S-44300-00001750.pdf

OregonBuys Bid # S-44300-00001750

STATE OF OREGON

COVER PAGE

OREGON STATE HOSPITAL (OSH)

JUNCTION CITY CAMPUS

IS ISSUING THIS INTERMEDIATE PROCUREMENT UNDER OREGON

BUYS # S-44300-00001750

OPTOMETRY ASSESSMENTS

Date of Issue: January 24, 2022

Opening Date: February 25, 2022

Single Point of Contact (SPC): Mark Bustamante

Address: 635 Capitol Street

City, State, Zip Salem, OR 97301

E-mail: mark.bustamante@dhsoha.state.or.us mailto:mark.bustamante@dhsoha.state.or.us

TABLE OF CONTENTS

SECTION 1: GENERAL INFORMATION

1.1 INTRODUCTION

1.2 SCHEDULE

1.3 SINGLE POINT OF CONTACT (SPC)

SECTION 2: AUTHORITY, OVERVIEW, AND SCOPE

2.1 AUTHORITY AND METHOD

2.2 DEFINITION OF TERMS

2.3 OVERVIEW AND PURPOSE

2.4 SCOPE OF WORK/SPECIFICATIONS

SECTION 3: PROCUREMENT REQUIREMENTS AND EVALUATION

3.1 MINIMUM OFFER REQUIREMENTS

3.2 MINIMUM SUBMISSION REQUIREMENTS

3.3 PROCUREMENT PROCESS

3.4 OFFERS CONTENT REQUIREMENTS

3.5 EVALUATION PROCESS

3.6 COST EVALUATION

3.7 NEXT STEP DETERMINATION

3.8 PREFERENCES

3.9 POINT AND SCORE CALCULATIONS

3.10 RANKING OF OFFERORS

SECTION 4: AWARD AND NEGOTIATION

4.1 AWARD NOTIFICATION PROCESS

4.2 CONTRACT NEGOTIATION

SECTION 5: ADDITIONAL INFORMATION

5.1 CERTIFIED FIRM PARTICIPATION

5.2 GOVERNING LAWS AND REGULATIONS

5.3 OWNERSHIP/PERMISSION TO USE MATERIALS

5.4 CANCELLATION OF SOLICITATION; REJECTION OF OFFERS; NO DAMAGES

5.5 COST OF SUBMITTING AN OFFER

5.6 STATEWIDE E-WASTE/RECOVERY PROCEDURE

5.7 RECYCLABLE PRODUCTS

SECTION 6: LIST OF ATTACHMENTS

ATTACHMENT A SAMPLE CONTRACT

ATTACHMENT B DISCLOSURE EXEMPTION AFFIDAVIT

ATTACHMENT C OFFEROR INFORMATION AND CERTIFICATION SHEET

ATTACHMENT D REFERENCE CHECK FORM

ATTACHMENT E COST SHEET

ATTACHMENT F COBID CERTIFICATION / OUTREACH PLAN

ATTACHMENT G RESPONSIBILITY INQUIRY

https://www.oregon.gov/das/Procurement/Tutorials/TOC.mp4 https://www.oregon.gov/das/Procurement/Tutorials/TOC.mp4

SECTION 1: GENERAL INFORMATION

1.1 INTRODUCTION

The State of Oregon, acting by and through the Oregon Health Authority, (“Agency”), is issuing this Intermediate Procurement for an Optometrist to provide routine Optometry Assessments for OSH patients at the Junction City Campus.

Additional details on the Scope of the goods or services or both are included in the Scope of Work section.

Agency anticipates the award of one Contract from this solicitation. The initial term of the Contract is anticipated to be XX years with options to renew up to a maximum of XX years.

1.2 SCHEDULE

The table below represents a tentative schedule of events. All times are listed in Pacific Time. All dates listed are subject to change. N/A denotes that event is not applicable to this solicitation.

Event Date Time

Questions / Requests for Clarification Due 02/11/2022 3:00 PM

Opening (offer Due) 02/25/2022 3:00 PM

Issuance of Notice of Award (approx.) 03/04/2022

1.3 SINGLE POINT OF CONTACT (SPC)

The SPC for this solicitation is identified on the Cover Page, along with the SPC’s contact information. Offeror shall direct all communications related to any provision of the solicitation, whether about the technical requirements of the solicitation, contractual requirements, the solicitation process, or any other provision only to the SPC.

SECTION 2: AUTHORITY, OVERVIEW, AND SCOPE

2.1 AUTHORITY AND METHOD

Agency is issuing this solicitation pursuant to its authority under ORS 413.033.

Agency is using the Intermediate Procurement solicitation method set forth in ORS 279B.070 and OAR .

2.2 DEFINITION OF TERMS

For the purposes of this solicitation, capitalized words will refer to the following definitions.

2.2.1 General Definitions

Capitalized terms not specifically defined in this document are defined in OAR 137.047.0100.

2.3 OVERVIEW AND PURPOSE

The State of Oregon, Oregon Health Authority (OHA) is soliciting for a provider of

Optometry Services that is able to provide these services to patients for Oregon State

Hospital (OSH). OSH services are provided at the Junction City location. Oregon State

Hospital is the State of Oregon’s largest provider of rehabilitative psychiatric care to patients found guilty except for insanity; unfit to stand trial; civilly committed; or otherwise admitted to OSH. Contract may be issued to the highest ranked Proposer meeting the minimum qualifications and willing to perform the Services at the rates specified in the Contract, as established by OHA. In addition to the Proposal, the

Proposer must complete and return the Contractor Tax Identification Information, included as Attachment 2 to this RFP.

The Contractor shall provide Services at the agreed-upon rates, as shall be specified in the

Payment Provisions issued to Contractor for specific Person Directed Services. Once a

Contractor’s proposal has been accepted, and a Contract has been executed between

Contractor and OHA, the Contractor will become enrolled as a Provider for Medicaid and

Medicare billing purposes.

The Contract will be issued for a term of approximately five (5) year from the effective date of the Contract. OHA reserves the right to amend and modify the consideration (the

Work to be performed or the rates of payment) according to the terms of the Contract.

Any amendments to a Contract must be in writing.

OHA will issue a Contract, a sample of which is included in this RFP Attachment A

Sample Contract.”

OHA makes no guarantee of referrals or the amount of Work to be referred to any

Provider for Services. Referral is based on the need for specific Contractor.

2.4 SCOPE OF WORK/SPECIFICATIONS

Provide routine optometry consultations and assessments for OHA patients in Junction City for about 8 hours per month. Document all findings, testing, procedures, results, and recommendation.

SECTION 3: PROCUREMENT REQUIREMENTS AND EVALUATION

3.1 MINIMUM OFFER REQUIREMENTS

3.1.1 BUSINESS

• Must be legally able to conduct business in the State of Oregon

• A documented minimum of three (3) years’ experience in Optometry Assessments.

• Possess a degree from a US accredited college of Optometry.

• Upon execution of the contract, obtain and maintain necessary insurance requirements as stated in Attachment A, Exhibit C, throughout the life of the contract.

3.2 MINIMUM SUBMISSION REQUIREMENTS

3.2.1 Offeror Format and Quantity

Offer should follow the format and reference the sections listed in the Offer Content Requirements section. Responses to each section and subsection should be labeled to indicate the item being addressed. Offer must describe in detail how requirements of this solicitation will be met and may provide additional related information.

Offeror shall submit one electronic copy of its Offer to the Single Point of Contact at:

mark.bustamante@dhsoha.state.or.us . In addition, if Offeror believes any of its Offer is exempt from disclosure under Oregon Public Records Law (ORS 192.311 through 192.478), Offeror shall complete and submit the Disclosure Exemption Affidavit (Attachment B) and a fully redacted version of its Offer, clearly identified as the redacted version.

3.2.2 Authorized Representative

A representative authorized to bind the Offeror shall sign the Offer. Failure of the authorized representative to sign the Offer may subject the offer to rejection by Agency.

3.3 PROCUREMENT PROCESS

3.3.1 Public Notice

The solicitation, including all Amendments and attachments, are published in the OregonBuys e-procurement system Solicitation documents will not be mailed to prospective Offerors.

Agency shall advertise all Amendments on OregonBuys e-procurement system.

Prospective Offeror is solely responsible for checking OregonBuys to determine whether or not any Amendments have been issued. Amendments are incorporated into the solicitation by this reference.

3.3.2 Questions / Requests for Clarification

All inquiries, whether relating to the solicitation process, administration, deadline or method of award, or to the intent or technical aspects of the solicitation must:

https://oregonbuys.gov/bso

• Be emailed to the SPC

• Reference the OregonBuys bid number

• Identify Offeror’s name and contact information

• Be sent by an authorized representative

• Refer to the specific area of the solicitation being questioned (i.e. page, section and paragraph number); and

• Be received by the due date and time for Questions/Requests for Clarification identified in the Schedule

3.3.3 Pre-Offer Conference

A pre-submittal conference will not be held for this solicitation.

3.3.4 Offer Submission

Offeror is solely responsible for ensuring its Offer is received by the SPC in accordance with the solicitation requirements before Opening. Agency is not responsible for any delays in mail or by common carriers or by transmission errors or delays or mistaken delivery. Offers submitted by any means not authorized may be rejected.

Offers must be submitted electronically to the SPC at:

mark.bustamante@dhsoha.state.or.us

3.3.5 Modification or Withdrawal of Offers

Any Offeror who wishes to make modifications to an Offer already received by Agency shall submit its modification in one of the manners listed in the offer Submission Options section and must denote the specific change(s) to the offer submission.

If an Offeror wishes to withdraw a submitted Offer, it shall do so prior to Opening. The Offeror shall submit a Written notice Signed by an authorized representative of its intent to withdraw its Offer in accordance with OAR 125-247-0440. The notice must include the OregonBuys Bid number and be submitted to the SPC.

3.3.6 Offer Opening Date

Offer and all required submittal items must be received by the SPC on or before Opening.

All Offer modifications or withdrawals must be completed prior to Opening.

Offers received after Opening are considered LATE and will NOT be accepted for evaluation. Late Offers will be returned to the respective Offeror or destroyed.

3.3.7 Offer Rejection

Agency may reject an Offer for any of the following reasons:

• Offeror fails to substantially comply with all prescribed solicitation procedures and requirements, including but not limited to the requirement that Offeror’s authorized representative sign the offer.

• Offeror fails to meet the responsibility requirements of ORS 279B.110.

• Offeror has undisclosed liquidated and delinquent debt owed to the State of Oregon or any of its agencies, boards, commissions, departments or divisions.

• Offeror makes any contact regarding this solicitation with State representatives such as State employees or officials other than the SPC or those the SPC authorizes, or inappropriate contact with the SPC.

• Offeror attempts to inappropriately influence a member of the Evaluation Committee.

• Offeror is conditioned on Agency’s acceptance of any other terms and conditions or rights to negotiate any alternative terms and conditions that are not reasonably related to those expressly authorized for negotiation in the solicitation or Amendment.

3.3.8 Opening of Offers

There will be no public Opening of Offers. Offers received will not be available for inspection until after the evaluation process has been completed and the Notice Award is issued. However, Agency will record and make available the identity of all Offerors after Opening.

3.4 OFFERS CONTENT REQUIREMENTS

Offeror must address each of the items listed in this section and all other requirements set forth in this solicitation. Offeror shall describe the Goods to be provided or the Services to be performed or both. An Offer that merely offers to provide the goods or services as stated in this solicitation will be considered non-Responsive to this solicitation and will not be considered further.

3.4.1 Offeror Information and Certification Sheet

The Offeror shall complete and submit the Offeror Information and Certification Sheet (Attachment C).

3.4.2 References

Provide at least 3 references from current or former client firms for similar projects performed for any clients within the last 2 years. References must verify the quality of previous, related Work.

Agency may check to determine if references provided support Offeror’s ability to comply with the requirements of this solicitation. Agency may use references to obtain additional information, break tie scores, or verify any information needed. Agency may contact any reference (submitted or not) to verify Offeror’s qualifications.

Offeror shall send the Reference Check Form (Attachment D) to its references. Reference forms must be completed by the reference, returned to the Offeror and submitted with the Offer prior to opening.

3.4.3 Costs

Submit a detailed Cost Sheet (Attachment E) stating the price for each deliverable and the total price for the entire project. Include a breakdown of all labor, profit and expenses.

3.4.4 Public Record/Confidential or Proprietary Information

All Offers are public record and are subject to public inspection after Agency issues the Notice of the Intent to Award. If an Offeror believes that any portion of its Offer contains any information that is a trade secret under ORS Chapter 192.345(2) or otherwise is exempt from disclosure under the Oregon Public Records Law (ORS 192.311 through 192.478), Offeror shall complete and submit the Disclosure Exemption Affidavit (Attachment B) and a fully redacted version of its Offer.

Offeror is cautioned that cost information generally is not considered a trade secret under Oregon Public Records Law (ORS 192.311 through 192.478) and identifying the Offer, in whole, as exempt from disclosure is not acceptable. Agency advises each Offeror to consult with its own legal counsel regarding disclosure issues.

If Offeror fails to identify the portions of the Offer that Offeror claims are exempt from disclosure, Offeror has waived any future claim of non-disclosure of that information.

3.5 EVALUATION PROCESS

3.5.1 Responsiveness and Responsibility Determination

Offers received prior to Opening will be reviewed for Responsiveness to all solicitation requirements including compliance with Minimum Requirements section and offer Content Requirements section. If the Offer is unclear, the SPC may request clarification from Offeror. However, clarifications may not be used to rehabilitate a non-Responsive Offer. If the SPC finds the Offer non-Responsive, the Offer may be rejected, however, Agency may waive mistakes in accordance with OAR 125-247-0470.

In accordance with OAR 137-047-0261(6)(a)(A), Agency may establish a Competitive Range of all Offerors who have made a good faith effort in submitting a offer in response to this solicitation for the purpose of correcting deficiencies in Offers for determining responsiveness during Round 1.

At any time prior to award, Agency may reject an Offeror found to be not Responsible.

3.5.2 Evaluation Criteria

Offers meeting the requirements outlined in the Offer Content Requirements section will be evaluated by an Evaluation Committee. Evaluators will assign a score of 0% to 100% for each evaluation criterion listed below in this section.

SPC may request further clarification to assist the Evaluation Committee in gaining additional understanding of offers. A response to a clarification request must be to clarify or explain portions of the already submitted Offer and may not contain new information not included in the original Offer.

3.5.2.1 Evaluation Item 1 (Maximum Score 60 Points)

o How well do the professional qualifications and experience of Proposer’s Key Person(s) qualify Proposer with the expertise necessary to perform the Work described in Section 2.4 Scope of Work?

(Maximum Score: 25 points) o How well do the role(s) of Proposer’s Key Person(s) in prior similar projects qualify Proposer to perform the Work described in Section 2.4 Scope of Work?

(Maximum Score: 25 points) o How well does the educational background of Proposer’s Key Person(s) qualify Proposer to perform the Work described in Section 3.1 Minimum Requirements?

(Maximum Score: 10 points)

3.5.2.2 Evaluation Item 2 (Maximum Score 10 Points)

Points will be assigned for the cost (single hourly rate) required in the Cost Proposal (per section 5.3) to provide all services in Section 3, Scope of Work.

The points will be assigned using the following calculation:

(L/X)*Y = A Where: X = Proposer’s hourly rate being scored L = Lowest Proposer’s hourly rate A = Awarded points Y = Total Points Possible 10

3.6 COST EVALUATION

The SPC will conduct the cost evaluation. The SPC will award a score to each Cost Sheet based upon the percentage of the proposed cost as compared to the lowest Offeror’s cost using the following formula:

lowest cost of all Offerors X cost points possible = cost score cost being scored

3.7 NEXT STEP DETERMINATION

Agency may conduct additional rounds of competition if in the best interest of the State.

Additional rounds of competition may consist of, but will not be limited to:

• Establishing a Competitive Range

• Presentations/Demonstrations/Additional Submittal Items

• Interviews

• Best and Final Offers

If Agency elects to conduct additional round(s), Agency shall provide written notice to all Offerors describing the next step. At any time, Agency may dispense with the selected additional round and: (1) issue a Notice of Intent to Award to the highest ranking Responsible Offeror; or (2) elect to conduct an alternative round of competition; or (3) cancel the solicitation.

3.8 PREFERENCES

3.8.1 Oregon Supplies and Services

3.8.2 Recycled Materials

In comparing Goods from two or more Offerors, if at least one Offeror proposes Goods manufactured with Recycled Materials, and at least 1 Offeror does not, Agency will select the Offeror proposing Goods manufactured from Recycled Materials if each of the conditions specified in ORS 279A.125 (2) exists following any adjustments made to the cost of the Goods according to any applicable reciprocal preference.

3.8.3 Tiebreakers

Oregon Supplies: If Agency receives Offerors identical in cost, fitness, availability and quality and chooses to award a Contract, Agency shall award the Contract in accordance with the procedures outlined in OAR 125-246-0300.

3.9 POINT AND SCORE CALCULATIONS

Cost points are calculated as stated in the Cost Evaluation section. Points possible are as follows:

POINTS POSSIBLE

Professional Qualifications & Experience 25

Nature and Extent of Role in Prior Projects 25

Relevant Educational Background to RFP 10

Cost Evaluation 10

COST POINTS POSSIBLE 70

3.10 RANKING OF OFFERORS

The SPC will total the final average score (calculated by totaling the points awarded by each Evaluation Committee member and dividing by the number of members), together with references, and final price. After each applicable preference has been applied, SPC will determine rank order for each respective Offer and Offeror, with the highest score receiving the highest rank, and successive rank order determined by the next highest score.

SECTION 4: AWARD AND NEGOTIATION

4.1 AWARD NOTIFICATION PROCESS

4.1.1 Award Consideration

Agency, if it awards a Contract, shall award a Contract to the highest ranking Responsible Offeror(s) based upon the scoring methodology and process described in Section 3.

Agency may award less than the full Scope defined in this solicitation.

4.1.2 Notice of Award

Agency will notify all Offerors in Writing that Agency has awarded a Contract to the selected Offeror(s) subject to successful negotiation of any negotiable provisions.

4.1.3 Insurance

Prior to execution of the Contract, the apparent successful Offeror shall secure and demonstrate to Agency proof of insurance coverage meeting the requirements identified in the solicitation or as otherwise negotiated.

Failure to demonstrate coverage may result in Agency terminating Negotiations and commencing Negotiations with the next highest ranking Offeror. Offeror is encouraged to consult its insurance agent about the insurance requirements contained in Insurance Requirements (Exhibit C of Attachment A) prior to offer submission.

4.1.4 Taxpayer Identification Number

The apparent successful Offeror shall provide its Taxpayer Identification Number (TIN) and backup withholding status on a completed W-9 form if either of the following applies:

• When requested by Agency (normally in an intent to award notice), or

• When the backup withholding status or any other information of Offeror has changed since the last submitted W-9 form, if any.

Agency will not make any payment until Agency has a properly completed W-9.

4.1.5 Business Registry

If selected for award, Offeror shall be duly authorized by the State of Oregon to transact business in the State of Oregon before executing the Contract. The selected Offeror shall submit a current Oregon Secretary of State Business Registry number, or an explanation if not applicable.

All Corporations and other business entities (domestic and foreign) must have a Registered Agent in Oregon. See requirements and exceptions regarding Registered Agents. For more information, see Oregon Business Guide, How to Start a Business in Oregon and Laws and Rules. The titles in this subsection are available at the following Internet site: http://www.filinginoregon.com/index.htm.

4.2 CONTRACT NEGOTIATION

4.2.1 Negotiation

By submitting an offer, Offeror agrees to comply with the requirements of the solicitation, including the terms and conditions of the Sample Contract (Attachment A), with the exception of those terms reserved for negotiation.

Offeror shall review the attached Sample Contract and note exceptions. Unless Offeror notes exceptions to the terms and conditions identified as negotiable in its Offer, the State intends to enter into a Contract with the successful Offeror substantially in the form set forth in Sample Contract (Attachment A). It may be possible to negotiate some provisions of the final Contract; however, many provisions cannot be changed. Offeror is cautioned that the State of Oregon believes modifications to the standard provisions constitute increased risk and increased cost to the State.

Any Offer that is conditioned upon Agency’s acceptance of any other terms and conditions may be rejected. Any subsequent negotiated changes are subject to prior approval of the Oregon Department of Justice.

Agency will only negotiate the following provision:

• Term of the contract

• Descriptions of goods and services

• Compensation http://www.irs.gov/pub/irs-pdf/fw9.pdf http://www.filinginoregon.com/index.htm

In the event that the parties have not reached mutually agreeable terms within 30 calendar days, Agency may terminate Negotiations and commence Negotiations with the next highest ranking Offeror.

SECTION 5: ADDITIONAL INFORMATION

5.1 CERTIFIED FIRM PARTICIPATION

Pursuant to Oregon Revised Statute (ORS) Chapter 200, Agency encourages the participation of small businesses, certified by the Oregon Certification Office for Business Inclusion and Diversity (“COBID”) in all contracting opportunities. This includes certified small businesses in the following categories: disadvantaged business enterprise, minority-owned business, woman-owned business, a business that a service-disabled veteran owns or an emerging small business. Agency also encourages joint ventures or subcontracting with certified small business enterprises. For more information, visit:

https://oregon4biz.diversitysoftware.com/FrontEnd/VendorSearchPublic.asp?XID=6787&T N=oregon4biz

If the Contract has potential subcontracting opportunities, the successful Offeror may be required to submit a completed Certified Disadvantaged Business Outreach Plan (Attachment F) prior to execution.

5.2 GOVERNING LAWS AND REGULATIONS

This intermediate procurement is governed by the laws of the State of Oregon. Venue for any administrative or judicial action relating to this intermediate procurement, evaluation and award is the Circuit Court of Marion County for the State of Oregon; provided, however, if a proceeding must be brought in a federal forum, then it must be brought and conducted solely and exclusively within the United States District Court for the District of Oregon. In no event shall this Section be construed as a waiver by the State of Oregon of any form of defense or immunity, whether sovereign immunity, governmental immunity, immunity based on the eleventh amendment to the Constitution of the United States or otherwise, to or from any Claim or consent to the jurisdiction of any court.

5.3 OWNERSHIP/PERMISSION TO USE MATERIALS

All Offers submitted in response to this solicitation become the property of Agency. By submitting an Offer in response to this solicitation, Offeror grants the State a non-exclusive, perpetual, irrevocable, royalty-free license for the rights to copy, distribute, display, prepare derivative works of and transmit the Offer solely for the purpose of evaluating the Offer, negotiating a Contract, if awarded to Offeror, or as otherwise needed to administer the intermediate procurement process, and to fulfill obligations under Oregon Public Records Law (ORS 192.311 through 192.478).

https://oregon4biz.diversitysoftware.com/FrontEnd/VendorSearchPublic.asp?XID=6787&TN=oregon4biz https://oregon4biz.diversitysoftware.com/FrontEnd/VendorSearchPublic.asp?XID=6787&TN=oregon4biz

5.4 CANCELLATION OF SOLICITATION; REJECTION OF OFFERS; NO DAMAGES.

Pursuant to ORS 279B.100, Agency may reject any or all Offers in-whole or in-part, or may cancel this solicitation at any time when the rejection or cancellation is in the best interest of the State or Agency, as determined by Agency. Neither the State nor Agency is liable to any Offeror for any loss or expense caused by or resulting from the delay, suspension, or cancellation of the solicitation, award, or rejection of any Offer.

5.5 COST OF SUBMITTING AN OFFER

Offeror shall pay all the costs in submitting its offer, including, but not limited to, the costs to prepare and submit the offer, costs of samples and other supporting materials, costs to participate in demonstrations, or costs associated with protests.

5.6 STATEWIDE E-WASTE/RECOVERY PROCEDURE

If applicable, Offeror shall include information in its offer that demonstrates compliance with the Statewide E-Waste/Recovery Procedure 107-011-050_PR. Download the procedure by visiting www.oregon.gov/DAS, then enter the procedure number into the search bar, and find the procedure in the search results window.

5.7 RECYCLABLE PRODUCTS

Offeror shall use recyclable products to the maximum extent economically feasible in the performance of the Services or Work set forth in this document and the subsequent Contract.

(ORS 279B.025)

SECTION 6: LIST OF ATTACHMENTS

ATTACHMENT A SAMPLE CONTRACT

ATTACHMENT B DISCLOSURE EXEMPTION AFFIDAVIT

ATTACHMENT C OFFEROR INFORMATION AND CERTIFICATION SHEET

ATTACHMENT D REFERENCE CHECK FORM

ATTACHMENT E COST SHEET

ATTACHMENT F COBID CERTIFICATION / OUTREACH PLAN

ATTACHMENT G RESPONSIBILITY INQUIRY

http://www.oregon.gov/DAS

Attachment A

Contract Number 000000 SAMPLE CONTRACT

STATE OF OREGON

PERSONAL/PROFESSIONAL SERVICES CONTRACT

In compliance with the Americans with Disabilities Act, this document is available in alternate formats such as Braille, large print, audio recordings, Web-based communications and other electronic formats. To request an alternate format, please send an e-mail to dhs-oha.publicationrequest@state.or.us or call 503-378-3486 (voice) or 503-378-3523 (TTY) to arrange for the alternative format.

This Contract is between the State of Oregon, acting by and through its Oregon Health

Authority, hereinafter referred to as “OHA,” and, Contractor d.b.a. Facility or Assumed Name

Address

Address

Attention: (required)

Telephone: (required)

Fax: (required)

E-mail address: (required) hereinafter referred to as “Contractor.”

Work to be performed under this Contract relates principally to OHA’s

(Fill in with name of Office, Program, etc.)

(Insert address)

(Insert city, state, zip)

Contract Administrator: (Insert Name) or delegate

Telephone: (Insert)

Fax: (Insert)

E-mail address: (Insert)

Recitals (not standard practice but available as an option) mailto:dhs-oha.publicationrequest@state.or.us mailto:dhs-oha.publicationrequest@state.or.us

1. Effective Date and Duration.

This Contract shall become effective on the date this Contract has been fully executed by every party and, when required, approved by Department of Justice or on [insert start date], whichever date is later. Unless extended or terminated earlier in accordance with its terms, this Contract shall expire on [insert end date]. Contract termination shall not extinguish or prejudice OHA’s right to enforce this Contract with respect to any default by Contractor that has not been cured.

2. Contract Documents.

a. This Contract consists of this document and includes the following listed exhibits which are incorporated into this Contract:

(1) Exhibit A, Part 1: Statement of Work

(2) Exhibit A, Part 2: Payment and Financial Reporting

(3) Exhibit A, Part 3: Special Provisions

(4) Exhibit B: Standard Terms and Conditions

(5) Exhibit C: Insurance Requirements

(6) Exhibit D: Reserved

(7) Exhibit E, Part 1: Oregon State Supplemental General Provisions

(8) Exhibit E, Part 2 Oregon State Hospital, Confidentiality Agreement (OSH

Stock #75059)

(9) Exhibit E, Part 3 Oregon State Hospital Policy and Procedure 2.014, Medical Record – Handling, Transportation, and

Maintenance

(10) Exhibit E, Part 4 Oregon State Hospital Policy and Procedure 5.001, Drug-

Free Workplace

(11) Exhibit E, Part 5 Oregon State Hospital Policy and Procedure 5.009, Staff and Patient Relationships

(12) Exhibit E, Part 6 Oregon State Hospital Policy and Procedure 5.017, Dress

Code for Staff

(13) Exhibit E, Part 7 Oregon State Hospital Policy and Procedure 7.008, Patient Abuse or Mistreatment Allegation Reporting

(14) Exhibit E, Part 8 Oregon State Hospital, Patient Abuse Form 7.008-frm

(15) Exhibit E, Part 9 Oregon State Hospital Policy and Procedure 8.007, Identification Badges

(16) Exhibit E, Part 10 Oregon State Hospital Policy and Procedure 8.023, Parking at Oregon State Hospital

(17) Exhibit E, Part 11 Oregon State Hospital Policy and Procedure 8.024, Tool and Sharp Security

(18) Exhibit E, Part 12 Oregon State Hospital Policy and Procedure 8.027, Weapons on Campus

(19) Exhibit E, Part 13 Oregon State Hospital Policy and Procedure 8.033, Violence Free Workplace/Campus

(20) Exhibit E, Part 14 Outside Vendor Services Report, OSH Form 03808 4-

9/2006

(21) Exhibit F Subcontractor Provisions (optional – may be removed)

There are no other contract documents unless specifically referenced and incorporated in this Contract.

b. This Contract and the documents listed in Section 2., Contract Documents, Subsection a. above, shall be in the following descending order of precedence:

this Contract less all exhibits, Exhibits D, B, A, C, F, E and G.

3. Consideration.

a. The maximum, not-to-exceed compensation payable to Contractor under this

Contract, which includes any allowable expenses, is $[insert amount]. OHA will not pay Contractor any amount in excess of the not-to-exceed compensation of this Contract for completing the Work and will not pay for Work performed before the date this Contract becomes effective or after the termination or expiration of this Contract. If the maximum compensation is increased by amendment of this Contract, the amendment must be fully effective before

Contractor performs Work subject to the amendment.

b. Interim payments to Contractor shall be subject to ORS 293.462, and shall be made in accordance with the payment schedule and requirements in Exhibit A, Part 2, “Payment and Financial Reporting.”

c. OHA will only pay for completed Work under this Contract. For purposes of this

Contract, “Work” means the tasks or services and deliverables accepted by OHA as described in Exhibit A, Part 1, “Statement of Work.”

4. Contractor or Subrecipient Determination. In accordance with the State Controller’s

Oregon Accounting Manual, policy 30.40.00.104, OHA’s determination is that:

Contractor is a subrecipient Contractor is a contractor Not applicable

Catalog of Federal Domestic Assistance (CFDA) #(s) of federal funds to be paid through this Contract: _______

5. Contractor Data and Certification.

a. Contractor Information. This information is requested pursuant to ORS

305.385.

PLEASE PRINT OR TYPE THE FOLLOWING INFORMATION

Contractor Name (exactly as filed with the IRS):

Street address:

City, state, zip code:

Email address:

Telephone: ( ) Facsimile: ( )

Is Contractor a nonresident alien, as defined in 26 U.S.C. § 7701(b)(1)?

(Check one box): YES NO

Business Designation: (Check one box):

Professional Corporation Nonprofit Corporation Limited Partnership

Limited Liability Company Limited Liability Partnership Sole Proprietorship

Corporation Partnership Other

Contractor Proof of Insurance. Contractor shall provide the following information upon submission of the signed Contract. All insurance listed herein and required by Exhibit C, must be in effect prior to Contract execution.

Professional Liability Insurance Company: ___________________________________________

Policy #: ______________________________________ Expiration Date: ________________

Commercial General Liability Insurance Company: ____________________________________

Policy #: ______________________________________ Expiration Date: ________________

Workers’ Compensation: Does Contractor have any subject workers, as defined in ORS

656.027? (Check one box): YES NO If YES, provide the following information:

Workers’ Compensation Insurance Company: ________________________________________

Policy #: ______________________________________ Expiration Date: ________________

b. Certification. Without limiting the generality of the foregoing, by signature on this Contract, the undersigned hereby certifies under penalty of perjury that:

(1) Contractor is in compliance with all insurance requirements in Exhibit C of this Contract and notwithstanding any provision to the contrary, Contractor shall deliver to the OHA Contract Administrator (see page 1 of this Contract) the required Certificate(s) of Insurance within 30 days of execution of this Contract. By certifying compliance with all insurance as required by this Contract, Contractor acknowledges it may be found in breach of the Contract for failure to obtain required insurance. Contractor may also be in breach of the Contract for failure to provide Certificate(s) of Insurance as required and to maintain required coverage for the duration of the Contract;

(2) Contractor acknowledges that the Oregon False Claims Act, ORS 180.750 to 180.785, applies to any “claim” (as defined by ORS 180.750) that is made by (or caused by) the Contractor and that pertains to this Contract or to the project for which the Contract work is being performed. Contractor certifies that no claim described in the previous sentence is or will be a

“false claim” (as defined by ORS 180.750) or an act prohibited by ORS

180.755. Contractor further acknowledges that in addition to the remedies under this Contract, if it makes (or causes to be made) a false claim or performs (or causes to be performed) an act prohibited under the Oregon

False Claims Act, the Oregon Attorney General may enforce the liabilities and penalties provided by the Oregon False Claims Act against the

Contractor;

(3) The undersigned is authorized to act on behalf of Contractor and represents and warrants that Contractor has complied with the tax laws of the State of Oregon and the applicable tax laws of any political subdivision of Oregon. Contractor shall, throughout the duration of this

Contract and any extensions, comply with all tax laws of this state and all applicable tax laws of any political subdivision of Oregon. For the purposes of this Section, “tax laws” includes: (i) All tax laws of Oregon, including but not limited to ORS 305.620 and ORS chapters 316, 317, and

318; (ii) Any tax provisions imposed by a political subdivision of Oregon that applied to Contractor, to Contractor’s property, operations, receipts, or income, or to Contractor’s performance of or compensation for any work performed by Contractor; (iii) Any tax provisions imposed by a political subdivision of Oregon that applied to Contractor, or to goods, services, or property, whether tangible or intangible, provided by

Contractor; and (iv) Any rules, regulations, charter provisions, or ordinances that implemented or enforced any of the foregoing tax laws or provisions.

The Contractor acknowledges that the Oregon Department of

Administrative Services will report this Contract to the Oregon

Department of Revenue (DOR). The DOR may take any and all actions permitted by law relative to the collection of taxes due to the State of

Oregon or a political subdivision, including (i) garnishing the Contractor’s compensation under this Contract or (ii) exercising a right of setoff against

Contractor’s compensation under this Contract for any amounts that may be due and unpaid to the State of Oregon or its political subdivisions for which the DOR collects debts;

(4) The information shown in Section 5a, “Contractor Information” above is

Contractor’s true, accurate and correct information;

(5) To the best of the undersigned’s knowledge, Contractor has not discriminated against and will not discriminate against minority, women or emerging small business enterprises certified under ORS 200.055 in obtaining any required subcontracts;

(6) Contractor and Contractor’s employees and agents are not included on the list titled “Specially Designated Nationals” maintained by the Office of

Foreign Assets Control of the United States Department of the Treasury and currently found at: https://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx;

(7) Contractor is not listed on the non-procurement portion of the General

Service Administration’s “List of Parties Excluded from Federal procurement or Non-procurement Programs” currently found at:

https://www.sam.gov/portal/public/SAM/;

(8) Contractor is not subject to backup withholding because:

(a) Contractor is exempt from backup withholding;

(b) Contractor has not been notified by the IRS that Contractor is subject to backup withholding as a result of a failure to report all interest or dividends; or

(c) The IRS has notified Contractor that Contractor is no longer subject to backup withholding; and

(9) Contractor Federal Identification Number (FEIN) or Social Security

Number (SSN) provided is true and accurate. If this information changes, Contractor shall provide OHA with the new FEIN or SSN within 10 days.

https://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx https://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx https://www.sam.gov/portal/public/SAM/

CONTRACTOR, BY EXECUTION OF THIS CONTRACT, HEREBY

ACKNOWLEDGES THAT CONTRACTOR HAS READ THIS CONTRACT,

UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND

CONDITIONS.

CONTRACTOR: YOU WILL NOT BE PAID FOR SERVICES RENDERED PRIOR TO

NECESSARY STATE APPROVALS

6. Signatures. This Contract and any subsequent amendments may be executed in several counterparts, all of which when taken together shall constitute one agreement binding on all parties, notwithstanding that all parties are not signatories to the same counterpart.

Each copy of the Contract and any amendments so executed shall constitute an original.

Contractor Name

By:

Authorized Signature Printed Name

Title Date

State of Oregon, acting by and through its Oregon Health Authority

By:

Authorized Signature Printed Name

Title Date

Approved for Legal Sufficiency:

With Protect Form on, click here With Protect Form on, click here

Department of Justice Date

EXHIBIT A

Part 1

Statement of Work

(Be specific and complete)

1. Services to be Provided by Contractor shall include:

a. Description of outcomes.

b. Deliverables/Quantities.

c. Specifications or Performance Standards.

OHA requires that the Contractor meets the highest standards prevalent in the industry or business most closely involved in providing the appropriate goods or services.

d. Delivery Schedule.

Part 2

Payment and Financial Reporting

1. Payment Provisions.

a. As consideration for the services provided by the Contractor during the period specified Section 1. Effective Date and Duration, OHA shall pay the Contractor a maximum not-to-exceed amount as specified in Section 3. Consideration, to be paid as follows:

b. Contractor understands and agrees that this Contract does not provide or guarantee

Contractor any minimum amount of work, which is to be provided on an “as-needed” basis.

c If Oregon State Hospital rejects any work, it shall provide Contractor written notice of rejection that includes an explanation of how the work is deficient.

Contractor shall cure such deficiencies at no cost or expense to OHA and resubmit the deficient work within fourteen (14) calendar days of receipt of the notice of rejection, or such longer time as Oregon State Hospital may specify in its notice of rejection. If the work is still deficient, Oregon State Hospital may allow

Contractor an additional chance to cure, or may request that OHA declare

Contractor in default pursuant to Exhibit B, Section 10.

d. Contractor shall submit monthly invoices for Work performed to Oregon State

Hospital’s Accounting Services, either by mail: 2600 Center Street NE, B02-152, Salem, OR 97301 or e-mail: AccountingOffice.MiscSalem@state.or.us.

(1) In the upper left hand corner of the invoice the following information must be included: the contract number, the total consideration amount, and the balance prior to current months invoice and the remaining balance of the contract after current invoice charges.

(2) Invoice shall include the service date(s), rate(s) charged for service(s) and have a total for all services.

(3) Invoices that do not comply with the format stipulated in d.(1) and d.(2) above may be held up for payment until the proper invoice format is submitted for payment.

2. Travel and Other Expenses. (Optional)

OHA will not reimburse Contractor for any travel or additional expenses under this

Contract.

Part 3

Special Provisions

1. Confidentiality of Information.

a. Client Information:

(1) All information as to personal facts and circumstances obtained by the

Contractor on the client (“Client Information”) shall be treated as privileged communications, shall be held confidential, and shall not be divulged without the written consent of the client, his or her guardian, or the responsible parent when the client is a minor child, or except as required by other terms of this Contract. Nothing prohibits the disclosure of information in summaries, statistical, or other form, which does not identify particular individuals.

(2) The use or disclosure of Client Information shall be limited to persons directly connected with the administration of this Contract. Confidentiality policies shall be applied to all requests from outside sources.

(3) If Contractor, or any of its officers, directors, employees, agents, or subcontractors receives or has access to confidential Social Security

Administration (SSA), or Federal Tax Information (FTI) records in the performance of Work under this Contract, Contractor shall comply, and ensure that all of Contractor’s officers, directors, employees, agents and subcontractors comply, with the following provisions:

(a) With respect to SSA records:

(i) Provide a current list of employees and employees of any agent or subcontractor with access to SSA records;

(ii) Adhere to the same security requirements as employees of

OHA;

(iii) Abide by all relevant Federal laws, restrictions on access, use, disclosure, and the security requirements contained within OHA’s agreement with SSA;

(iv) Provide its employees and agents the same security awareness training as OHA’s employees; and

(v) Include the provisions of this Section 1.a.(3)(a) in any subcontract.

(b) With respect to Federal Tax Information (FTI), as defined in IRS

Publication 1075:

(i) Contractor and its officers, directors and employees with access to, or who use FTI provided by OHA must meet the background check requirements defined in IRS Publication

1075;

(ii) Any FTI made available to Contractor shall be used only for the purpose of carrying out the provisions of this Contract.

Contractor shall treat all information contained in FTI as confidential and that information shall not be divulged or made known in any manner to any person except as may be necessary in the performance of this Contract. Inspection by or disclosure to anyone other than an officer or employee of the Contractor is prohibited;

(iii) Contractor shall account for all FTI upon receipt and shall properly store all FTI before, during, and after processing.

In addition, all FTI related output and products will be given the same level of protection as required for the source material;

(iv) No work involving FTI furnished under this Contract will be subcontracted without prior written approval of the IRS;

(v) Maintain a list of employees who are authorized access to

FTI. Such list will be provided to OHA and, upon request, to the IRS reviewing office; and

(vi) Include the provisions of this Section 1.a.(3)(b) in any subcontract.

(c) Failure to abide by any of the requirements in this subsection could result in criminal or civil penalties and result in termination of this

Contract.

(d) Contractor may be subject to periodic and ongoing security reviews to ensure compliance with the requirements of Section

1.a.(3).

(4) Except as prohibited by Section 1.a.(3) above, OHA, Contractor and any subcontractor will share information as necessary to effectively serve

OHA clients.

b. Non-Client Information:

(1) Each Party acknowledges that it and any of its officers, directors, employees and agents may, in the course of performing its responsibilities under the Contract, be exposed to or acquire information that is confidential to the other Party. To the extent permitted by law, any and all information of any form provided to a Party or its officers, directors, employees and agents in the performance of the Contract that reasonably could at the time of its disclosure be understood to be confidential shall be deemed to be confidential information of the originating Party

(“Confidential Non-Client Information”).

(2) Confidential Non-Client Information shall be deemed not to include information that:

(a) Is or becomes (other than by disclosure by the Party acquiring such information) publicly known or is contained in a publicly available document except to the extent applicable law still restricts disclosure;

(b) Is furnished by the originating Party to others without restrictions similar to those imposed on the receiving Party under the Contract;

(c) Is rightfully in the receiving Party’s possession without the obligation of nondisclosure prior to the time of its disclosure by the originating Party under the Contract;

(d) Is obtained from a source other than the originating Party without the obligation of confidentiality;

(e) Is disclosed with the written consent of the originating Party; or

(f) Is independently developed by the receiving Party’s officers, directors, employees and agents who can be shown to have had no access to the Confidential Non-Client Information.

(3) Nondisclosure. The receiving Party shall hold all Confidential Non-Client

Information in strict confidence, using at least the same degree of care that it uses in maintaining the confidentiality of its own confidential information; shall not sell, assign, license, market, transfer or otherwise dispose of, give or disclose Confidential Non-Client Information to third parties; shall not use Confidential Non-Client Information for any purposes whatsoever other than as contemplated by this Contract or reasonably related thereto; and shall advise any of its officers, directors, employees and agents that receive or have access to the Confidential Non-

Client Information of their obligations to keep Confidential Non-Client

Information confidential. These confidentiality obligations do not restrict disclosure of information otherwise qualifying as Confidential Non-Client

Information if the receiving Party can show that either of the following conditions exists: (i) the information was disclosed in response to a subpoena or court order duly issued in a judicial or legislative process, in which case the receiving Party shall notify the originating Party of the subpoena five days prior to the disclosure, unless such notice could not reasonably be given; or (ii) the disclosure was required to respond to a request for the information made under the Oregon Public Records Law, ORS 192.311 to 192.478. The receiving Party shall notify the originating

Party of a public records request five days prior to the disclosure.

c. Upon request and pursuant to the instructions of OHA, Contractor shall return or destroy all copies of Confidential Information, and Contractor shall certify in writing the return or destruction of all Confidential Information.

d. "Client" means any individual, family or provider:

(1) For whom OHA must provide Services and incidental or specialized

Goods, in any combination thereof (“Services and Incidental Supplies”), according to state, federal law, rule, and policy. Those Services and

Incidental Supplies include but are not limited to treatment, care, protection, and support without regard to the proximity of the services being provided;

(2) Who in fact receives and utilizes services provided by OHA primarily for that individual's or family's benefit;

(3) Who is under the custody, care, or both of OHA; or

(4) Who provides direct care or Services and is a proxy or representative of the non-provider Client.

2. Amendments.

a. OHA reserves the right to amend or extend the Contract under the following general circumstances:

(1) OHA may extend the Contract for additional periods of time up to a total

Contract period of 5 years, and for additional money associated with the extended period(s) of time. The determination for any extension for time may be based on OHA’s satisfaction with performance of the work or services provided by the Contractor under this Contract.

(2) OHA may periodically amend any payment rates throughout the life of the

Contract proportionate to increases in Portland Metropolitan Consumer

Price Index; and to provide Cost Of Living Adjustments (COLA) if OHA so chooses. Any negotiation of increases in rates to implement a COLA will be as directed by the Oregon…