RFQ 99SWC-S107 Medical and Related Services.docx
DOCX document 338 KB Posted
- Attached to
- Medical & Related Services
- Solicitation number
- 99SWC-S107
- Issued by
- Churchill County, Nevada
About this file
This document is a Request for Qualifications (RFQ) issued by the State of Nevada Purchasing Division for Medical & Related Services to be provided statewide as needed. The State is seeking Statements of Qualifications (SOQs) from qualified vendors and will award multiple contracts as determined in the best interests of the State. The contracts will have an initial term of four (4) years with an option to renew for five (5) one (1) year extensions. The State will hold a teleconference on April 11, 2018 to allow vendors to ask questions. Responses will be reviewed and qualified on an ongoing basis, with anticipated Board of Examiners approval on July 10, 2018 and contract start dates upon approval.
The services requested may include a wide range of medical and related services such as anesthesia, audiology, dental, mental health, radiology, therapy, and more. Pricing for the services will be negotiated based on licensure, board certification, experience, and qualifications. The State does not guarantee any minimum volume of service, and the contracts may be used by various state and local government entities, though they are not required to do so. Vendors must meet all mandatory qualifications, including having current Nevada licensure and being in good standing with the applicable boards.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment E Insurance~1.docx | DOCX document | |
| ATTACHMENT F Certification Regarding Lobbying~1.docx | DOCX document | |
| List of Services updated 4-25-18.docx | DOCX document | |
| Attachment C Professional Qualification.pdf | ||
| Attachment D Contract~1.docx | DOCX document | |
| Attachment H Sample Work Order~1.doc | DOC document | |
| Section 3 Background Information Sheet~3.pdf | ||
| Vendor Information Sheet.pdf | ||
| Attachment A 99SWC-S107.docx | DOCX document | |
| Attachment B Submission Letter.pdf |
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Text version
State of Nevada
Brian Sandoval
Department of Administration
Governor
Purchasing Division
Patrick Cates
Director
515 E. Musser Street, Suite 300 Carson City, NV 89701
Jeffrey Haag
Administrator
State of Nevada
Purchasing Division
Request for Qualifications: 99SWC-S107
For
MEDICAL & RELATED SERVICES
Release Date: March 30, 2018
Deadline for Submission and Opening Date and Time: Ongoing
Refer to Section 7, RFQ Timeline for the complete RFQ schedule
For additional information, please contact:
Ronda Miller, Purchasing Officer II
State of Nevada, Purchasing Division
515 E. Musser Street, Suite 300
Carson City, NV 89701
Phone: 775-684-684-0182
Email address: rlmiller@admin.nv.gov
| (TTY for Deaf and Hard of Hearing: | 1-800-326-6868 | |
| Ask the relay agent to dial: | 1-775-684-0182/V.) |
Refer to Section 8 for instructions on submitting an RFQ Response
VENDOR INFORMATION SHEET FOR RFQ 99SWC-S107
Vendor Shall:
A) Provide all requested information in the space provided next to each numbered question. The information provided in Sections V1 through V6 shall be used for development of the contract;
B) Type or print responses; and
C) Include this Vendor Information Sheet in Section III of the Technical SOQ proposal.
| V1 |
| Company Name |
| V2 |
| Street Address |
| V3 |
| City, State, ZIP |
| V4 |
| Telephone Number |
| Area Code: |
| Number: |
| Extension: |
| V5 |
| Facsimile Number |
| Area Code: |
| Number: |
| Extension: |
| V6 |
| Toll Free Number |
| Area Code: |
| Number: |
| Extension: |
| V7 |
| Contact Person for Questions / Contract Negotiations, |
including address if different than above
Name:
Title:
Address:
Email Address:
| V8 |
| Telephone Number for Contact Person |
| Area Code: |
| Number: |
| Extension: |
| V9 |
| Facsimile Number for Contact Person |
| Area Code: |
| Number: |
| Extension: |
| V10 |
| Name of Individual Authorized to Bind the Organization |
| Name: |
| Title: |
| V11 |
| Signature (Individual shall be legally authorized to bind the vendor per NRS 333.337) |
| Signature: |
| Date: |
TABLE OF CONTENTS
| 1. | PROJECT OVERVIEW | 4 |
| 2. | REQUEST FOR QUALIFICATIONS | 4 |
| 3. | BACKGROUND | 6 |
| 4. | COST | 8 |
| 5. | FINANCIAL | 8 |
| 6. | RFQ TIMELINE | 9 |
| 7. | RFQ RESPONSE SUBMISSION REQUIREMENTS, FORMAT AND CONTENT | 9 |
| 8. | RFQ RESPONSE EVALUATION AND AWARD PROCESS | 10 |
| 9. | TERMS AND CONDITIONS | 10 |
| ATTACHMENT A – APPLICATION CHECKLIST | 15 | |
| ATTACHMENT B – SUBMISSION LETTER | 16 | |
| ATTACHMENT C – PROFESSIONAL QUALIFICATION AND CONFIDENTIALITY | 17 | |
| ATTACHMENT D – CONTRACT FORM | 18 | |
| ATTACHMENT E – INSURANCE SCHEDULE | 19 | |
| ATTACHMENT F – CERTIFICATION REGARDING LOBBYING | 20 | |
| ATTACHMENT G – W9 | 21 | |
| ATTACHMENT H – SAMPLE WORKORDER | 22 |
Prospective vendors are advised to review Nevada’s ethical standards requirements, including but not limited to, NRS 281A, which can be found on the Purchasing Division’s website (http://purchasing.nv.gov).
All applicable Nevada Revised Statutes (NRS) and Nevada Administrative Code (NAC) documentation can be found at: www.leg.state.nv.us/law1.cfm.
PROJECT OVERVIEW
The State of Nevada Purchasing Division is seeking Statements of Qualifications (SOQs) from qualified vendors to provide Medical & Related Services statewide as needed.
The State will award multiple contracts in conjunction with this RFQ, as determined in the best interests of the State. The State may award regionally (Northern, Southern, Rural) as needed by using agencies. Vendor’s proposal shall identify the geographic region(s) in which services are being offered.
The State reserves the right to accept vendor proposals for qualifications on an ongoing basis. Any future awards will be written based upon termination dates concurrent with contracts awarded because of the original RFQ. The State does not guarantee any minimum volume of service.
These contracts shall be used by all State agencies located in geographic regions serviced by the contractor. The University and Community College System, the Court System, the Legislative Counsel Bureau, and Political Subdivisions (i.e., cities, counties, school districts, etc.) may use the contract(s) resulting from this RFQ; however, they are not required to do so.
The State will hold a teleconference on April 11, 2018 at 2:00 pm PST to allow vendors to ask questions.
Call in information:
Nevada State Purchasing 775-687-0999 or 702-486-5260 Collaboration Code: 40187#
The State Purchasing Division shall administer contract(s) resulting from this RFQ. The resulting contract(s) shall be for an initial contract term of four (4) years, with an option to renew for five (5) one (1) year extensions, if agreed upon by both parties and in the best interests of the State. Board of Examiners approval anticipated on July 10, 2018. Each qualified vendor is to have an executed contract with the state upon 10 days of receiving an award. Vendors who fail to return an executed contract in 10 days of receipt are subject to disqualification.
REQUEST FOR QUALIFICATIONS
PROCESS
The process by which RFQ Responses shall be considered for award under this RFQ consists of the following:
Eligibility and Evaluation
The determination of whether or not the vendor qualifies under the set of Qualifications (refer to Section 2.3). If a vendor is determined to not meet any of the Qualifications, the response in its entirety shall not be considered for award.
If the vendor meets all the Qualifications, the vendor will be evaluated and placed on list for any State of Nevada agency to utilize.
Once a vendor is placed on the list any using agency will contact vendors dependent upon services needed and present vendor with a work order outlying needs and agreed upon cost.
Initial Evaluation
An evaluation committee will be established to review and qualify the initial responses.
Ongoing Evaluation
Once the initial contracts have been executed, any vendors submitting responses will be reviewed for eligibility and submitted to a review panel for approval to move forward with a contract.
SERVICES
Services may include, but are not limited to:
· Anesthesia;
· Audiology;
· Consultations;
· Dental;
· Diagnosis;
· Diatician;
· Examinations;
· Hospital or surgeon fees.
· Medical facility fees;
· Medical Diagnostic;
· Medicine Management;
· Mental Capacity Evaluation;
· Neurology;
· Orthopedic;
· Optometry (including Specialists);
· Pediatric Physician;
· Pharmacist;
· Prosthetics;
· Psychiatry (including assessments, counseling, employment support, youth);
· Radiology;
· Speech Therapy;
· Therapy (including Occupational, Physical);
· Therapy (including Marriage and Family); and
· Therapy (including drug testing and substance abuse).
QUALIFICATIONS
It is mandatory that each component listed below be addressed and submitted for review. Failure to address each component shall result in disqualification of the RFQ response.
It is mandatory that each vendor have current Nevada licensure and be in good standing with the applicable board.
Vendors proposing to receive an award through this RFQ shall provide the following information:
Application Checklist Submission Letter All applicable license and Insurance Information Professional Qualification and Confidentiality
Note: Agencies using the resulting contracts may have additional documents vendors must sign prior to start date.
BACKGROUND
VENDOR INFORMATION
Vendors shall provide a company profile in the table format below.
| Question |
| Response |
Company name:
Ownership (sole proprietor, partnership, etc.):
State of incorporation:
Date of incorporation:
# of years in business:
List of top officers:
Location of company headquarters:
Location(s) of the office that shall provide the services described in this RFQ:
Location(s) from which employees shall be assigned for this project:
Please be advised, pursuant to NRS 80.010, a corporation organized pursuant to the laws of another state shall register with the State of Nevada, Secretary of State’s Office as a foreign corporation before a contract can be executed between the State of Nevada and the awarded vendor, unless specifically exempted by NRS 80.015.
The selected vendor, prior to doing business in the State of Nevada, shall be appropriately licensed by the State of Nevada, Secretary of State’s Office pursuant to NRS76. Information regarding the Nevada Business License can be located at http://nvsos.gov.
| Question |
| Response |
Nevada Business License Number:
Legal Entity Name:
Is “Legal Entity Name” the same name as vendor is doing business as?
Yes
No
If “No”, provide explanation.
Has the vendor ever been engaged under contract by any State of Nevada agency?
Yes
No
If “Yes”, complete the following table for each State agency for whom the work was performed. Table can be duplicated for each contract being identified.
| Question |
| Response |
Name of State agency:
State agency contact name:
Dates when services were performed:
Type of duties performed:
Total dollar value of the contract:
Are you now or have you been within the last two (2) years an employee of the State of Nevada, or any of its agencies, departments, or divisions?
Yes
No
If “Yes”, please explain when the employee is planning to render services, while on annual leave, compensatory time, or on their own time?
If you employ (a) any person who is a current employee of an agency of the State of Nevada, or (b) any person who has been an employee of an agency of the State of Nevada within the past two (2) years, and if such person shall be performing or producing the services which you shall be contracted to provide under this contract, you shall disclose the identity of each such person in your response to this RFQ, and specify the services that each person shall be expected to perform.
Disclosure of any significant prior or ongoing contract failures, contract breaches, civil or criminal litigation in which the vendor has been alleged to be liable or held liable in a matter involving a contract with the State of Nevada or any other governmental entity. Any pending claim or litigation occurring within the past six (6) years which may adversely affect the vendor’s ability to perform or fulfill its obligations if a contract is awarded as a result of this RFQ shall also be disclosed.
Does any of the above apply to your company?
Yes
No
If “Yes”, please provide the following information. Table can be duplicated for each issue being identified.
| Question |
| Response |
Date of alleged contract failure or breach:
Parties involved:
Description of the contract failure, contract breach, or litigation, including the products or services involved:
Amount in controversy:
Resolution or current status of the dispute:
| If the matter has resulted in a court case: |
| Court |
| Case Number |
Status of the litigation:
Vendors shall review and provide if awarded a contract the insurance requirements as specified in Attachment E, Insurance Schedule for RFQ 99SWC-S107.
COST
Services Provided by Position Classification; may be negotiated individually based on licensure, board certification, experience and certified specialty qualifications or combinations of the aforementioned.
Note: Some programs and services have a set rate and may not be negotiable. This will be determined by the using agency.
FINANCIAL
PAYMENT
Upon review and acceptance by the State, payments for invoices are normally made within 45 – 60 days of receipt, providing all required information, documents and/or attachments have been received.
Pursuant to NRS 227.185 and NRS 333.450, the State shall pay claims for supplies, materials, equipment and services purchased under the provisions of this RFQ electronically, unless determined by the State Controller that the electronic payment would cause the payee to suffer undue hardship or extreme inconvenience.
BILLING
The State does not issue payment prior to receipt of goods or services.
The vendor shall bill the State as outlined in the approved contract and/or payment schedule.
The State presently has a Procurement Card Program that participating State agencies may use to pay for some of their purchases. The Program is issued through a major financial institution and is treated like any other major credit card. Using agencies may desire to use the card as a method of payment. No additional charges or fees shall be imposed for using the card. Please indicate in your proposal response if you will accept
TIMELINESS OF BILLING
The State is on a fiscal year calendar. All billings for dates of service prior to July 1 shall be submitted to the State no later than the third Friday in July of the same year. A billing submitted after the third Friday in July that forces the State to process the billing as a stale claim pursuant to NRS 353.097, shall subject the contractor to an administrative fee not to exceed $100.00. This is the estimate of the additional costs to the State for processing the billing as a stale claim and this amount shall be deducted from the stale claims payment due the contractor.
RFQ TIMELINE
The following represents the proposed timeline for this project. All times stated are Pacific Time (PT). These dates represent a tentative schedule of events. The State reserves the right to modify these dates at any time.
| Task |
| Date/Time |
| RFQ Release |
| March 28, 2018 |
| RFQ Teleconference for Q&A |
| April 11, 2018 @ 2:00 pm PST |
| Deadline for submission and opening of SOQs |
| Ongoing |
| Anticipated BOE approval |
| July 10, 2018 |
| Contract start date (contingent upon BOE approval) |
| Upon BOE approval |
RFQ RESPONSE SUBMISSION REQUIREMENTS, FORMAT AND CONTENT
The vendors initial response will be submitted per this section. Additional information may be required when vendors work with a using agency to determine the scope of work and agreed upon cost. Refer to Attachment H Sample Work Order.
Note: Using agencies may have additional mandated forms they must use.
GENERAL SUBMISSION REQUIREMENTS
Vendors shall submit their proposals by using Create Quote through the State electronic procurement website, https://NevadaEPro.com, in accordance with the instructions below.
Refer to Instructions for Vendors Responding to a Bid in the Important Links section on the front page of NevadaEPro for instructions on how to submit a Quote using NevadaEPro.
The Proposal shall contain the following:
Application Checklist;
Submission Letter;
Professional Qualification and Confidentiality; and All applicable license and Insurance Information
CONFIDENTIALITY
As a potential contractor of a public entity, vendors are advised that full disclosure is required by law.
Vendors are required to submit written documentation in accordance with the RFQ response marked “confidential” conforms to NRS §333.333, which states “Only specific parts of the RFQ response may be labeled a “trade secret” as defined in NRS §600A.030(5)”. Not conforming to these requirements shall cause your proposal to be deemed non-compliant and shall not be accepted by the State of Nevada.
It is the vendor’s responsibility to act in protection of the labeled information and agree to defend and indemnify the State of Nevada for honoring such designation.
Failure to label any information that is released by the State shall constitute a complete waiver of any and all claims for damages caused by release of said information.
RFQ RESPONSE EVALUATION AND AWARD PROCESS
The information in this section does not need to be returned with the vendor’s response.
Qualifications shall be evaluated on a pass/fail basis.
TERMS AND CONDITIONS
PROCUREMENT AND SOQ TERMS AND CONDITIONS
The information in this section does not need to be returned with the vendor’s RFQ response.
This procurement is being conducted in accordance with NRS Chapter 333 and NAC Chapter 333.
The State reserves the right to alter, amend, or modify any provisions of this RFQ, or to withdraw this RFQ, at any time prior to the award of a contract pursuant hereto, if it is in the best interest of the State to do so.
The State reserves the right to waive informalities and minor irregularities in RFQ responses received.
For ease of responding to the RFQ, vendors are encouraged to download the RFQ from the Purchasing Division’s website at https://NevadaEPro.com.
The State reserves the right to reject any or all proposals received prior to contract award (NRS 333.350).
The State reserves the right to limit the scope of work prior to award, if deemed in the best interest of the State per NRS 333.350.
The State shall not be obligated to accept the lowest priced proposal, but shall make an award in the best interest of the State of Nevada after all factors have been evaluated (NRS 333.335).
Proposals which appear unrealistic in the terms of technical commitments, lack of technical competence, or are indicative of failure to comprehend the complexity and risk of this project, may be rejected.
Proposals from employees of the State of Nevada shall be considered in as much as they do not conflict with the State Administrative Manual, NRS Chapter 281 and NRS Chapter 284.
Proposals may be modified or withdrawn by written notice received prior to the proposal opening time. Withdrawals received after the proposal opening time will not be considered except as authorized by NRS 333.350(3).
Vendors are to work with the using agency to determine the scope of work and agreed upon cost. The awarded vendor agrees to provide the services at the costs, rates and fees as set forth in their proposal with using agency No other costs, rates or fees shall be payable to the awarded vendor for implementation of their proposal.
The State is not liable for any costs incurred by vendors prior to entering into a formal contract. Costs of developing the proposal response or any other such expenses incurred by the vendor in responding to the RFQ, are entirely the responsibility of the vendor, and shall not be reimbursed in any manner by the State.
Proposals submitted per proposal submission requirements become the property of the State, selection or rejection does not affect this right; proposals shall be returned only at the State’s option and at the vendor’s request and expense. The flash drive or CD from each vendor shall be retained for official files.
Any unsuccessful vendor may file an appeal in strict compliance with NRS 333.370 and Chapter 333 of the Nevada Administrative Code.
NRS 333.290 grants a preference to materials and supplies that can be supplied from a “charitable, reformatory or penal institution of the State” that produces such goods or services through the labor of inmates. The Administrator reserves the right to secure these goods, materials or supplies from any such eligible institution, if they can be secured of equal quality and at prices not higher than those of the lowest acceptable bid received in response to this solicitation. In addition, NRS 333.410 grants a preference to commodities or services that institutions of the State are prepared to supply through the labor of inmates. The Administrator will apply the preferences stated in NRS 333.290 and 333.410 to the extent applicable.
CONTRACT TERMS AND CONDITIONS
The information in this section does not need to be returned with the vendor’s RFQ response.
The contractual authority, as identified by the not to exceed amount of the contract, does not obligate the State of Nevada to expend funds or purchase goods or services up to that amount; the purchase amount will be controlled by the individual using agency’s purchase orders or other authorized means of requisition for services and/or goods as submitted to and accepted by the vendor.
The awarded vendor will be the sole point of contract responsibility. The State will look solely to the awarded vendor for the performance of all contractual obligations which may result from an award based on this RFQ, and the awarded vendor shall not be relieved for the non-performance of any or all subcontractors.
The awarded vendor shall maintain, for the duration of its contract, insurance coverages as set forth in the fully executed contract. Work on the contract shall not begin until after the awarded vendor has submitted acceptable evidence of the required insurance coverages. Failure to maintain any required insurance coverage or acceptable alternative method of insurance will be deemed a breach of contract.
The State will not be liable for Federal, State, or Local excise taxes per NRS 372.325.
The State reserves the right to negotiate final contract terms with any vendor selected per NAC 333.170. The contract between the parties shall consist of the RFQ together with any modifications thereto, and the awarded vendor’s proposal, together with any modifications and clarifications thereto that are submitted at the request of the State during the evaluation and negotiation process. In the event of any conflict or contradiction between or among these documents, the documents shall control in the following order of precedence: the final executed contract, any modifications and clarifications to the awarded vendor’s proposal, the RFQ, and the awarded vendor’s proposal. Specific exceptions to this general rule may be noted in the final executed contract. The State shall not indemnify vendor from any liability or damages, including but not limited to attorney’s fees and costs, arising under any contract resulting from this RFQ.
Local governments (as defined in NRS 332.015) are intended third party beneficiaries of any contract resulting from this RFQ and any local government may join or use any contract resulting from this RFQ subject to all terms and conditions thereof pursuant to NRS 332.195. The State is not liable for the obligations of any local government which joins or uses any contract resulting from this RFQ.
Any person who requests or receives a Federal contract, grant, loan or cooperative agreement shall file with the using agency a certification that the person making the declaration has not made, and shall not make, any payment prohibited by subsection (a) of 31 U.S.C. 1352.
Pursuant to NRS Chapter 613 in connection with the performance of work under this contract, the contractor agrees not to unlawfully discriminate against any employee or applicant for employment because of race, creed, color, national origin, sex, sexual orientation or age, including, without limitation, with regard to employment, upgrading, demotion or transfer, recruitment or recruitment advertising, layoff or termination, rates of pay or other forms of compensation, and selection for training, including, without limitation apprenticeship.
The contractor further agrees to insert this provision in all subcontracts, hereunder, except subcontracts for standard commercial supplies or raw materials.
PROJECT TERMS AND CONDITIONS
The information in this section does not need to be returned with the vendor’s RFQ response.
Personally Identifiable Information (PII)
If a vendor obtains Social Security numbers or other personally identifiable information as part of its work under this contract the vendors shall protect the confidentiality of that information, including using appropriate network security to safeguard information being stored on computers. Vendor shall immediately inform the State of any data breach that may have exposed Social Security numbers or other personally identifiable information.
Award of Related Contracts
The State may undertake or award supplemental contracts for work related to this project or any portion thereof. The contractor shall be bound to cooperate fully with such other contractors and the State in all cases.
All subcontractors shall be required to abide by this provision as a condition of the contract between the subcontractor and the prime contractor.
State Owned Property
The awarded vendor shall be responsible for the proper custody and care of any State owned property furnished by the State for use in connection with the performance of the contract and shall reimburse the State for any loss or damage.
Inspection/Acceptance of Work
It is expressly understood and agreed all work done by the contractor shall be subject to inspection and acceptance by the State.
Any progress inspections and approval by the State of any item of work shall not forfeit the right of the State to require the correction of any faulty workmanship or material at any time during the course of the work and warranty period thereafter, although previously approved by oversight.
Nothing contained herein shall relieve the contractor of the responsibility for proper installation and maintenance of the work, materials and equipment required under the terms of the contract until all work has been completed and accepted by the State.
Travel
If travel is required, the following processes shall be followed:
All travel shall be approved in writing in advance by the Department.
Requests for reimbursement of travel expenses shall be submitted on the State Claim for Travel Expense Form with original receipts for all expenses.
The travel expense form, with original signatures, shall be submitted with the vendor’s invoice.
Vendor shall be reimbursed travel expenses and per diem at the rates allowed for State employees at the time travel occurs.
The State is not responsible for payment of any premium, deductible or assessments on insurance policies purchased by vendor for a rental vehicle.
ATTACHMENT A – APPLICATION CHECKLIST
To open the document, double click on the icon.
If you are unable to access the above inserted file once you have doubled clicked on the icon, please contact Nevada State Purchasing at srvpurch@admin.nv.gov for an emailed copy
ATTACHMENT B – SUBMISSION LETTER
once you have doubled clicked on the icon, ATTACHMENT C – PROFESSIONAL QUALIFICATION AND CONFIDENTIALITY once you have doubled clicked on the icon, ATTACHMENT D – CONTRACT FORM
Vendors shall review the terms and conditions of the standard contract used by the State for all services of independent contractors. It is not necessary for vendors to complete the contract form with their proposal. To review the contract form, click on the following link:
once you have doubled clicked on the icon, ATTACHMENT E – INSURANCE SCHEDULE
Vendors shall review the Insurance Schedule, as this will be the schedule used for the scope of work.
once you have doubled clicked on the icon, srvpurch@admin.nv.gov for an emailed copy.
ATTACHMENT F – CERTIFICATION REGARDING LOBBYING
once you have doubled clicked on the icon, ATTACHMENT G – W9 once you have doubled clicked on the icon, ATTACHMENT H – SAMPLE WORKORDER
Note: Using agencies may have additional mandated forms they must use.
once you have doubled clicked on the icon, please contact Nevada State Purchasing at srvpurch@admin.nv.gov for an emailed copy
Medical and Related Services RFQ 99SWC-S107 Page 5 of 34 image2.emf
Attachment A Application Checklist.docx
RFQ 99SWC-S107
Attachment A
Application Checklist
(Eligibility Review)
Complete and return this form as part of your submission along with all applicable documentation below.
APPLICANT
STATE USE ONLY
Applicant Name: (please print)
Reviewer Name: (please print)
Area of Expertise:
Area of Expertise:
Region/Location of services:
Region/Location of services:
□ Application Submission Letter
□ Application Submission Letter
□ State Professional or Medical License (list and provide copies) a.____________________________________ b.____________________________________ c.____________________________________ d.____________________________________ e.____________________________________ f._____________________________________
□ State Professional or Medical License (list and provide copies) a.____________________________________ b.____________________________________ c.____________________________________ d.____________________________________ e.____________________________________ f._____________________________________
□ Insurance Requirements
□ Insurance Requirements
□ Nevada Secretary of State Business License
□ Nevada Secretary of State Business License
□ Sent W9
□ Sent W9
Signature Date
Signature Date image3.emf
Attachment B Submission Letter.docx
RFQ #99SWC-S107
ATTACHMENT B
SAMPLE APPLICATION SUBMISSION LETTER: FAILURE TO SUBMIT A LETTER IN THIS FORMAT WITH THE REQUIRED INFORMATION MAY RESULT IN DISQUALIFICATION
[APPLICANTS SHOULD USE THEIR BUSINESS LETTERHEAD]
Date
Applicant Name
Address of Bidder’s Principal Place of Business
Applicant’s Telephone Number
Applicant’s Fax Number
Applicant’s Email Address
Name of Contract Person, if different from Applicant Name
Re: Response Submission for RFQ #____-___
Dear Sir or Madam:
1. Enclosed please find the Response of _______________ (vendor) with respect to the above Request for Qualifications (RFQ). This Response includes all required documents as outlined in Section 2.2 of the RFQ. In addition to these completed Attachments, the response includes the following additional materials (if any):
2. I am authorized to submit this Response on behalf of vendor, to make representations on behalf of vendor and to commit vendor contractually.
3. I have read the Solicitation Document and Sample Contract. In submitting this response, vendor accepts all terms and conditions stated in the Solicitation Document, including those set forth in the following amendments which vendor has downloaded (please complete, indicating if no amendments were issued):
Amendment Number(s) Date(s) Issued
___No Amendments were issued with respect to this RFQ
4. Vendor represents that it meets all minimum qualifications set forth in this RFQ and is capable, willing and able to perform the services described in Section 2.2 Services.
5. By my signature below, I certify that all statements and information provided in Vendor’s Response are true and complete.
Sincerely, (Signature)
Typed Name and Title of Bidder or Authorized Representative image4.emf
Attachment C Professional Qualificaiton and Confidentiality.xlsx Sheet1
Attachment C
PROFESSIONAL QUALIFICATION AND CONFIDENTIALITY
APPLICANT'S NAME:
OFFICE ADDRESS: MAILING:
EMAIL: PHONE:
FAX: BIRTHDATE:
GENDER: MALE: FEMALE:
GRADUATE EDUCATION:
MD
(Name of College) (Year of Degree)
PhD:
(Name of College) (Year of Degree)
PsyD:
(Name of College) (Year of Degree)
EDD:
(Name of College) (Year of Degree)
POST GRADUATE SCHOOL TRAINING (Internship, residency, fellowship, etc):
NAME OF INSTITUTION:
TYPE OF TRAINING:
YEAR OF TRAINING:
LICENSE NUMBER: STATE:
EXPIRATION DATE: TAX ID#
NATIONAL BOARD: YES NO BOARD ELIGIBILITY: YES NO YEAR:
BOARD CERTIFIED: YES NO
NATIONAL REGISTER OF HEALTH SERVICES PROVIDERS ON PSYHCOLOGY: YES NO YEAR:
AREAS OF MEDICAL OR PSYCHOLOGICAL EXPERTISE:
SIGNATURE: DATE:
image5.emf
Attachment D Contract.docx
CETS#
RFQ#
CONTRACT FOR SERVICES OF INDEPENDENT CONTRACTOR
A Contract Between the State of Nevada
Acting by and Through its
Agency Name:
Address:
City, State, Zip Code:
Contact:
Phone:
Fax:
Email:
Contractor Name:
Address:
City, State, Zip Code:
Contact:
Phone:
Fax:
Email:
WHEREAS, NRS 333.700 authorizes officers, departments, institutions, boards, commissions, and other agencies in the Executive Department of the State Government which derive their support from public money in whole or in part to engage, subject to the approval of the Board of Examiners (BOE), services of persons as independent contractors; and
WHEREAS, it is deemed that the service of Contractor is both necessary and in the best interests of the State of Nevada.
NOW, THEREFORE, in consideration of the aforesaid premises, the parties mutually agree as follows:
REQUIRED APPROVAL. This Contract shall not become effective until and unless approved by the Nevada State Board of Examiners.
DEFINITIONS.
“State” – means the State of Nevada and any State agency identified herein, its officers, employees and immune contractors as defined in NRS 41.0307.
“Contracting Agency” – means the State agency identified above.
“Contractor” – means the person or entity identified above that performs services and/or provides goods for the State under the terms and conditions set forth in this Contract.
“Fiscal Year” – means the period beginning July 1st and ending June 30th of the following year.
“Contract” – Unless the context otherwise requires, “Contract” means this document entitled Contract for Services of Independent Contractor and all Attachments or Incorporated Documents.
“Contract for Independent Contractor” – means this document entitled Contract for Services of Independent Contractor exclusive of any Attachments or Incorporated Documents.
1. CONTRACT TERM. This Contract shall be effective as noted below, unless sooner terminated by either party as specified in Section 10, Contract Termination. Contract is subject to Board of Examiners’ approval (anticipated to be Date ).
Effective from:
Date
To:
Date
NOTICE. All communications, including notices, required or permitted to be given under this Contract shall be in writing and directed to the parties at the addresses stated above. Notices may be given: (i) by delivery in person; (ii) by a nationally recognized next day courier service, return receipt requested; or (iii) by certified mail, return receipt requested. If specifically requested by the party to be notified, valid notice may be given by facsimile transmission or electronic mail to the address(es) such party has specified in writing.
INCORPORATED DOCUMENTS. The parties agree that this Contract, inclusive of the following attachments, specifically describes the scope of work. This Contract incorporates the following attachments in descending order of constructive precedence:
ATTACHMENT AA:
STATE SOLICITATION OR RFP # and AMENDMENTS #
ATTACHMENT BB:
INSURANCE SCHEDULE
ATTACHMENT CC:
SERVICES PROVIDED
ATTACHMENT DD:
CONTRACTOR’S RESPONSE
Any provision, term or condition of an Attachment that contradicts the terms of this Contract for Independent Contractor, or that would change the obligations of the State under this Contract for Independent Contractor, shall be void and unenforceable.
CONSIDERATION. The parties agree that Contractor will provide the services specified in Section 5, Incorporated Documents at a cost as noted below:
per
Total Contract or installments payable at:
Total Contract Not to Exceed:
The State does not agree to reimburse Contractor for expenses unless otherwise specified in the incorporated attachments. Any intervening end to a biennial appropriation period shall be deemed an automatic renewal (not changing the overall Contract term) or a termination as the result of legislative appropriation may require.
ASSENT. The parties agree that the terms and conditions listed on incorporated attachments of this Contract are also specifically a part of this Contract and are limited only by their respective order of precedence and any limitations specified.
BILLING SUBMISSION: TIMELINESS. The parties agree that timeliness of billing is of the essence to the Contract and recognize that the State is on a Fiscal Year. All billings for dates of service prior to July 1 must be submitted to the state no later than the third Friday in July of the same calendar year. A billing submitted after the third Friday in July, which forces the State to process the billing as a stale claim pursuant to NRS 353.097, will subject Contractor to an administrative fee not to exceed one hundred dollars ($100.00). The parties hereby agree this is a reasonable estimate of the additional costs to the state of processing the billing as a stale claim and that this amount will be deducted from the stale claim payment due to Contractor.
INSPECTION & AUDIT.
Books and Records. Contractor agrees to keep and maintain under generally accepted accounting principles (GAAP) full, true and complete records, contracts, books, and documents as are necessary to fully disclose to the State or United States Government, or their authorized representatives, upon audits or reviews, sufficient information to determine compliance with all State and federal regulations and statutes.
Inspection & Audit. Contractor agrees that the relevant books, records (written, electronic, computer related or otherwise), including, without limitation, relevant accounting procedures and practices of Contractor or its subcontractors, financial statements and supporting documentation, and documentation related to the work product shall be subject, at any reasonable time, to inspection, examination, review, audit, and copying at any office or location of Contractor where such records may be found, with or without notice by the State Auditor, the relevant State agency or its contracted examiners, the department of Administration, Budget Division, the Nevada State Attorney General’s Office or its Fraud Control Units, the state Legislative Auditor, and with regard to any federal funding, the relevant federal agency, the Comptroller General, the General Accounting Office, the Office of the Inspector General, or any of their authorized representatives. All subcontracts shall reflect requirements of this Section.
Period of Retention. All books, records, reports, and statements relevant to this Contract must be retained a minimum three (3) years, and for five (5) years if any federal funds are used pursuant to the Contract. The retention period runs from the date of payment for the relevant goods or services by the state, or from the date of termination of the Contract, whichever is later. Retention time shall be extended when an audit is scheduled or in progress for a period reasonably necessary to complete an audit and/or to complete any administrative and judicial litigation which may ensue.
CONTRACT TERMINATION.
Termination Without Cause. Regardless of any terms to the contrary, this Contract may be terminated upon written notice by mutual consent of both parties. The State unilaterally may terminate this contract without cause by giving not less than three hundred sixty five (365) days’ notice in the manner specified in Section 4, Notice. If this Contract is unilaterally terminated by the State, Contractor shall use its best efforts to minimize cost to the State and Contractor will not be paid for any cost that Contractor could have avoided.
State Termination for Non-Appropriation. The continuation of this Contract beyond the current biennium is subject to and contingent upon sufficient funds being appropriated, budgeted, and otherwise made available by the State Legislature and/or federal sources. The State may terminate this Contract, and Contractor waives any and all claims(s) for damages, effective immediately upon receipt of written notice (or any date specified therein) if for any reason the contracting Agency’s funding from State and/or federal sources is not appropriated or is withdrawn, limited, or impaired.
Termination with Cause for Breach. A breach may be declared with or without termination. A notice of breach and termination shall specify the date of termination of the Contract, which shall not be sooner than the expiration of the Time to Correct, if applicable, allowed under subsection 10D. This Contract may be terminated by either party upon written notice of breach to the other party on the following grounds:
If Contractor fails to provide or satisfactorily perform any of the conditions, work, deliverables, goods, or services called for by this Contract within the time requirements specified in this Contract or within any granted extension of those time requirements; or
If any state, county, city, or federal license, authorization, waiver, permit, qualification or certification required by statute, ordinance, law, or regulation to be held by Contractor to provide the goods or services required by this Contract is for any reason denied, revoked, debarred, excluded, terminated, suspended, lapsed, or not renewed; or
If Contractor becomes insolvent, subject to receivership, or becomes voluntarily or involuntarily subject to the jurisdiction of the Bankruptcy Court; or
If the State materially breaches any material duty under this Contract and any such breach impairs Contractor’s ability to perform; or
If it is found by the State that any quid pro quo or gratuities in the form of money, services, entertainment, gifts, or otherwise were offered or given by Contractor, or any agent or representative of Contractor, to any officer or employee of the State of Nevada with a view toward securing a contract or securing favorable treatment with respect to awarding, extending, amending, or making any determination with respect to the performing of such contract; or
If it is found by the State that Contractor has failed to disclose any material conflict of interest relative to the performance of this Contract.
Time to Correct. Unless the breach is not curable, or unless circumstances do not permit an opportunity to cure, termination upon declared breach may be exercised only after service of formal written notice as specified in Section 4, Notice, and the subsequent failure of the breaching party within fifteen (15) calendar days of receipt of that notice to provide evidence, satisfactory to the aggrieved party, showing that the declared breach has been corrected. Upon a notice of breach, the time to correct and the time for termination of the contract upon breach under subsection 10C, above, shall run concurrently, unless the notice expressly states otherwise.
Winding Up Affairs Upon Termination. In the event of termination of this Contract for any reason, the parties agree that the provisions of this Section survive termination:
The parties shall account for and properly present to each other all claims for fees and expenses and pay those which are undisputed and otherwise not subject to set off under this Contract. Neither party may withhold performance of winding up provisions solely based on nonpayment of fees or expenses accrued up to the time of termination;
Contractor shall satisfactorily complete work in progress at the agreed rate (or a pro rata basis if necessary) if so requested by the Contracting Agency;
Contractor shall execute any documents and take any actions necessary to effectuate an assignment of this Contract if so requested by the Contracting Agency;
Contractor shall preserve, protect and promptly deliver into State possession all proprietary information in accordance with Section 21, State Ownership of Proprietary Information.
REMEDIES. Except as otherwise provided for by law or this Contract, the rights and remedies of the parties shall not be exclusive and are in addition to any other rights and remedies provided by law or equity, including, without limitation, actual damages, and to a prevailing party reasonable attorneys’ fees and costs. For purposes of an award of attorneys’ fees to either party, the parties stipulate and agree that a reasonable hourly rate of attorneys’ fees shall be one hundred and fifty dollars ($150.00) per hour. The State may set off consideration against any unpaid obligation of Contractor to any State agency in accordance with NRS 353C.190. In the event that Contractor voluntarily or involuntarily becomes subject to the jurisdiction of the Bankruptcy Court, the State may set off consideration against any unpaid obligation of Contractor to the State or its agencies, to the extent allowed by bankruptcy law, without regard to whether the procedures of NRS 353C.190 have been utilized.
LIMITED LIABILITY. The State will not waive and intends to assert available NRS Chapter 41 liability limitations in all cases. Contract liability of both parties shall not be subject to punitive damages. Damages for any State breach shall never exceed the amount of funds appropriated for payment under this Contract, but not yet paid to Contractor, for the Fiscal Year budget in existence at the time of the breach. Contractor’s tort liability shall not be limited.
FORCE MAJEURE. Neither party shall be deemed to be in violation of this Contract if it is prevented from performing any of its obligations hereunder due to strikes, failure of public transportation, civil or military authority, act of public enemy, accidents, fires, explosions, or acts of God, including without limitation, earthquakes, floods, winds, or storms. In such an event the intervening cause must not be through the fault of the party asserting such an excuse, and the excused party is obligated to promptly perform in accordance with the terms of the Contract after the intervening cause ceases.
INDEMNIFICATION AND DEFENSE. To the fullest extent permitted by law, Contractor shall indemnify, hold harmless and defend, not excluding the State’s right to participate, the State from and against all liability, claims, actions, damages, losses, and expenses, including, without limitation, reasonable attorneys’ fees and costs, arising out of any breach of the obligations of Contractor under this contract, or any alleged negligent or willful acts or omissions of Contractor, its officers, employees and agents. Contractor’s obligation to indemnify the State shall apply in all cases except for claims arising solely from the State’s own negligence or willful misconduct. Contractor waives any rights of subrogation against the State. Contractor’s duty to defend begins when the State requests defense of any claim arising from this Contract.
REPRESENTATIONS REGARDING INDEPENDENT CONTRACTOR STATUS. Contractor represents that it is an independent contractor, as defined in NRS 333.700(2) and 616A.255, warrants that it will perform all work under this contract as an independent contractor, and warrants that the State of Nevada will not incur any employment liability by reason of this Contract or the work to be performed under this Contract. To the extent the State incurs any employment liability for the work under this Contract; Contractor will reimburse the State for that liability.
INSURANCE SCHEDULE.
Refer to Attachment H of the RFQ for Insurance Requirements.
COMPLIANCE WITH LEGAL OBLIGATIONS. Contractor shall procure and maintain for the duration of this Contract any state, county, city or federal license, authorization, waiver, permit qualification or certification required by statute, ordinance, law, or regulation to be held by Contractor to provide the goods or services required by this Contract. Contractor shall provide proof of its compliance upon request of the Contracting Agency. Contractor will be responsible to pay all taxes, assessments, fees, premiums, permits, and licenses required by law. Real property and personal property taxes are the responsibility of Contractor in accordance with NRS 361.157 and NRS 361.159. Contractor agrees to be responsible for payment of any such government obligations not paid by its subcontractors during performance of this Contract.
WAIVER OF BREACH. Failure to declare a breach or the actual waiver of any particular breach of the Contract or its material or nonmaterial terms by either party shall not operate as a waiver by such party of any of its rights or remedies as to any other breach.
SEVERABILITY. If any provision contained in this Contract is held to be unenforceable by a court of law or equity, this Contract shall be construed as if such provision did not exist and the non-enforceability of such provision shall not be held to render any other provision or provisions of this Contract unenforceable.
ASSIGNMENT/DELEGATION. To the extent that any assignment of any right under this Contract changes the duty of either party, increases the burden or risk involved, impairs the chances of obtaining the performance of this Contract, attempts to operate as a novation, or includes a waiver or abrogation of any defense to payment by State, such offending portion of the assignment shall be void, and shall be a breach of this Contract. Contractor shall neither assign, transfer nor delegate any rights, obligations nor duties under this Contract without the prior written consent of the State.
STATE OWNERSHIP OF PROPRIETARY INFORMATION. Any data or information provided by the State to Contractor and any documents or materials provided by the State to Contractor in the course of this Contract (“State Materials”) shall be and remain the exclusive property of the State and all such State Materials shall be delivered into State possession by Contractor upon completion, termination, or cancellation of this Contract.
PUBLIC RECORDS. Pursuant to NRS 239.010, information or documents received from Contractor may be open to public inspection and copying. The State has a legal obligation to disclose such information unless a particular record is made confidential by law or a common law balancing of interests. Contractor may label specific parts of an individual document as a “trade secret” or “confidential” in accordance with NRS 333.333, provided that Contractor thereby agrees to indemnify and defend the State for honoring such a designation. The failure to so label any document that is released by the State shall constitute a complete waiver of any and all claims for damages caused by any release of the records.
CONFIDENTIALITY. Contractor shall keep confidential all information, in whatever form, produced, prepared, observed or received by Contractor to the extent that such information is confidential by law or otherwise required by this Contract.
FEDERAL FUNDING. In the event federal funds are used for payment of all or part of this Contract, Contractor agrees to comply with all applicable federal laws, regulations and executive orders, including, without limitation the following:
Contractor certifies, by signing this Contract, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in this transaction by any federal department or agency. This certification is made pursuant to Executive Orders 12549 and 12689 and Federal Acquisition Regulation subpart 9.4, and any relevant program-specific regulations. This provision shall be required of every subcontractor receiving any payment in whole or in part from federal funds.
Contractor and its subcontracts shall comply with all terms, conditions, and requirements of the Americans with Disabilities Act of 1990 (P.L. 101-136), 42 U.S.C. 12101, as amended, and regulations adopted thereunder, including 28 C.F.R. Section 35, inclusive, and any relevant program-specific regulations.
Contractor and it subcontractors shall comply with the requirements of the Civil Rights Act of 1964 (P.L. 88-352), as amended, the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and any relevant program-specific regulations, and shall not discriminate against any employee or offeror for employment because of race, national origin, creed, color, sex, religion, age, disability or…
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