RFP ATTACHMENTS.docx

THE DEPARTMENT OF BEHAVIORAL HEALTH AND

DEVELOPMENTAL SERVICES (DBHDS)

1220 BANK STREET

RICHMOND, VA 23219

NOTE TO OFFEROR:

The following attachments must be completed, and submitted as your proposal; failure to submit a complete proposal may result in you receiving lower evaluation scores.

The following documents must be completed and submitted as your proposal as an attachment.

Resumes of all staff to be assigned to a contract, if awarded.

Copies of degrees and/or certificates for all staff assigned to this contract, if awarded.

A copy of a valid license to provide dentistry services in the State of Virginia, if awarded.

Credentials and training of staff assigned to provide services, if awarded.

ATTACHMENT A: OFFEROR DATA SHEET

The offeror must have the capability and capacity in all respects in order to fully satisfy all of the contractual requirements.

OFFEROR/COMPANY NAME:

COMPANY ADDRESS:

eVA VENDOR ID#:

DSBSD CERTIFICATION #:

DSBSD CERTIFICATION TYPE & EXPIRATION:

DUNS#:

ARE YOU A SUBSIDIARY FIRM?

YES NO

If yes, list the name and location of your parent afficiation:

CONTRACTOR’S REPRESENTATIVE:

The Contractor shall assign one (1) representative to be in contact with DBHDS for any questions regarding your proposal; as well as any contract that may result from this solicitation. The Contractor’s representative shall handle and resolve all issues including, but not limited to billing and reporting.

Representative’s Name:

Representative’s Telephone:

Representative’s Email:

ADDRESS WHERE DENTAL SERVICES SHALL BE PROVIDED (If you have more than one location, provide the Address for each location);

ADDENDUM ACKNOWLEDGEMENT (if applicable): I/We acknowledge receipt of the following addendum:

Addendum No: ____________________ Dated: _________________________ Addendum No: ____________________ Dated: _________________________ Addendum No: ____________________ Dated: _________________________

☐ I understand the Contractor Requirements as stated in Section IV. Statement of Needs. I agree to adhere to each of the requirements stated in statement of needs. If anything changes at any time during the contract period, I shall notify the DBHDS Contract Administrator, in writing, within two (2) business days.

☐ I understand and agree to the Fixed Rate Service Model as described in Section X. Pricing Schedule and the corresponding Attachments.

OFFEROR QUESTIONNAIRE: Do not leave anything blank, write “N/A” or “none” for anything that’s not applicable.

COMPANY BACKGROUND INFORMATION:

How many full-time employees does your company have? __________________________________________ How many part-time employees does your company have? __________________________________________ What is the annual volume of business? _________________________________________________________ How long have you been providing dentistry services? _____________________________________________ Have you practiced in any other states? _________________________________________________________ If yes, where and for how long? _______________________________________________________________

SPECIFIC PLANS FOR PROVIDING THE PROPOSED SERVICES, IF AWARDED A CONTRACT.

What is your plan to achieve the objectives as defined in Section IV. Statement of Needs?

How will your company work to transition individuals from other dentists that may be currently providing services to your office?

How will your company establish a timeline for the transition of services?

SELF EVALUATION.

Describe the specific features that may distinguish you/your company from other dentists.

How do you evaluate the effectiveness of the services that you/your company provides?

CUSTOMER SERVICE.

How will you/your company deal with problems and/or complaints presented by the DBHDS Dental Program Lead?

How will you/your company deal with problems and/or complaints presented by an individual and/or family member?

If problems and/or complaints are initially handled by anyone other than you, at what point would it be escalated to you?

KEY PERFORMANCE INDICATORS (KPI). Identify metrics that shall be used in measuring your/your company’s performance against the resulting contract. The KPI’s must be:

Specific, Measurable, Attainable, Reportable & Trackable

In compliance with this Request For Proposals (RFP) and all conditions imposed in this RFP, the undersigned firm hereby offers and agrees to furnish all goods and services in accordance with the attached signed proposal or as mutually agreed upon by subsequent negotiation, and the undersigned firm hereby certifies that all information provided below and in any schedule attached hereto is true, correct, and complete.

Name of Firm:

Address of Firm:

Printed Name:

Signature:

Email Address:

Date:

ATTACHMENT B: SMALL BUSINESS SUBCONTRACTING PLAN

It is the goal of the Commonwealth that over 42% of its purchases be made from small businesses. All potential offerors are required to return this document with their response.

Small Business: "Small business (including micro)” means a business which holds a certification as such by the Virginia Department of Small Business and Supplier Diversity (DSBSD) on the due date for proposals. This shall also include DSBSD-certified women- owned and minority-owned businesses and businesses with DSBSD service disabled veteran owned status when they also hold a DSBSD certification as a small business on the proposal due date. Currently, DSBSD offers small business certification and micro business designation to firms that qualify.

Certification applications are available through DSBSD online at www.SBSD.virginia.gov (Customer Service).

Offeror Name:

Instructions A. If you are certified by the DSBSD as a micro/small business, complete only Section A of this form.

B. If you are not a DSBSD-certified small business, complete Section B of this form. For the offeror to receive credit for the small business subcontracting plan evaluation criteria, the offeror shall identify the portions of the contract that will be subcontracted to DSBSD-certified small business for the initial contract period the initial contract period in Section B.

Offerors which are small businesses themselves will receive the maximum available points for the small business participation plan evaluation criterion, and do not have any further subcontracting requirements.

Offerors which are not certified small businesses will be assigned points based on proposed expenditures with DSBSD certified small businesses for the initial contract period in relation to the offeror’s total price for the initial contract period.

Points will be assigned based on each offeror’s proposed subcontracting expenditures with DSBSD-certified small businesses for the initial contract period as indicated in Section B in relation to the offeror’s total price.

Section A If your firm is certified by the DSBSD provide your certification number and the date of certification.

Certification number: Certification Date:

Section B If the “I plan to use subcontractors box is checked,” populate the requested information below, per subcontractor to show your firm's plans for utilization of DSBSD-certified small businesses in the performance of this contract for the initial contract period in relation to the offeror’s total price for the initial contract period. Certified small businesses include but are not limited to DSBSD-certified women-owned and minority-owned businesses and businesses with DSBSD service disabled veteran-owned status that have also received the DSBSD small business certification. Include plans to utilize small businesses as part of joint ventures, partnerships, subcontractors, suppliers, etc. It is important to note that these proposed participation will be incorporated into the subsequent contract and will be a requirement of the contract. Failure to obtain the proposed participation dollar value or percentages may result in breach of the contract.

B. Plans for Utilization of DSBSD-Certified Small Businesses for this Procurement

SUBCONTRACTOR #1:

Description of Work:

SUBCONTRACTOR #2:

Description of Work:

SUBCONTRACTOR #3:

Description of Work:

ATTACHMENT C: STATE CORPORATION COMMISION FORM

Virginia State Corporation Commission (SCC) registration information.

is a corporation or other business entity with the following SCC identification number: ____________ is not a corporation, limited liability company, limited partnership, registered limited liability partnership, or business trust is an out-of-state business entity that does not regularly and continuously maintain as part of its ordinary and customary business any employees, agents, offices, facilities, or inventories in Virginia (not counting any employees or agents in Virginia who merely solicit orders that require acceptance outside Virginia before they become contracts, and not counting any incidental presence of the offeror in Virginia that is needed in order to assemble, maintain, and repair goods in accordance with the contracts by which such goods were sold and shipped into Virginia from offeror’s out-of-state location) is an out-of-state business entity that is including with this proposal an opinion of legal counsel which accurately and completely discloses the undersigned offeror’s current contacts with Virginia and describes why those contacts do not constitute the transaction of business in Virginia within the meaning of § 13.1-757 or other similar provisions in Titles 13.1 or 50 of the Code of Virginia.

**NOTE** >> Check the following box if you have not completed any of the foregoing options but currently have pending before the SCC an application for authority to transact business in the Commonwealth of Virginia and wish to be considered for a waiver to allow you to submit the SCC identification number after the due date for proposals (the Commonwealth reserves the right to determine in its sole discretion whether to allow such waiver):

The Offeror:

ATTACHMENT D: PROPRIETARY/CONFIDENTIAL INFORMATION IDENTIFICATION

Trade secrets or proprietary information submitted by an Offeror shall not be subject to public disclosure under the Virginia Freedom of Information Act; however, the Offeror must invoke the protections of § 2.2-4342F of the Code of Virginia, in writing, either before or at the time the data or other material is submitted. The written notice must specifically identify the data or materials to be protected including the section of the proposal in which it is contained, as well as the page numbers, and must state the reasons why protection is necessary. The proprietary or trade secret material submitted must be identified by some distinct method such as highlighting or underlining and must indicate only the specific words, figures, or paragraphs that constitute trade secret or proprietary information. In addition, a summary of proprietary information submitted shall be submitted on this form. The classification of an entire proposal document, line item prices, and/or total proposal prices as proprietary or trade secrets is not acceptable. If, after being given reasonable time, the Offeror refuses to withdraw such a classification designation, the proposal will be rejected.

Name of Firm/Offeror: ______________________________, invokes the protections of § 2.2-4342F of the Code of Virginia for the following portions of my proposal submitted on __________ (Date).

Signature:

Title:

ATTACHMENT E: BUSINESS ASSOCIATE AGREEMENT

COMMONWEALTH of VIRGINIA

DEPARTMENT OF

Richmond, VA 23218-1797

BUSINESS ASSOCIATE AGREEMENT

PRIVACY AND SECURITY OF PROTECTED HEALTH INFORMATION

THIS BUSINESS ASSOCIATE AGREEMENT is made as of ENTER DATE, by the Department of Behavioral Health and Developmental Services (herein referred to as “Covered Entity”), with an office at 1220 Bank Street, Richmond, VA 23219 and [Insert Name of Business Associate] (here in referred to as “Business Associate”), a corporation, department or other entity with office at [Insert Location of Business Associate].

This BUSINESS ASSOCIATE AGREEMENT (herein referred to as the “Agreement”) constitutes a non-exclusive agreement between the Covered Entity, which administers health services, and the Business Associate named above.

The Covered Entity and Business Associate have entered into this Business Associate Agreement to comply with the Health Insurance Portability and Accountability Act (HIPAA). The parties signing this Agreement shall comply fully with the provisions of the HIPAA Rules.

NOW THEREFORE, the parties, intending to be legally bound, agree as follows:

I. Definitions: As used in this contract, the terms below will have the following meanings:

a. Business Associate shall generally have the same meaning as the term “business associate” at 45 CFR 160.103, and in reference to the party to this agreement, shall mean [Insert Name of Business Associate].

b. Covered Entity shall generally have the same meaning as the term “covered entity” at 45 CFR 160.103, and in reference to the party to this agreement, shall mean Department of Behavioral Health and Developmental Services.

c. Protected Health Information (PHI): Any information that is created or received by a Covered Entity that relates to the past, present, or future physical or mental health or condition of an individual, limited to the information created or received by Business Associate from or on behalf of Covered Entity.

d. HIPAA Rules shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Part 160 and Part 164.

II. Obligations and Activities of Business Associate:

a. Business Associate agrees to not use or disclose Protected Health Information other than as permitted or required by the Agreement or as required by law.

b. Business Associate agrees to use appropriate safeguards and comply with Subpart C of 45 C.F.R. Part 164 to prevent use or disclosure of the Protected Health Information other than as provided for by this Agreement.

c. Business Associate agrees to report to Covered Entity any use or disclosure of the Protected Health Information not provided for by this Agreement of which it becomes aware, including breaches of unsecured protected health information, as required at 45 C.F.R. 164.410.

d. In accordance with 45 C.F.R. 164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that any subcontractors that create, receive, maintain, or transmit protected health information on behalf of the Business Associate agree to the same restrictions, conditions, and requirements that apply to the Business Associate with respect to such information.

e. Report to the Covered Entity any security incident of which it becomes aware.

f. Business Associate shall notify the Covered Entity of a breach of unsecured PHI on the first day on which such breach is known by Business Associate or an employee, officer or agent of Business Associate other than the person committing the breach, or as soon as possible following the first day on which Business Associate or an employee, officer or agent of Business Associate other than the person committing the breach should have known by exercising reasonable diligence of such breach. Notification shall include, to the extent possible, the identification of each individual whose unsecured PHI has been, or is reasonably believed by the Business Associate to have been, accessed, acquired, used or disclosed during the breach. Business Associate shall also provide the Covered Entity with any other available information at the time Business Associate makes notification to the Covered Entity or promptly thereafter as information becomes available. Such additional information shall include (i) a brief description of what happened, including the date of the breach; (ii) a description of the types of unsecured PHI that were involved in the breach; (iii) any steps the Business Associate believes individuals should take to protect themselves from potential harm resulting from the breach; and (iv) a brief description of what Business Associate is doing to investigate the breach, mitigate harm to individuals, and protect against any future breaches.

For purposes of this paragraph, unsecured PHI means protected health information that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by the U.S. Secretary of Health and Human Services.

g. Business Associate agrees to provide access, at the request of Covered Entity to Protected Health Information to Covered Entity or, as directed by Covered Entity, to an Individual in order to meet the requirements under 45 CFR 164.524.

h. Business Associate agrees to make internal practices, books, and records, including policies and procedures and Protected Health Information, available to the Secretary of the U.S. Department of Health and Human Services for the purpose of determining compliance with the HIPAA Rules.

i. Business Associate agrees to document and provide to Covered Entity such disclosures of Protected Health Information and information as would be required for Covered Entity to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528.

j. Make any amendment(s) to Protected Health Information in a designated record set as directed or agreed to by the covered entity pursuant to 45 C.F.R. 164.526, or take other measures as necessary to satisfy covered entity's obligations under 45 C.F.R. 164.526.

III. General Use and Disclosure Provisions:

a. Business Associate may only use or disclose Protected Health Information as provided in the underlying Agreement

b. Business Associate may use or disclose Protected Health Information as required by law.

c. Business Associate agrees to make uses and disclosures and requests for Protected Health Information consistent with Covered Entity’s minimum necessary policies and procedures.

d. Business Associate may not use or disclose Protected Health Information in a manner that would violate Subpart E of 45 CFR Part 164 if done by covered entity, except for the specific uses and disclosures set forth below.

e. Business Associate may disclose Protected Health Information for the proper management and administration of the Business Associate, provided that disclosures are required by law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached.

IV. Obligations of Covered Entity:

a. Covered Entity shall notify Business Associate of any limitations in its notice of privacy practices of Covered Entity in accordance with 45 CFR 164.520, to the extent that such limitation may affect Business Associate’s use or disclosure of Protected Health Information.

b. Covered Entity shall notify Business Associate of any changes in, or revocation of, permission by Individual to use or disclose Protected Health Information, to the extent that such changes may affect Business Associate’s use or disclosure of Protected Health Information.

c. Covered Entity shall notify Business Associate of any restriction to the use or disclosure of Protected Health Information that Covered Entity has agreed to in accordance with 45 CFR 164.522, to the extent that such restriction may affect Business Associate’s use or disclosure of Protected Health Information.

V. Permissible Request by Covered Entity:

Covered Entity shall not request Business Associate to use or disclose Protected Health Information in any manner that would not be permissible under the Privacy Rule if done by Covered Entity.

VI. Termination:

Either party may terminate this Agreement immediately if it determines that the other party has violated a material term of this Agreement. This Agreement shall remain in effect unless terminated for cause with immediate effect, or until terminated by either party with not less than thirty (30) days prior written notice to the other party, which notice shall specify the effective date of the termination; provided, however, that any termination shall not affect the respective obligations or rights of the parties arising under this Agreement before the effective date of termination.

VII. Effect of Termination:

Upon termination of this Agreement for any reason, Business Associate shall return or destroy all Protected Health Information received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity. This provision shall apply to Protected Health Information that is in the possession of subcontractors or agents of Business Associate. Business Associate shall retain no copies of the Protected Health Information. In the event that Business Associate determines that returning or destroying the Protected Health Information is infeasible, Business Associate shall provide to Covered Entity notification of the conditions that make return or destruction of Protected Health Information infeasible. Upon agreement that return or destruction of Protected Health Information is infeasible, Business Associate shall extend the protections of this Agreement to such Protected Health information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such Protected Health Information.

VIII. Amendment:

Upon the enactment of any law or regulation affecting the use or disclosure of PHI, or the publication of any decision of a court of the United States or of this state relating to any such law, or the publication of any interpretive policy or opinion of any governmental agency charged with the enforcement of any such law or regulation, the parties shall work in good faith to amend this Agreement in such manner as is necessary to comply with such law or regulation. If the parties are unable to agree on an amendment within thirty (30) days thereafter, either of them may terminate this Agreement by written notice to the other.

EACH PARTY has caused this Agreement to be properly executed on its behalf as of the date first above written.

CONTRACTOR:

PURCHASING AGENCY: Department of Behavioral Health and Developmental Services

[endnoteRef:1] [1: ]

Issuing Office: DBHDS Office of Information Services & Technology File Name: DBHDS Business Associate Agreement Original: 05/27/2016 Revised: 3/30/2020 Professional Services RFP#720-5228-115358 (Attachments) image3.png image1.gif image2.png