information):

Name:_______________________________________

Email:_______________________________________ Phone:_____________________________________

Business Designation (check one):

Corporation Partnership Sole Proprietorship Non-Profit Limited Liability Company

Minority (MBE), Women (WBE), Service-Disabled Veteran (SDV), and Emerging Small Business (ESB):

Certified by the State of Oregon (provide certification number as applicable):

MBE WBE SDV ESB

Self-identified (check as applicable):

MBE WBE SDV ESB