New FIRST AMENDMENT TO AGREEMENT - ACGOV.org · 2015. 5. 14. · A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER

Procurement Contract 7476

FIRST AMENDMENT TO AGREEMENT

This First Amendment to Agreement ("First Amendment") is made by the County

of Alameda ("County") and Medversant Technologies, LLC, ("Contractor") with respect

to that certain agreement entered by them on May 1, 2012 (referred to herein as the

"Agreement") pursuant to which Contractor provides credential verification services to

County.

County and Contractor agree as follows:

1. For valuable consideration, the receipt and sufficiency of which are hereby

acknowledged, County and Contractor agree to amend the Agreement in the

following respects:

2. Except as otherwise stated in this First Amendment, the terms and provisions of

this Amendment will be effective as of the date this First Amendment is executed

by the County ("Effective Date").

3. The term of the Agreement is currently scheduled to expire on June 30, 2014. As

of the Effective Date, the term of the Agreement is extended through June 30,

2015.

4. DEBARMENT AND SUSPENSION CERTIFICATION:

a. By signing this First Amendment and Exhibit D, Debannent and

Suspension Certification, Contractor/Grantee agrees to comply with

applicable federal suspension and debarment regulations, including but not

limited to 7 Code of Federal Regulations (CFR) 3016.35, 28 CFR 66.35, 29

CFR 97.35, 34 CFR 80.35, 45 CFR 92.35 and Executive Order 12549.


b. By signing this agreement, Contractor certifies to the best of its knowledge

and belief, that it and its principals:

(1) Are not presently debarred, suspended, proposed for debarment,

declared ineligible, or voluntary excluded by any federal department

or agency;

(2) Shall not knowingly enter into any covered transaction with a person

who is proposed for debarment under federal regulations, debarred,

suspended, declared ineligible, or voluntarily excluded from

participation in such transaction.

5. Except as expressly modified by this First Amendment, all of the terms and

conditions of the Agreement are and remain in full force and effect.

2

(


IN WITNESS WHEREOF, the parties hereto have executed this Amendment to the Agreement as of the day and year first above written.

COUNTY OF ALAMEDA

Name: SCOTI HAGGERTY

------------Keith Cat son Scott l+fijj-et>f 1 ·

Title: President of the Board of Supervisors

Approved as to Form: County Counsel Donna R. Ziegler

By: ~~ Deputy County Counsel Farand Kan

\- (<-~

3

CONTRACTOR/COMP ANY NAME

By:~f\......,.__. ~-'-------11·~--J Sighature

Name:_N_t>b_'f_ft~l ~-~-h~Q~b __ (Printed)

rn1e: 'Ve· TeJiwlo~ o(kA~

Date: 1 / 5} H>/'f I

By signing above, signatory warrants and represents that he/she executed this Amendment in his/her authorized capacity and that by his/her signature on this Amendment, he/she or the entity upon behalf of which he/she acted, executed this Amendment


EXHIBITD

COUNTY OF ALAMEDA DEBARMENT AND SUSPENSION CERTIFICATION

The contractor, under penalty of perjury, certifies that, except as noted below, contractor, its principals, and any named or unnamed subcontractor:

• Is not currently under suspension, debarment, voluntary exclusion, or

determination of ineligibility by any federal agency;

• Has not been suspended, debarred, voluntarily excluded or determined ineligible by

any federal agency within the past three years;

• Does not have a proposed debarment pending; and

• Has not been indicted, convicted, or had a civil judgment rendered against it by a

court of competent jurisdiction in any matter involving fraud or official misconduct

within the past three years.

If there are any exceptions to this certification, insert the exceptions in the following space.

Exceptions will not necessary result in denial of award, but will be considered in determining contractor responsibility. For any exception noted above, indicate below to whom it applies, initiating agency, and dates of action.

Notes: Providing false information may result in criminal prosecution or administrative sanctions. The above certification is part of the Standard Services Agreement. Signing this Standard Services Agreement on the signature portion thereof shall also constitute signature of this Certification.

CONTRACTOR: Medversant Technologies, LLC

PRINCIPAL: -~~~~j~ft~\ '~' '(_~~~g~'-' -- TITLE: ~ ~ . 'la t1rib ht ~eba>,li W)

SIGNATURE: _())'""'--"---· --~"--"->-I, ~rl-'~'"""'~-· ___

4

_ DA TE: __ q_;__,\.__5 __._} _J lt_,___ __ _

ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY)

~ 04/02/2014

THIS CERTIFICATE IS ISSUED AS A MATIER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

PRODUCER CONTACT Hisham Elzein NAME: Zein Insurance Services, Inc. r .. ~~N~n Extl: (818)887-8780 I rffc Nol: (818)887-5050 21800 Oxnard St. Ste 480 E·MAIL [email protected] Woodland Hills, CA 91367 ADDRESS:

Phone: (818) 887-8780 Fax: (818) 887-5050 INSURER(S) AFFORDING COVERAGE NAIC#

INSURER A : Travelers Property Co. of America (A+) 40282 INSURED INSURER B:

Medversant Technologies, LLC INSURER C :

3201 Cherry Ridge Drive, Suite 8212 INSURER D :

San Antonio TX 90071- INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR TYPE OF INSURANCE

ADDL SUBR I POLICY EFF POLICY EXP LTR , .. .,., WVD POLICY NUMBER MM/DD/YYYYI IMM/DD/YYYYI LIMITS

A GENERAL LIABILITY y ZLP12T17027 - 03/01/2014 03/01/2015 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED

x COMMERCIAL GENERAL LIABILITY PREMISES IEa occurrence\ $ 1,000,000 - D CLAIMS-MADE [RJ OCCUR - MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 -GENERALAGGREGATE $ 1,000,000 -

GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP/OP AGG $ 2,000,000

X1 POLICY n ~r8-r lxl LOC EBL- Employee BenE $ 1,000,000 A AUTOMOBILE LIABILITY y BA-7729P169 03/01/2014 03/01/2015 COMBINED SINGLE LIMIT 1,000,000 IEa accident) $ -x ANY AUTO BODILY INJURY (Per person) $

- -ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ - -

NON-OWNED PROPERTY DAMAGE x HIRED AUTOS x AUTOS IPer accident\ $

y Comprehensive & Cc $ ACV

A UMBRELLA LIAB ~ OCCUR y ZUP12T17039 03/01/2014 03/01/2015 EACH OCCURRENCE $ 4,000,000 -EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000

OED I x I RETENTION $ 0 $

A WORKERS COMPENSATION HJ-UB-7046P09-14 03/30/2014 03/30/2015 x 1 TV/i~~nJi¥-s 1 I OJ~·

AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE 0

N/A E.L. EACH ACCIDENT $ 1,000,000

OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE • EA EMPLOYEE $ 1,000,000

~~;sc~f~i[~ o~OPERATIONS below E.L. DISEASE · POLICY LIMIT $ 1,000,000

A Cyberfirst E & 0 Liability y ZPL 14P77 03/01/201'1 03/01/2015 Limit 3,000,000 A Blanket Business Income y ZLP12T17027 03/01/201.:1 03/01/2015 Limit 1,000,000 A BPP-Contents CoevraQe y ZLP12T17027 03/01/201'1 03/01/2015 Limit 290,466 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101 , Additional Remarks Schedule, If more space Is required)

This is a certificate of the liability insurance limits for the above named insured.

30 day cancellation for non-payment of premium

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED lN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

/.li?/i:1!f £/5-<i· ~ I

© 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD

SLEB Waiver Request Detail Page 1of2

OFFICE OF ACQUISITION POLICY (OAP) REQUEST FOR AUTHORIZATION TO WAIVE SLEB PROGRAM REQUIREMENTS l 1 ;:JbS [

For Federal grant funds: Procurements using Federal grant funds which prohibtt geographical preferences require the Federal Grant Funds SLEB Waiver Request form to be submitted for approval to the Audttor-Controller Office of Contract Compliance (OCC) prior to solictting bids/proposals and awarding contracts . For further information contact 0 5500.

Non-Federal SLEB waivers may be submitted online. Complete online SLEB waiver requests in ALCOWEB under the "For Work" section. See "Submit Online SLEB Ill supporting documentation including three quotes or approved Sole Source. NOTE: If onllne access Is not available, please follow the procedures below to submit your request.

For ALL Requests over $3,000: Complete #1-9 below, complete #10 ~over $100,000 (First Source applies) , sign and print your name on line 11 , submtt hard copy wtth SUPP< for approval to GSA-OAP Business Outreach Officer, QIC 26021 AND email soft copy (PDF or Word) to [email protected]. Upon approval, the procurement will I Purchasing. NOTE: A SLEB waiver Is NOT required for the following :

• Approved Sole Source Exceptions for goods and services wtth a cumulative fiscal year total upto $25,000. • P.O. Change Order (POC) wtth a cumulative fiscal year total upto $25,000 and no changes in vendor, product or fiscal year.

For Requests over $25.000. a SLEB Waiver Number will be issued as required to enter a Procurement Contract in ALCOLINK. OAP will email signed approvals (wtth Waiver r and denials to Requesting Departments and GSA Purchasing. NOTE: All questions require a complete response. Enter "NIA" or "None", etc., as applicable. Do not leave blank lines.

1. Please check appropriate box and complete department/contact Information below. ~ Requesting Department [O' GSA Purchasing managing the competttive process Department: !Behavioral Health Care Services EJ Contact Name: ~~-ac-k-ie_J_o-rd_a_n---~ Email: [email protected]

GSA Purchasing/Audttor: lg Same as Department Contact Contact Name: !Sharon Woolley G Email: [sharon.woolley@aic!c!:o=v=.o=r====:

2. Recommended Vendor (Name): [Mectversant Technologij PO#: [NIA REQ#: ~ Street Address : 1355 S. Grand Avenue, Suite 1700 City : tk!is Ang~ State: l cal~omia B

3. Procurement Type (check all appropriate boxes below): [[New Contract [Q_ Renewal Contract [Q Contract Amendment-Term ([contract Amendment-Value [Q: OtherC

4. Total PO/Contract Value (Including Increase, If any)$ 60000.00 ; Increase Value (If any) S.2:,~ .-------"

Contract Term Start Date 09125/2014 e. End Date 13012016 • OR One-Time Purchase tP 5. Goods/Services Procurement Description:

Credential Verification Services

868 characters remaining.

6. Brief explanation of why goods/services are required: Provides Behavioral Health Care Service with primary source credential and re-credentialing verification services


7. Date Goods/Services Needed: 0912512014 ;& a. What are the consequences If the date goods/services needed Is not met? County has to address quality issues concerning choosing providers for their clients . Exposure of liability for the county is minimized by ensuring that providers are properly credentialed & meet ac~eptable health care systems standards . Credentialing service is required o stay in compliance


Telepho

Telepho1

8. Explanation of why the non-SLEB contractor/subcontractor (In #2 above) Is being recommended and, If procurement over $25,000, why they are unable to subc (s) for a minimum of 20%: They are unable to subcontract with a SLEB for a minimum of 20 % due to the nature of credentialing I\ service . Medversant offers online credentialing services for our providers (MDs , MFTs, social workers, etc.) We import/upload application packets of our providers into their system and they V 367 characters remaining. -

9. Explain what attempts were made to locate a SLEB prime or, If procurement over $25,000, SLEB subcontractor(s), Including: (g Copies of bids received and/or detailed statement of efforts made to contact and negotiate wtth certified businesses, including list of SLEBs contacted , names of indivi

phone numbers, dates contacted and bid prices attached. In the section below, list the documents that have been attached:

a.

b.

BHCS sent out an RFQ on 3/17/14 to six small , 1 emerging and six non certified vendors listed in the SLEB database . Medversant is the only vendor who responded to the RFQ . Calls were made to the other vendors the RFQ was sent to and voice mails messages were left but vendors did not respond . 607 characters remaining.

List of ttems or selected portions of work proposed to be performed by certified business in order to increase the likelihood of achieving the stated goal:

see attached


Description of information provided to certified contractors/subcontractors regard ing the plans, specifications and anticipated time schedule for portions of the work to be P' see attached

c.


Supporting Documents:

10. If the contract Is over $100,000, is the recommended vendor able to comply with the First Source Program?

" y

L http://alcoweb.acgov.org/slebwaiverrequest __ app/addUpdateRequest.do?action~detail&req ... 9/26/2014

~ . . SLEB Waiver Request Detail

Yes: [Q] No: [Ql If No, explain:

L_ 900 characters remaining.

Expedite? [@' (Check this box to expedite processing)

DHOUTS2 Signature of Agency/Department Head or Deslgnee or GSA Purchas ing Manager (If GSA Purchasing managed the process)

David Houts

Print Name

OAP to complete below:

A. Request Approved: [§ Waiver Valid Through: [06/30t2016 , ~

Reason: No known SLEB vendor available.


B. Request Denied: [Q] Reason:

L__ -900 characters remaining.

C. Disregard: lQ; Reason: r


LMOORE Signed by GSA-Office of Acquisition Polley (Required)

SLEB Waiver Number:~

Page 2 of 2

09/22/2014

Date

09/25/2014 Date

http://alcoweb.acgov.org/slebwaiverrequest_ app/addUpdateRequest.do ?action=detail&req... 912612014


FIRST AMENDMENT TO AGREEMENT

This First Amendment to Agreement ("First Amendment") is made by the County

of Alameda ("County") and Medversant Technologies, LLC, ("Contractor") with respect

to that certain agreement entered by them on May 1, 2012 (referred to herein as the

"Agreement") pursuant to which Contractor provides credential verification services to

County.

County and Contractor agree as follows:

1. For valuable consideration, the receipt and sufficiency of which are hereby

acknowledged, County and Contractor agree to amend the Agreement in the

following respects:

2. Except as otherwise stated in this First Amendment, the terms and provisions of

this Amendment will be effective as of the date this First Amendment is executed

by the County ("Effective Date").

3. The term of the Agreement is currently scheduled to expire on June 30, 2014. As

of the Effective Date, the term of the Agreement is extended through June 30,

2015.

4. DEBARMENT AND SUSPENSION CERTIFICATION:

a. By signing this First Amendment and Exhibit D, Debannent and

Suspension Certification, Contractor/Grantee agrees to comply with

applicable federal suspension and debarment regulations, including but not

limited to 7 Code of Federal Regulations (CFR) 3016.35, 28 CFR 66.35, 29

CFR 97.35, 34 CFR 80.35, 45 CFR 92.35 and Executive Order 12549.


b. By signing this agreement, Contractor certifies to the best of its knowledge

and belief, that it and its principals:

(1) Are not presently debarred, suspended, proposed for debarment,

declared ineligible, or voluntary excluded by any federal department

or agency;

(2) Shall not knowingly enter into any covered transaction with a person

who is proposed for debarment under federal regulations, debarred,

suspended, declared ineligible, or voluntarily excluded from

participation in such transaction.

5. Except as expressly modified by this First Amendment, all of the terms and

conditions of the Agreement are and remain in full force and effect.

2

(


IN WITNESS WHEREOF, the parties hereto have executed this Amendment to the Agreement as of the day and year first above written.

COUNTY OF ALAMEDA

Name: SCOTI HAGGERTY

------------Keith Cat son Scott l+fijj-et>f 1 ·

Title: President of the Board of Supervisors

Approved as to Form: County Counsel Donna R. Ziegler

By: ~~ Deputy County Counsel Farand Kan

\- (<-~

3

CONTRACTOR/COMP ANY NAME

By:~f\......,.__. ~-'-------11·~--J Sighature

Name:_N_t>b_'f_ft~l ~-~-h~Q~b __ (Printed)

rn1e: 'Ve· TeJiwlo~ o(kA~

Date: 1 / 5} H>/'f I

By signing above, signatory warrants and represents that he/she executed this Amendment in his/her authorized capacity and that by his/her signature on this Amendment, he/she or the entity upon behalf of which he/she acted, executed this Amendment


EXHIBITD

COUNTY OF ALAMEDA DEBARMENT AND SUSPENSION CERTIFICATION

The contractor, under penalty of perjury, certifies that, except as noted below, contractor, its principals, and any named or unnamed subcontractor:

• Is not currently under suspension, debarment, voluntary exclusion, or

determination of ineligibility by any federal agency;

• Has not been suspended, debarred, voluntarily excluded or determined ineligible by

any federal agency within the past three years;

• Does not have a proposed debarment pending; and

• Has not been indicted, convicted, or had a civil judgment rendered against it by a

court of competent jurisdiction in any matter involving fraud or official misconduct

within the past three years.

If there are any exceptions to this certification, insert the exceptions in the following space.

Exceptions will not necessary result in denial of award, but will be considered in determining contractor responsibility. For any exception noted above, indicate below to whom it applies, initiating agency, and dates of action.

Notes: Providing false information may result in criminal prosecution or administrative sanctions. The above certification is part of the Standard Services Agreement. Signing this Standard Services Agreement on the signature portion thereof shall also constitute signature of this Certification.

CONTRACTOR: Medversant Technologies, LLC

PRINCIPAL: -~~~~j~ft~\ '~' '(_~~~g~'-' -- TITLE: ~ ~ . 'la t1rib ht ~eba>,li W)

SIGNATURE: _())'""'--"---· --~"--"->-I, ~rl-'~'"""'~-· ___

4

_ DA TE: __ q_;__,\.__5 __._} _J lt_,___ __ _

ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY)

~ 04/02/2014

THIS CERTIFICATE IS ISSUED AS A MATIER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

PRODUCER CONTACT Hisham Elzein NAME: Zein Insurance Services, Inc. r .. ~~N~n Extl: (818)887-8780 I rffc Nol: (818)887-5050 21800 Oxnard St. Ste 480 E·MAIL [email protected] Woodland Hills, CA 91367 ADDRESS:

Phone: (818) 887-8780 Fax: (818) 887-5050 INSURER(S) AFFORDING COVERAGE NAIC#

INSURER A : Travelers Property Co. of America (A+) 40282 INSURED INSURER B:

Medversant Technologies, LLC INSURER C :

3201 Cherry Ridge Drive, Suite 8212 INSURER D :

San Antonio TX 90071- INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR TYPE OF INSURANCE

ADDL SUBR I POLICY EFF POLICY EXP LTR , .. .,., WVD POLICY NUMBER MM/DD/YYYYI IMM/DD/YYYYI LIMITS

A GENERAL LIABILITY y ZLP12T17027 - 03/01/2014 03/01/2015 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED

x COMMERCIAL GENERAL LIABILITY PREMISES IEa occurrence\ $ 1,000,000 - D CLAIMS-MADE [RJ OCCUR - MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 -GENERALAGGREGATE $ 1,000,000 -

GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP/OP AGG $ 2,000,000

X1 POLICY n ~r8-r lxl LOC EBL- Employee BenE $ 1,000,000 A AUTOMOBILE LIABILITY y BA-7729P169 03/01/2014 03/01/2015 COMBINED SINGLE LIMIT 1,000,000 IEa accident) $ -x ANY AUTO BODILY INJURY (Per person) $

- -ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ - -

NON-OWNED PROPERTY DAMAGE x HIRED AUTOS x AUTOS IPer accident\ $

y Comprehensive & Cc $ ACV

A UMBRELLA LIAB ~ OCCUR y ZUP12T17039 03/01/2014 03/01/2015 EACH OCCURRENCE $ 4,000,000 -EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000

OED I x I RETENTION $ 0 $

A WORKERS COMPENSATION HJ-UB-7046P09-14 03/30/2014 03/30/2015 x 1 TV/i~~nJi¥-s 1 I OJ~·

AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE 0

N/A E.L. EACH ACCIDENT $ 1,000,000

OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE • EA EMPLOYEE $ 1,000,000

~~;sc~f~i[~ o~OPERATIONS below E.L. DISEASE · POLICY LIMIT $ 1,000,000

A Cyberfirst E & 0 Liability y ZPL 14P77 03/01/201'1 03/01/2015 Limit 3,000,000 A Blanket Business Income y ZLP12T17027 03/01/201.:1 03/01/2015 Limit 1,000,000 A BPP-Contents CoevraQe y ZLP12T17027 03/01/201'1 03/01/2015 Limit 290,466 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101 , Additional Remarks Schedule, If more space Is required)

This is a certificate of the liability insurance limits for the above named insured.

30 day cancellation for non-payment of premium

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED lN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

/.li?/i:1!f £/5-<i· ~ I

© 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD

SLEB Waiver Request Detail Page 1of2

OFFICE OF ACQUISITION POLICY (OAP) REQUEST FOR AUTHORIZATION TO WAIVE SLEB PROGRAM REQUIREMENTS l 1 ;:JbS [

For Federal grant funds: Procurements using Federal grant funds which prohibtt geographical preferences require the Federal Grant Funds SLEB Waiver Request form to be submitted for approval to the Audttor-Controller Office of Contract Compliance (OCC) prior to solictting bids/proposals and awarding contracts . For further information contact 0 5500.

Non-Federal SLEB waivers may be submitted online. Complete online SLEB waiver requests in ALCOWEB under the "For Work" section. See "Submit Online SLEB Ill supporting documentation including three quotes or approved Sole Source. NOTE: If onllne access Is not available, please follow the procedures below to submit your request.

For ALL Requests over $3,000: Complete #1-9 below, complete #10 ~over $100,000 (First Source applies) , sign and print your name on line 11 , submtt hard copy wtth SUPP< for approval to GSA-OAP Business Outreach Officer, QIC 26021 AND email soft copy (PDF or Word) to [email protected]. Upon approval, the procurement will I Purchasing. NOTE: A SLEB waiver Is NOT required for the following :

• Approved Sole Source Exceptions for goods and services wtth a cumulative fiscal year total upto $25,000. • P.O. Change Order (POC) wtth a cumulative fiscal year total upto $25,000 and no changes in vendor, product or fiscal year.

For Requests over $25.000. a SLEB Waiver Number will be issued as required to enter a Procurement Contract in ALCOLINK. OAP will email signed approvals (wtth Waiver r and denials to Requesting Departments and GSA Purchasing. NOTE: All questions require a complete response. Enter "NIA" or "None", etc., as applicable. Do not leave blank lines.

1. Please check appropriate box and complete department/contact Information below. ~ Requesting Department [O' GSA Purchasing managing the competttive process Department: !Behavioral Health Care Services EJ Contact Name: ~~-ac-k-ie_J_o-rd_a_n---~ Email: [email protected]

GSA Purchasing/Audttor: lg Same as Department Contact Contact Name: !Sharon Woolley G Email: [sharon.woolley@aic!c!:o=v=.o=r====:

2. Recommended Vendor (Name): [Mectversant Technologij PO#: [NIA REQ#: ~ Street Address : 1355 S. Grand Avenue, Suite 1700 City : tk!is Ang~ State: l cal~omia B

3. Procurement Type (check all appropriate boxes below): [[New Contract [Q_ Renewal Contract [Q Contract Amendment-Term ([contract Amendment-Value [Q: OtherC

4. Total PO/Contract Value (Including Increase, If any)$ 60000.00 ; Increase Value (If any) S.2:,~ .-------"

Contract Term Start Date 09125/2014 e. End Date 13012016 • OR One-Time Purchase tP 5. Goods/Services Procurement Description:

Credential Verification Services


6. Brief explanation of why goods/services are required: Provides Behavioral Health Care Service with primary source credential and re-credentialing verification services


7. Date Goods/Services Needed: 0912512014 ;& a. What are the consequences If the date goods/services needed Is not met? County has to address quality issues concerning choosing providers for their clients . Exposure of liability for the county is minimized by ensuring that providers are properly credentialed & meet ac~eptable health care systems standards . Credentialing service is required o stay in compliance


Telepho

Telepho1

8. Explanation of why the non-SLEB contractor/subcontractor (In #2 above) Is being recommended and, If procurement over $25,000, why they are unable to subc (s) for a minimum of 20%: They are unable to subcontract with a SLEB for a minimum of 20 % due to the nature of credentialing I\ service . Medversant offers online credentialing services for our providers (MDs , MFTs, social workers, etc.) We import/upload application packets of our providers into their system and they V 367 characters remaining. -

9. Explain what attempts were made to locate a SLEB prime or, If procurement over $25,000, SLEB subcontractor(s), Including: (g Copies of bids received and/or detailed statement of efforts made to contact and negotiate wtth certified businesses, including list of SLEBs contacted , names of indivi

phone numbers, dates contacted and bid prices attached. In the section below, list the documents that have been attached:

a.

b.

BHCS sent out an RFQ on 3/17/14 to six small , 1 emerging and six non certified vendors listed in the SLEB database . Medversant is the only vendor who responded to the RFQ . Calls were made to the other vendors the RFQ was sent to and voice mails messages were left but vendors did not respond . 607 characters remaining.

List of ttems or selected portions of work proposed to be performed by certified business in order to increase the likelihood of achieving the stated goal:

see attached


Description of information provided to certified contractors/subcontractors regard ing the plans, specifications and anticipated time schedule for portions of the work to be P' see attached

c.


Supporting Documents:

10. If the contract Is over $100,000, is the recommended vendor able to comply with the First Source Program?

" y

L http://alcoweb.acgov.org/slebwaiverrequest __ app/addUpdateRequest.do?action~detail&req ... 9/26/2014

~ . . SLEB Waiver Request Detail

Yes: [Q] No: [Ql If No, explain:

L_ 900 characters remaining.

Expedite? [@' (Check this box to expedite processing)

DHOUTS2 Signature of Agency/Department Head or Deslgnee or GSA Purchas ing Manager (If GSA Purchasing managed the process)

David Houts

Print Name

OAP to complete below:

A. Request Approved: [§ Waiver Valid Through: [06/30t2016 , ~

Reason: No known SLEB vendor available.


B. Request Denied: [Q] Reason:

L__ -900 characters remaining.

C. Disregard: lQ; Reason: r


LMOORE Signed by GSA-Office of Acquisition Polley (Required)

SLEB Waiver Number:~

Page 2 of 2

09/22/2014

Date

09/25/2014 Date

http://alcoweb.acgov.org/slebwaiverrequest_ app/addUpdateRequest.do ?action=detail&req... 912612014