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					     Medical Society of the State of New York
Program: Health Information Technology Pilot Program
         FAU Control Number: 0607061007


             Request for Application
    (For Technical and Financial Submissions)


    Health Information Technology Pilot Program




Questions Due: March 7, 2007
Applications Due: April 20, 2007


Contact Name & Address:        Medical Society of the State of New York
                               One Commerce Plaza, Suite 1103
                               Albany, NY 12210
                               c/o Ron Pucherelli, HIT Project Administrator
                               Tel: 518-465-8085
                               E-mail rpucherelli@mssny.org
                             Table of Contents
I.       Introduction                                                      Page

         Program Introduction ……………………………………………………                         4
         Program Administrator .…………………………………………………                        4,5

II.      Who May Apply

         Project and Applicant Information …………………………………..….               5
         Funding Restrictions ………………………………………………..…..                      5
         Minimum Applicant Eligibility Requirements …………………………             6
         Preferred Applicant Target Efforts…………...………………………….              6
         Project Characteristic Priorities………………………………………….                6,7

III.     Program Summary

         HIT Pilot Program Summary and Objectives……………………………… 7
         Project Expectations …………………………………………………….. 7,8
         Work Plan Outcomes ……………………………………………………. 8

IV.      Administrative Requirements

       A. Issuing Agency …………………………………………………………..                          8
       B. Question and Answer Phase……………………………………………...                    8,9
          - Other Reports/Documents …………………………………………...…                   9
       C. Applicant Conference and Letter of Interest …………………………….         9
       D. How to File an Application ………………………………………………                    9
       E. The Administrator’s Reserved Rights ……………………………………               10
       F. Term of Contract …………………………………………………………                          10
       G. Payment and Reporting Requirements …………………………………..               10-12
          - Size and Number of Grants …………………………………………….                   10,11
          - Geographic Distribution ………………………………………………..                   11
          - Funding Period …………………………………………………….……                         11
          - Disbursement …………………………………………………….……..                         11,12
       H. Vendor Responsibility Questionnaire ……………………………………               12,13
       I. General Specifications ……………………………………………………                      13,14
       J. Grant Contract and Appendices……………… ………………………......              14-15

V.       Completing the Application

         A. Application Content ………………………………………………….                       15,16
            -Project Budget Information Submitted by Applicants.……………...   16
         B. Application Format …………………………………………………..                       17
         C. Review and Award Process …..………………………………………                    17,18

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                                              2
VI.   Attachments ……………………………………………………………                                   19-60

      Attachment 1: Lead Applicant Information ………………………….…                 19
      Attachment 2: Project and Applicant Criteria Checklist ………………..       20,21
      Attachment 3: Project Narrative .……………………………………….                     22-24
      Attachment 4: Applicant Characteristics ……………………………….                 25
      Attachment 5: Project Budget Summary ……………………………….                    26
      Attachment 6: Project Budget Detail ……………………………….......               27
      Attachment 7: Project Budget Disbursement and Allocation ..…………       28
      Attachment 8: Sample Project Work Plan ………………………………                   29
      Attachment 9: Frequently Asked Questions ……………………………                  31-36
      Attachment 10: Standard Grant Contract with Appendices A, C, D, X..   37-54
      Attachment 11: Vendor Responsibility Questionnaire …………………            55-60




                                              3
I.     Introduction
Program Introduction
In recognition of the real barriers that exist to the adoption of information technology in health care,
especially in small medical practices, the State of New York has made available grant funding for pilot
projects “designed to promote the development of electronic information exchange technologies in
order to facilitate the adoption of interoperable health records.” A Request for Application (RFA)
process will be utilized to award grant funding to the applicants who best fit the legislative funding
criteria and additional priorities developed by the Medical Society of New York Task Force on Health
Information Technology.

This state initiative is supported by legislation (Chapter 74, section 206 of the public health law, sub-
division 18-a) that includes funding for physician education in health information technology (HIT)
and for support of formation of Regional Health Information Organizations (RHIOs), in addition to
this grant-making program. The commissioner of the Department of Health of the State of New York
is authorized to issue the grant funding.

The Commissioner of the Department of Health has with the approval of the Comptroller of the State
of New York designated the Medical Society of the State of New York (hereafter, MSSNY) the
recipient of a sole source award to implement the legislation, in coordination with the Department of
Health. MSSNY formed a Task Force on Health Information Technology with over twenty
representatives from around the state, including from county and specialty medical societies, as well as
physicians and group practice managers from diverse practice settings, and representatives from the
hospital and payor communities. The Task Force on HIT developed this RFA, based on the enabling
language and intent, subject to the approval of the New York State Department of Health. Projects
will be selected based on how well they meet the criteria and priorities in this RFA, subject to the
restrictions outlined.

Health care stakeholders on the national and state level agree that emerging health information
technology is necessary to transform our current paper-based system to a quality focused,
interoperative, interconnected system which generates cost efficiencies while reducing medical error
and enhancing medical outcomes. All physicians – whether they are members of small, medium or
large group practices and whether they are active in their State and County Medical Society or their
Specialty Society – must play a leadership role in driving this vision forward if it is to be brought to
successful fruition.

Program Administrator
MSSNY, as an organization which represents close to thirty thousand practicing physicians, is
uniquely situated to play a pivotal role in assuring that physicians are:
    adequately apprised of the emerging role of health information technologies;
    properly educated regarding the appropriate systems to employ; and
    appropriately targeted to receive seed funding for the development and/or implementation of
       interoperative technologies for electronic health records and/or electronic prescribing systems.

MSSNY’s organizational structure can be easily used to facilitate the adoption and growth of

                                                    4
emerging interoperative technologies. The development of regional health information organizations
(RHIOs), often referred to as the building blocks of an interoperative electronic network, is essential to
the vision of the Office of the National Coordinator for Health Information Technology’s (ONCHIT).
That vision articulates the extraordinary changes necessary to transform our current system into an
interconnected healthcare community. MSSNY, which is federated with all of the county medical
societies in New York State, provides a common source of information and a ready set of tools
through which physicians within a county or a region of New York State can be informed of the
importance of the shift to electronic health information technologies and connected with the support
needed to implement their practice transformation to an interoperative health information
environment. Moreover, it is this structure which can be used to identify physician leaders who would
foster the interest and collaboration of other physicians and stakeholders at the regional level which is
necessary to initiate and/or continue and expand regionalized electronic health information pilot
programs.



II.    Who May Apply
Project and Applicant Information

A Project Applicant responding to this RFA shall consist of a group of entities that jointly wish to
move to interoperability in HIT, as specified in this RFA. There shall be a lead applicant and
collaborating partner applicants.

Lead Applicant
The lead applicant shall be an independent entity involved in physician practice and closely involved
with physicians in the community where the project will take place. Applicants can be physician
practices, local county or specialty medical societies, physician-governed Independent Practice
Organizations, or similar organizations. The lead applicant must be prepared to coordinate
implementation of the project.

Partner Applicants
Other partners, who may receive state funding as part of the project, may include established RHIO’s,
specialty practices, physician organizations, or other providers, such as laboratories, pharmacies, or
home care agencies.

Funding Restrictions
The following are not eligible to receive funding, either as lead applicants or as partner applicants. To
the extent that they are included in proposals as partner applicants, they would have to provide their
own project funding to support their involvement:
      Hospital-based and/or -subsidized physician practices
      Hospitals
      HIT vendors
      Health care payors
      Governmental agencies




                                                    5
A. Minimum Applicant Eligibility Requirements (Failure to meet one of these requirements will
   result in the application being ineligible.)

       1. Community-based initiatives in which a locally-organized group of health care
       participants, with a “lead applicant” and several “partner applicants,” are moving together
       toward inter-operability;

       2. Independent primary care practitioners are central participants in the project, with primary
       care broadly defined to include physicians trained in internal medicine, family practice,
       general practice, pediatricians, emergency room physicians, and obstetrician-gynecologists;

       3. Solo practitioners and small/medium-sized medical practices, with fewer than ten
       physicians, are key participants;

       4. Multiple community-based, independent, health care “partner applicants”, as appropriate
       to the interoperability goals of the project are actively included;

       5. Entities are inclusive in their physician membership, with open membership.

B. Preferred Applicant Target Efforts (Projects demonstrating or including these elements will
   be given higher priority in the selection and award of the program grants.)

       1. Demonstrated efforts by lead and all partner applicants to educate themselves about health
       information technology (HIT) and/or take steps towards initial implementation of HIT in
       relevant aspects of their medical practices.

       2. At least one partner applicant has a demonstrated background in health information
       technology capabilities.

       3. Lead applicant has coordinating capacity and has demonstrated the experience needed to
       facilitate successful project completion.

C. Project Characteristic Priorities (Projects demonstrating or including these elements will
   be given higher priority in the selection and award of the program grants.)

       1. Local or regional physician-focused projects demonstrating patient-centered care.

       2. Likelihood for successful project implementation within designated timeframe and grant
       funds.

       3. Potential for outcomes measurement in order to evaluate impact of project implementation

       4. High degree of interoperability to be achieved among project participants and others
       involved in the local care or public health system, on a non-exclusive basis.

       5. Potential for project expansion locally, or for replicability in other areas.

       6. Affirmation of willingness to become health information “champions” e.g. share their
       experiences with others and educate other physicians.
                                                   6
        7. Projects will utilize electronic health record systems to exchange health information
        between physicians, consultants, laboratories, pharmacies and patients and/or engage in the
        use of Ambulatory Order Entry (AOE) and/or electronic prescriptions (ePrescribing).

       8. Applicant members, who intend to utilize funding to support an ambulatory EHR, indicate
       that their EHR vendor(s) of choice is/are certified or has/have applied for certification by the
       Certification Committee for Health Information Technology (CCHIT). If the vendor has
       applied for certification, applicant will secure documentary proof from said vendor and submit
       together with the application.

       9. Applicant members, who intend to utilize funding to support a standalone ePrescribing
       component, indicate that their eRx vendor(s) of choice is/are certified or has/have applied for
       certification by SureScripts. If the vendor has applied for certification, applicant will secure
       documentary proof from said vendor and submit together with the application.


III. Program Summary and Objectives/ Project Expectations/ Work Plan
Outcomes

HIT Pilot Program Summary and Objectives
The Medical Society of the State of New York has received a grant from the New York State
Department of Health to implement a Health Information Technology Pilot Program. The program is
multifaceted and is comprised of an educational initiative whereby MSSNY, using faculty from the
HIT Task Force, will conduct several seminars and CME programs for physicians to present
information concerning HIT, EHR and ePrescribing, and a grant initiative to provide seed funding to
physicians, particularly solo and small group practices to purchase electronic health record technology
and who actively pursue community collaboration efforts in the exchange of patient information.

The objectives of this program are to:
    interconnect physicians through regional collaborations
    promote personalized health and consumer choice through technology
    enhance health care outcomes and health status through interoperable public health
       surveillance systems and streamlined quality monitoring

Project Expectations
In addition to working towards the overall program objectives, the program’s expectations of projects
that will be awarded grants are as follows:

   1. Affirmation of willingness on the part of project-related physicians affiliated or associated with
      lead applicant to become health information “champions” and share their experiences with
      other physicians, promote the use of electronic health record systems, educate the physician
      community and encourage the collaboration to exchange electronic patient health information.




                                                   7
     2. Grant applicant awardees will demonstrate projects utilizing electronic health record systems to
        exchange health information of patients and/or submit electronic prescriptions, order tests,
        retrieve lab results, etc.
     3. Present the potential for joining a Regional Health Information Organization (RHIO) or
        expanding inclusion of hospitals, labs, IPAs, etc.
     4. Demonstrate the potential for outcomes measurement to reflect improvements in patient health
        care delivery and results.
     5. Provide the potential for expansion of project or interoperability with others

Workplan Outcomes
Since this is a two-year grant, each grantee will furnish MSSNY with individual project or work plans
outlining tasks and milestones indicating progress and success made, if any, as defined in the Grant
Contract, Appendix D: “Program Workplan”. See Attachment 8 for a sample plan.



IV. Administrative Requirements
A.      Issuing Agency
       This RFA is issued and administered by the Medical Society of the State of New York
       (MSSNY) under a grant with the NYS Department of Health. MSSNY, through its Task Force
       on HIT, will be responsible for the requirements specified herein and for the evaluation of all
       applications.

B.      Question and Answer Phase:
        All questions pertaining to the RFA and the Grant Contract must be addressed in writing or via
        e-mail to:

                Medical Society of the State of New York
                One Commerce Plaza, Suite 1103
                Albany, NY 12210
                c/o Ron Pucherelli, HIT Project Administrator
                Tel: 518-465-8085
                E-Mal: rpucherelli@mssny.org


        To the degree possible, each inquiry should cite the specific section and paragraph to which it
        refers. Submitted questions will be accepted until 5:00PM on March 7, 2007.

        Questions and responses, as well as any updates and/or modifications, will be posted on the
        following web site: www.mssny.org on March 16, 2007. Please note that only posted responses
        will be considered as “official” by MSSNY.

        Prospective applicants should note that all clarification and exceptions, including those relating
        to the terms and conditions of the contract, are to be raised prior to the submission of an

                                                    8
     application.

     Please also note that upon approval of award to an applicant’s Request For Application, only
     identifying information for the lead applicant will be necessary for the contract’s execution. In
     addition, as the recognized lead representative, said lead applicant will also be held responsible
     for the upholding of conditions agreed to as set forth within the contract.

     Other Reports/ Documents

     Grantees will submit reports, copies of signed contracts with EHR Software Vendors, copies of
     paid invoices related to said Software Vendor costs, Hardware Vendor costs,
     telecommunication/connectivity provider costs, consultant charges, as considered to be project-
     related expenditures as stated under Budget Category Items listed in Attachment 6, on a
     quarterly basis in accordance with Reporting Schedule outlined in the Grant Contract,
     Attachment 10, Appendix C. Any changes to original budget items and/or related expenses
     must be reported on Appendix X which is included as an attachment to the Grant Contract.

C.   Applicant Conference and Letter of Interest
     An Applicant Conference will NOT be held for this project.
     A Letter of Interest will NOT be used as part of the application process for this project.

D.   How to file an application
     The Application includes two (2) documents: the Technical Submission Packet and the
     Financial Submission Packet. Both must be sealed in separate envelopes and placed inside one
     envelope and must be received at the following address by 5:00 P.M. EST, April 20, 2007.
     Late applications will not be accepted.

            Medical Society of the State of New York
            One Commerce Plaza
            Albany, NY 12210
            c/o Ron Pucherelli, HIT Project Administrator

            Tel: 518-465-8085

     Applicants shall complete both the Financial and Technical Submission Packets and submit
     <2> original, signed applications and <8> copies of each packet in separately sealed
     envelopes and then mailed together inside one envelope. Each application packet must be
     clearly labeled with the appropriate Packet Name (Financial on one; Technical on the other),
     the number (C021298) of the RFA, and the Region and only include the appropriate
     Attachments and necessary documentation for each. The application instructions and
     submission packets will be made available at www.mssny.org and available for download to
     the applicant’s local personal computer. The documents were created in MS Word 2002. Please
     save the files and complete the information. Please ensure that each attachment within each
     submission packet begins on a new page. DO NOT ALTER ANY WORDING CONTAINED
     IN EITHER SUBMISSION PACKET. CHANGES WILL RESULT IN THE APPLICATION
     BEING VOIDED. Applications WILL NOT be accepted via fax or e-mail.

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     It is the lead applicant’s responsibility to see that applications are delivered to the appropriate
     MSSNY address, prior to the date and time specified above. Late applications due to delay by
     the carrier or not received by MSSNY by the filing date and time will not be considered.

E.   MSSNY RESERVES THE RIGHT TO:
     1. Reject any or all applications received in response to this RFA.

     2. Award more than one contract resulting from this RFA.

     3. Waive or modify minor irregularities in applications received after prior notification to the
        applicant.

     4. Adjust or correct cost figures with the concurrence of the applicant if errors exist and can
        be documented to the satisfaction of MSSNY and the State Comptroller.

     5. Negotiate with applicants responding to this RFA, including amounts to be granted
        pursuant to this RFA, within the requirements to serve the best interests of the State.

     6. Modify the detail specifications should no applications be received that meet all these
        requirements.

     7. If MSSNY is unsuccessful in negotiating a contract with the selected applicant within an
        acceptable time frame, MSSNY may begin contract negotiations with the next qualified
        applicant(s) in order to serve and realize the best interests of the State.

     8. MSSNY reserves the right to award grants based on geographic or regional considerations
        to serve the best interests of the state.

F.   Term of Contract
     Any contract resulting from this RFA will be effective only upon approval by the New York
     State Office of the Comptroller.

     It is expected that executed contracts resulting from this RFA will be in force for a period of
     twenty-four (24) months.

G.   Payment & Reporting Requirements

     Size and Number of Grants
     Total available funding for this pilot project is approximately $4.5 million. A relatively small
     number of grants will be awarded. Grant size will range from a minimum of $250,000 to a
     maximum of $1,125,000. The grant will NOT cover the full costs of implementing the
     project; grant funding is intended to cover up to 50% of project costs incurred for any
     applicant. Together, this means that minimum proposals will have a total minimum project
     budget of $500,000 (i.e. 50% grant funding of $250,000 and 50% applicant funds of

                                                 10
$250,000). To obtain the maximum grant award of $1, 125,000, applicants will need to
provide a minimum of an additional $1,125,000 funding from other sources. Other sources
which can be used to satisfy the requirements for applicant funds include grants received by the
applicant from private foundations and federal agencies, and applicant self-funding. Grant
funds received from the State of New York cannot be used to satisfy this requirement.
Applicants may submit a project budget greater than $2,250,000 if more than $1,125,000 in
additional other funds are available, but the maximum grant funding award is $1,125,000. In
the event that inadequate funds exist to award each successful applicant the full amount
requested, MSSNY reserves the right to negotiate a reduction in the amount awarded to the
project.

Geographic Distribution
Preference will be given to awarding grants so as to achieve geographic distribution of project
grants broadly throughout the State of New York. Every effort will be made to provide such
distribution, unless certain conditions exist (see Disbursement below).

New York State will be divided into six (6) geographic regions:

New York City Region: this region will include each of the five boroughs of New York City.

Capital-North Region: this region will include: Albany, Rensselear, Columbia, Greene,
Schoharie, Otesego, Montgomery, Schenectady, Saratoga, Fulton, Washington, Warren,
Hamilton, Essex, Franklin and Clinton counties.

Central New York Region: this region will include: St. Lawrence, Jefferson, Lewis, Oswego,
Oneida, Herkimer, Madison, Onondaga, Cayuga, Tompkins, Schulyer, Chemung, Tioga,
Cortland, Chenango, and Broome counties.

West NY Region: this region will include: Wayne, Seneca, Yates, Ontario, Steuben,
Livingston, Monroe, Orleans, Genesee, Niagara, Erie, Wyoming, Chautauqua, Cattaraugus and
Alleghany counties.

Lower Hudson Valley Region: this region will include: Dutchess, Putnam, Ulster, Orange,
Delaware, Rockland, Sullivan and Westchester counties.

Long Island Region: this region will include: Nassau and Suffolk counties.

Applicants are required to indicate the Region for which the application is submitted. Failure to
comply will result in disqualification.

Funding Period
Project funding is to cover a period of twenty-four (24) months. However, scheduled timing of
funding payments will be mutually agreed upon in grant agreements, which will be executed
with each grantee. Payment schedules will be outlined in the Grant Contract, Attachment 10,
Appendix C “Payment and Reporting Schedule”.


                                           11
     Disbursement

     Those applicant entries attaining the highest point total in each region will be awarded a grant
     unless no entry in a region meets the minimum scoring requirement. In that event, the next
     highest score, regardless of region, may be awarded a grant. If there is a surplus or deficit of
     funds, MSSNY will determine how funding will be dispersed to applicants upon further
     investigation and analysis.

     Upon execution of a grant contract and MSSNY’s receipt of funding from the State , an
     application awardee will receive a payment equal to 25% of the total grant award. This
     payment, as well as remaining payments, will be paid directly to the lead applicant who will, in
     turn, be responsible for disbursement to all partner applicants. The remainder of the grant
     award will be paid in equal installments on a quarterly basis upon MSSNY’s receipt of such
     installment funding from the State or as defined in the Grant Contract, Attachment 10,
     Appendix C “Payment and Reporting Schedule”. Each subsequent payment is contingent upon
     the achievement of each milestone enumerated in the grant contract.

     The lead applicant shall submit invoices and required reports of expenditures to MSSNY on a
     quarterly basis as outlined in the Grant Contract, Attachment 10, Appendix C “Payment and
     Reporting Schedule”. MSSNY will review, reconcile to submitted budget and submit to the
     State's designated payment office.

     Payment of subsequent grant balances by the State (NYS Department of Health) shall be made
     in accordance with the grant contract executed by MSSNY and the awardee. Payment terms
     will be based on the terms and conditions as set forth in the Grant Contract, Attachment 10,
     Appendix C “Payment and Reporting Schedule”.

     All payment and reporting requirements will be detailed in Attachment 10, Appendix C
     “Payment and Reporting Schedule”, of the final grant contract.

H.   Vendor Responsibility Questionnaire

     New York State Procurement Law requires that state agencies award contracts only to
     responsible vendors.

     Lead applicants will be required to provide Vendor Responsibility information in the
     event they are chosen as part of the final award selection process and the award exceeds
     one hundred thousand dollars ($ 100,000). This information does NOT need to be
     completed as part of the initial submission of an application in response to this RFA.

     ATTACHMENT 11 contains the “Vendor Responsibility Questionnaire” that must be
     completed by all successful applicants, with the exception of Governmental Agencies
     (Government Agencies are defined to mean: State and Federal Governmental Agencies,
     counties, cities, towns, villages, school districts, community colleges, Board of Cooperative
     Education Services [BOCES], Vocational Education Extension Bards [VEEB's], water, fire,
     and sewer districts, public libraries, and water and soil districts), Public Corporations (Public
     Corporations are defined to mean: Public Authorities, Public Benefit Corporations, and
     Industrial Development Agencies), and Research Foundations (Research Foundations are

                                                 12
     defined to mean: Aging Research, Inc.; Health Research, Inc.; Research Foundation for Mental
     Hygiene; Research Foundations of CUNY and SUNY; and Welfare Research, Inc.).

     Successful applicants will be advised to complete and submit the questionnaire upon
     notification of their tentative award. A final award determination will be dependent on the
     ability of the State to determine the responsibility of the applicant.

     In addition to the questionnaire, the lead applicant will be required to provide the following in
     the event their project is chosen as part of the final award selection process:

         Proof of financial stability in the form of audited financial statements, Dunn &
          Bradstreet Reports, etc.
         Evidence of NYS Department of State Registration
         Proof of NYS Charities Registration (if applicable)
         Copy of Certificate of Article of Incorporation

I.   General Specifications
     1.     By signing the specified Attachment Forms, each lead applicant attests to its express
            authority to sign on behalf of the partner applicants.

     2.     Applicant Awardee will possess, at no cost to the State, all qualifications, licenses and
            permits to engage in the required business as may be required within the jurisdiction
            where the work specified is to be performed. Workers to be employed in the
            performance of this contract will possess the qualifications, training, licenses and
            permits as may be required within such jurisdiction.

     3.     Submission of an application indicates the applicant’s acceptance of all conditions and
            terms contained in this RFA. If this applicant does not accept a certain condition or
            term, this must be clearly noted in a cover letter to the application.

     4.     An applicant may be disqualified from receiving awards if such applicant or any
            subsidiary, affiliate, partner, officer, agent or principal thereof, or anyone in its employ,
            has previously failed to perform satisfactorily in connection with public bidding or
            contracts.

     5.     Provisions Upon Default

            a.      The services to be performed by the Applicant shall be at all times subject to the
                    direction and control of MSSNY as to all matters arising in connection with or
                    relating to the contract resulting from this RFA.

            b.      In the event that the Applicant, through any cause, fails to perform any of the
                    terms, covenants or promises of any contract resulting from this RFA, MSSNY
                    acting for and on behalf of the State, shall thereupon have the right to terminate
                    the contract by giving notice in writing of the fact and date of such termination
                    to the Applicant.


                                                 13
              c.      If, in the judgment of MSSNY, the Applicant acts in such a way which is likely
                      to or does impair or prejudice the interests of the State, MSSNY acting on
                      behalf of the State, shall thereupon have the right to terminate any contract
                      resulting from this RFA by giving notice in writing of the fact and date of such
                      termination to the Applicant Awardee. In such case the Applicant Awardee
                      shall receive equitable compensation for such services as shall, in the judgment
                      of the State Comptroller, have been satisfactorily performed by the Applicant
                      Awardee up to the date of the termination of this agreement, which such
                      compensation shall not exceed the total cost incurred for the work which the
                      Applicant Awardee was engaged in at the time of such termination, subject to
                      audit by the State Comptroller.

J.     Grant Contract and Appendices (For Information Purposes Only;
     Appendices E and H are not attached)
       Each grant awardee will execute a grant contract with MSSNY. A copy of a grant contract is
       included as Attachment 10.

       The following will be incorporated as appendices into any contract(s) resulting from this
       Request for Application.

              APPENDIX A -           Standard Clauses for All New York State Contracts

              APPENDIX C -           Payment and Reporting Schedule

              APPENDIX D -           Workplan

              APPENDIX X-            Report Amendments to Original Agreement

              APPENDIX H -           Federal Health Insurance Portability and Accountability Act
                                     (HIPAA) Business Associate Agreement <if applicable>

              APPENDIX E -           Unless the Applicant Awardee is a political sub-division of New
                                     York State, the Applicant Awardee shall provide proof,
                                     completed by the Applicant Awardee's insurance carrier and/or
                                     the Workers' Compensation Board, of coverage for:

                         Workers' Compensation, for which one of the following is incorporated into
                         this contract as Appendix E-1:

                            WC/DB-100, Affidavit For New York Entities And Any Out-Of-State
                             Entities With No Employees, That New York State Workers'
                             Compensation And/Or Disability Benefits Insurance Coverage Is Not
                             Required; OR
                            WC/DB -101, Affidavit That An OUT-OF STATE OR FOREIGN
                             EMPLOYER Working In New York State Does Not Require Specific
                             New York State Workers' Compensation And/Or Disability Benefits
                             Insurance Coverage; OR

                                                  14
                              C-105.2 -- Certificate of Workers' Compensation Insurance. PLEASE
                               NOTE: The State Insurance Fund provides its own version of this form,
                               the U-26.3; OR
                              SI-12 -- Certificate of Workers' Compensation Self-Insurance, OR GSI-
                               105.2 -- Certificate of Participation in Workers' Compensation Group
                               Self-Insurance

                           Disability Benefits coverage, for which one of the following is incorporated
                           into this contract as Appendix E-2:

                              WC/DB-100, Affidavit For New York Entities And Any Out-Of-State
                               Entities With No Employees, That New York State Workers'
                               Compensation And/Or Disability Benefits Insurance Coverage Is Not
                               Required; OR
                              WC/DB -101, Affidavit That An OUT-OF STATE OR FOREIGN
                               EMPLOYER Working In New York State Does Not Require Specific
                               New York State Workers' Compensation And/Or Disability Benefits
                               Insurance Coverage; OR
                              DB-120.1 -- Certificate of Disability Benefits Insurance OR the DB-
                               820/829 Certificate/Cancellation of Insurance; OR
                              DB-155 -- Certificate of Disability Benefits Self-Insurance

               NOTE: Do not include the Federal Health Insurance Portability and
               Accountability Act (HIPAA) Business Associate Agreement Workers’
               Compensation and Disability Benefits forms with your application.

               These documents will be requested as a part of the contracting process
               should you receive an award.

V.     Completing the Application Packets
A.     Application Content
A complete application submission consists of completed Technical and Financial Submission Packets
and must include the appropriate Attachments for that specific packet. The lead applicant MUST
submit all required documents in order for the project to be eligible for award consideration. If any of
these forms and required information are not completed and submitted in the required delivery manner
by the application due date, MSSNY will have no choice but to disqualify the application.

The Technical Submission Packet includes the following attachments that must be submitted for
a complete application:

Attachment 1, Lead Applicant Information, must be completed by the Lead Applicant who will
represent all partner applicants in the RFA process. If the lead applicant is a multi-physician practice,
then the practice must designate an individual to assume the lead role.

                                                    15
Attachment 2, Project and Applicant Criteria Checklist, must be completed by the Lead Applicant.
Total Project Budget information must match the aggregate total of lead and partner applicants’
Project Budget Detail totals.

Attachment 3, Project Narrative, This includes the list of questions and issues that should be
addressed in narrative description of the proposed project and should not be less than five (5) nor more
than eight (8) pages in length.

Attachment 4, Applicant Characteristics, This should include information about the lead applicant
and ALL partner applicants. It may be copied as necessary for additional partner applicants.

The Financial Submission Packet includes the following attachments that must be submitted for
a complete application:

Attachment 5, Project Budget Summary, must be completed and signed by the Lead Applicant.
If a Budget Line Item is entered, a justification must also be entered. This can also include budget-
related documentation, such as vendor work orders that contain unit cost for software, equipment,
connectivity, etc. Lead Applicants can enter Project Management fees for coordinating the assembly of
the application under the “Other” Budget Line Item. Enter “PM duties” and the number of hours spent
performing the role of project coordinator. Multiply each hour by $ 35.00 and enter total under HIT
Grant $$ Requested. This figure will be capped at $4,000 for the project’s duration.

Attachment 6, Project Budget Detail, must be completed and signed by each partner applicant. Lead
applicant should copy or duplicate this page and distribute to each partner applicant for that partner’s
detail budget information. If a Budget Line Item is entered, a justification must also be entered. This
can also include budget-related documentation, such as vendor work orders that contain unit cost for
software, equipment, connectivity, etc.

Attachment 7: Project Budget Disbursement and Allocation. This should list the proposed
allocation of the requested grant funding to the lead applicant and all partner applicants. Where funds
will be paid to a third party, e.g., a vendor, in the implementation of this project, the applicant who
will have contractual responsibility for paying the third party, and who thus will directly receive the
grant funds to be paid to the third party, should be listed as receiving that allocation. Please copy and
attach additional sheets for additional partner applicants, as needed.


Project Budget Information Submitted by Applicants

Applicants must submit a 24-month budget. All costs must be related to the project and how it will
satisfy the application requirements. Justification for each cost must be entered on the Budget
Summary and Detail Attachments to be submitted within the Financial Submission Packet. This would
also include attaching work orders, vendor estimates for software, hardware, etc. For all existing staff,
the Budget Justification must delineate how the percentage of time devoted to this initiative has been
determined. THIS FUNDING MAY ONLY BE USED TO EXPAND EXISTING ACTIVITIES OR
CREATE NEW ACTIVITIES PURSUANT TO THIS RFA. THESE FUNDS MAY NOT BE USED
TO SUPPLANT FUNDS FOR CURRENTLY EXISTING STAFF ACTIVITIES OR PRE-EXISTING
SOFTWARE, HARDWARE, ETC.

Note: Attachments 8, 10, and 11 will only be required to be completed by successful applicants before
                                                   16
the disbursement of grant funding under this program. They are not required as part of an initial
application in response to the RFA.

B.     Application Format
ALL APPLICATIONS MUST CONFORM TO THE FORMAT PRESCRIBED BELOW.
This format will facilitate reviewers’ ability to evaluate all applications more easily and equitably.
The application shall consist of the Project Narrative (as described above in Section V. A. and in
Attachment 3 of the Technical Submission Packet), which should not exceed eight (8) single-spaced
typed pages, and the other attachments 1, 2, and 4 (as described above in Application Content in
Section V.A. and on the instructions on each attachment page). The Financial Submission Packet
must include the Project Budget Summary (Attachment 5), a Project Budget Detail (Attachment 6) and
Project Budget Disbursement & Allocation (Attachment 7), and other budget-related documentation
for all application partners. All typed materials submitted shall use a 12 point Times New Roman font.

C.     Review & Award Process
Applications meeting the guidelines set forth above will be reviewed and evaluated competitively by
the MSSNY HIT Task Force. Applications will be scored and selected for awards based on applicants’
responses to requested information in the appropriate submission packets and specific attachments
identified in Section V: Application Content above. Please refer to Attachments 1 though 7 of this
document. The following represents the breakdown on which the application will be scored:

          Section of Application                    Attachment #               Maximum Points
Project Narrative Description                             3
       I. Project Overview                                                             25
       II. Statement of Need                                                           10
       III. System Implementation                                                      15
       IV. Quality Improvement                                                         15
Applicant Organizations                                1,2, & 4
      V. Lead Applicant Information,                                                   15
      Project and Applicant Criteria;,
      Applicant Characteristics

 TECHNICAL SUBMISSION SCORE                                                            80
Budget Summary and Detail                              5, 6, & 7
       I. Budget Information                                                           20

     FINANCIAL SUBMISSION SCORE                                                        20

                         TOTAL SCORE                                                  100

The Technical Submission must receive a minimum score of fifty (50) points in order to qualify.

Financial and Technical Submission Packets will be evaluated separately as specified by New York
State Law. Financial submissions will be evaluated based on the category of the proposal within a
                                                  17
region and the score will be derived using a normalization formula based on lowest cost per FTE. For
the purposes of calculating cost per FTE, each Physician will equal 1 FTE, a Physician Assistant will
equal ½ FTE, and a Nurse Practitioner will also be equal to ½ FTE and represent all FTEs that would
benefit from implementing the proposed technology enhancements. The total and detail FTE counts
must be included on Attachments 5 (Project Budget Summary) and 6 (Project Budget Detail)
respectively. Failure to comply will result in disqualification.

The formula is as follows: Financial Evaluation Score = (a/b) * 20 where ‘a’ = lowest cost per FTE of
all applicants in a category per region, and ‘b’ = cost per FTE of applicant proposal in a category in a
region being scored. This will derive the percent ratio of the maximum 20 points to be assigned to the
financial portion of the application. In the event only one proposal is submitted within a category
within a region, that proposal will receive the full financial score allowed (20 points).

Technical submissions will be evaluated on a base of 80 points as specified in the above table. The
proposal will also be evaluated for merit, viability and sustainability. Failure to meet the minimum
technical scoring requirements will result in disqualification.

Project categories will be determined by complexity of the collaborative proposal and scored against
like applications. Categories will be labeled as Simple, Moderate, and Complex for the purposes of
conducting a financial analysis of each proposal.

A Simple proposal could present collaborating physician practices sending secure clinical messaging
across provider settings, or conducting standalone ePrescribing, ACPOE or secure email.

A Moderate proposal could present collaborating physician practices engaging in a mix of partial
EHR or EMR without clinical decision support in place, and standalone ePrescribing and/or ACPOE
with at least one ancillary entity (a Lab or Hospital) providing patient data to physicians.

A Complex proposal could present collaborating physician practices with the majority engaging in full
EHR capabilities which include eRX and eDX components, utilizing clinical decision support to
conduct quality improvement efforts, clinical data repositories, and report capabilities, and exchanging
patient information with more than one ancillary entity (hospital(s) and lab(s).

The final evaluation may include a one-day briefing/summary meeting with applicant(s) in Albany,
NY in the event further clarification is needed, and it is considered a determining factor in the
selection process. This meeting is NOT intended to amend or enhance the submission. Any cost
related to this meeting or in response to this RFA is the obligation of the applicant and not the
responsibility of MSSNY or the Department of Health.

Applications failing to provide all response requirements or failing to follow the prescribed format
may be removed from consideration or points may be deducted.

If additional funding becomes available for this initiative, additional monies will be awarded in the
same manner as outlined in the award process described above.

Following the awarding of grants from this RFA, applicants may request a debriefing from MSSNY.
This debriefing will be provided in writing and will be limited to the positive and negative aspects of
the subject application only.


                                                   18
VI.   Attachments (These are ALL sample documents only. All Applicants must download and
      complete the Request For Application Submission Packet which is a separate document
      and available for download at www.mssny.org.)

      Attachment 1:      Lead Applicant Information
      Attachment 2:      Project and Applicant Criteria Checklist
      Attachment 3:      Project Narrative
      Attachment 4:      Applicant Characteristics
      Attachment 5:      Project Budget Summary
      Attachment 6:      Project Budget Detail (One page per Applicant)
      Attachment 7:      Project Budget Disbursement and Allocation
      Attachment 8:      Sample Project Work Plan
      Attachment 9:      Frequently Asked Questions (FAQs)
      Attachment 10:     Standard Grant Contract with Appendices
      Attachment 11:     Vendor Responsibility Questionnaire




                                            19
                   ATTACHMENT 1: Lead Applicant Information
This must be completed by the lead applicant who will represent all partner applicants in the RFA
process. If the lead applicant is a multi-physician practice, then the practice must designate an
individual to assume the lead role.

Application #: ___________________ (Applicants should leave this space blank.)

Project Name: _________________________________________ Region: ____________________
                                                                (See RFA sectionIV.G.2)

Lead Applicant Organization Name: _________________________________________

                            Address: _________________________________________

                                       _________________________________________

                     City/State/Zip:   _________________________________________

Main Phone Number: __(_____)_________________________________

Cell Phone Number:      __(_____)_________________________________

Fax Phone Number:       __(_____)_________________________________

Website URL, if any: _________________________________________

Tax Status: Please check one : ____ For Profit     ____Not-for Profit   ____Public

Employer Identification Number (EIN):            _____________________________

Parent Organization, If Any:           ___________________________________

Relationship to Parent Organization: ___________________________________

CONTACT INFORMATION FOR THIS LEAD APPLICANT

Contact Person Name:                   ___________________________________

Contact Person Title:                  ___________________________________

Contact Person Phone Number:           __(______)__________________________

Contact Person Cell Number:            __(______)__________________________

Contact Person Fax Number:             __(______)__________________________

Contact Person e-Mail Address:         ___________________________________


Lead Applicant Authorized Signature: ______________________________ Date: _____________

Print Name: _____________________________________ Title: ______________________________


                                                     20
ATTACHMENT 2: Project and Applicant Criteria Checklist

Must be completed by the lead applicant. Note: Total Project Budget information must match the
aggregate total of lead and partner applicants’ Project Budget Detail totals.

PROJECT NAME:                                           REGION:
Lead Applicant Name:
Partner Applicant Names (List below or on additional sheet, if necessary):




Total Grant Funding Requested:                        Total Project Budget:
Geographic area covered by project:
Project implementation timeframe (Start & End Dates):

Please check off which one or more of the following HIT Pilot Program Objectives this project
meets (see RFA Section III):
   ___        interconnect physicians through regional collaborations
   ___        promote personalized health and consumer choice through technology
   ___        enhance health care outcomes and health status through interoperable public health
              surveillance systems and streamlined quality monitoring

Please check off which one or more of the following Project Expectations this project meets (see
RFA Section III for full description of Expectations):

  ___         Affirmation of willingness on the part of project-related physicians affiliated or
              associated with lead or partner applicants to become health information “champions”
              and share their experiences with other physicians, promote the use of electronic health
              record systems, educate the physician community and encourage the collaboration to
              exchange electronic patient health information.

  ___         Grant applicant awardees will demonstrate projects utilizing electronic health record
              systems to exchange health information of patients and/or submit electronic
              prescriptions, order tests, retrieve lab results, etc.

  ___         Potential for joining a Regional Health Information Organization (RHIO) or expanding
              inclusion of hospitals, labs, IPAs, etc.

  ___         Potential for outcomes measurement and evaluation to reflect improvements in patient
              health care delivery and results.

  ___         Potential for expansion or interoperability



                                                  21
Please check off each Minimum Applicant Eligibility Requirement to confirm that this project
these requirements. Failure to meet one of these requirements will result in the application
being ineligible. (See RFA Section II):
___ Community-based initiative
___ Independent primary care participants are central participants
___ Solo and/or small-sized practices are key participants
___ Multiple community-based, independent, health care “partner applicants”
___ Participating membership organizations are inclusive in their physician membership, with open
       membership

Please check off which one or more of the following Preferred Applicant Target Efforts and
Project Characteristics this project meets (see RFA Section II):

Preferred Applicant Target Efforts:
___ Demonstrated education in health information technology or initial implementation steps
___ At least one applicant with background in HIT capabilities
___ Lead applicant with capacity and experience for successful project completion

Project Characteristics
___ Local or regional physician-focused projects demonstrating patient-centered care.

___    Likelihood for successful project implementation within designated timeframe and grant funds.

___    Potential for outcomes measurement in order to evaluate impact of project
       implementation

___    High degree of interoperability to be achieved among project participants and others involved
       in the local care or public health system, on a non-exclusive basis.

___    Potential for project expansion locally, or for replicability in other areas.

___    Affirmation of willingness to become health information “champions” e.g. share their
       experiences with others and educate other physicians.

____ Projects will utilize electronic health record systems to exchange health information between
     physicians, consultants, laboratories, pharmacies and patients and/or engage in the use of
     Ambulatory Order Entry (AOE) and/or electronic prescriptions (ePrescribing).

___    Applicant members, who intend to utilize funding to support an ambulatory EHR, indicate that
       their EHR vendor(s) of choice is/are certified or has/have applied for certification by the
       Certification Committee for Health Information Technology (CCHIT). If the vendor has
       applied for certification, applicant has submitted documentary proof from said vendor with the
       application. Applicant members, who intend to utilize funding to support a standalone
       ePrescribing component, indicate that their eRx vendor(s) of choice is/are certified or has/have
       applied for certification by SureScripts. If the vendor has applied for certification, applicant has
       submitted documentary proof from said vendor with the application.


                                                    22
                                   ATTACHMENT 3: Project Narrative

PROJECT NAME:                                                 REGION:
Lead Applicant Name:

Please describe the proposed project in narrative form in 5 – 8 pages; these pages are in addition
to the information required in the RFA Attachments 1,2, and4. In writing your narrative, please
address the following areas and questions, and number these responses accordingly in the
narrative. You may add other relevant attachments, beyond the narrative 5 – 8 pages, provided
the required extra copies are submitted along with the original application.


I.      Project Overview:

     1. Describe the project mission: what it will do, how it will do it, and the makeup of the
        project team’s organization including the roles of the various applicants.


     2. What are the goals of this project?


     3. How does this project meet:

        A. HIT Pilot Program Objectives indicated in Attachment 2: Project and Applicant
           Criteria Checklist?

        B. Minimum Applicant Eligibility Requirements indicated in Attachment 2: Project and
           Applicant Criteria Checklist?

        C. Preferred Applicant Target Efforts and Project Characteristics indicated in
           Attachment 2: Project and Applicant Criteria Checklist?


     4. How will the proposed project meet the Project Expectations that the HIT Pilot Program
        has for projects to be awarded grants, as described in Section III of the RFA?


     5. What are the concrete outcomes expected of this proposed project (include relevant and
        demonstrated instances to support how the capabilities of the implemented system would
        achieve the expected outcomes)?

        How will you evaluate whether the intended outcomes were achieved?


     6. Explain how progress towards meeting proposed project outcomes will be
        monitored.




                                                  23
7. Who will be responsible for coordinating the applicants and managing implementation of
   the project, and describe how will this be done?



II. Statement of Need:

1. Describe the need for grant funding to meet the HIT Pilot Program Objectives indicated in
   Attachment 2: Project and Applicant Criteria Checklist.


2. How will this grant help overcome existing barriers to adoption of HIT? Explain any
   anticipated problems to providing proposed services and the strategies for overcoming
   these barriers.


III. System Implementation:

1. If partner applicants are implementing full EHR systems, are these systems certified by
   CCHIT?


2. If any EHR system involved with this application has not achieved CCHIT certification
   as of the date of application, but the vendor has applied for certification, applicant must
   secure documentary proof from said vendor and submit it with this application.


3. If any standalone ePrescribing component involved with this application has not achieved
   SureScripts certification as of the date of application, but the vendor has applied for
   certification, applicant must secure documentary proof from said vendor and submit
   with this application.


4. If the project intends to/will participate in Regional Networks, task forces, coalitions
   and/or other planning bodies, describe the applicants’ roles and activities in these
   organizations.


5. Describe how the proposed program activities will be integrated within the community or
   regionally based organization.


6. Describe the group’s experience working collaboratively with other physician practices
   and other healthcare stakeholders in the community.


7. Describe the background and experience level in HIT capabilities of the applicant who will
   be providing the primary HIT expertise for the project.

                                             24
8. Describe the efforts taken or planned by the lead and partner applicants to educate
   themselves about HIT.


IV. Quality Improvement

1.   Describe how the project will use its expanded capability to conduct quality improvement
     efforts in clinical performance.

2. Clinical Measures: Discuss how you will track generally accepted ambulatory clinical
   performance measures, such as those approved by the National Quality Forum or
   Physicians’ Consortium for Performance Improvement. Describe how you would use the
   clinical measures' data to change the office practice.

3. Care management: Describe the use of your EHRs or other planned technical
   enhancements to develop registries in at least two clinical categories (such as coronary
   artery disease, diabetes, heart failure, hypertension or clinical preventive services).
   Discuss how you would use these registries to produce prompts and reminders for the
   clinicians and patients and also to develop patient-specific care plans.




                                            25
                                       ATTACHMENT 4: Applicant Characteristics

         PROJECT NAME:                                                  REGION:
         Lead Applicant:

         Please complete the following for EACH entity involved in the project, including the lead applicant
         and ALL partner applicants, regardless of whether that partner applicant would receive funding,
         directly or indirectly, from this project. Copy this sheet for additional applicants, as needed.


Applicant         Organiz-        Parent               Tax           If Medical     If Medical       If Medical Annual
Name              ation           Organization,        Status(2)     Practice,      Practice,        Practice, # Budget (3)
                  Type (1)        If Any                             Specialties    Specialties      of Annual
                                                                     & # Of         & # Of           Patient
                                                                     Doctors        PAs, NPs         Visits
Lead Applicant:


Partner App:


Partner App:


Partner App:


Partner App:




         1 Examples of organization types are: Independent Physician Practice (IPP), County Medical Society (CMS), Local
         Pharmacy (LP), Laboratory (L), Hospital (H), Health Care Payer (HPA), FQHC, RHIO…
         2 For-Profit, (FP), Not-For-Profit (NFP), Or Public Status (PS)
         3 For Independent Physician Practices, the annual budget is not required if the # of annual visits is provided

                                                                   26
                                    ATTACHMENT 5: Project Budget Summary

    PROJECT NAME:                                                    REGION:
    Lead Applicant:

    Please list project costs here and provide additional explanation of project budget in a narrative and
    attached to this Submission Packet. This must be completed and signed by the Lead Applicant.
    If a Budget Line Item is entered, a justification must also be entered. Lead Applicants can enter
    Project Management fees for coordinating the assembly of the application under the “Other” Budget
    Line Item. Enter “PM duties” and the number of hours spent performing the role of project
    coordinator. Multiply each hour by $ 35.00 and enter total under HIT Grant $$ Requested. This figure
    will be capped at $4,000 for the project’s duration.

                                      LINE ITEM                                                   SOURCE(S)
                                      JUSTIFICATION                                               OF OTHER
                                                                                                  $$
                       LINE           (Please attach                                              AVAILABLE,
                       ITEM           supporting              HIT GRANT                           including in-
    BUDGET             ACTUAL         documentation           $$                 OTHER $$         kind services     TOTAL
    LINE ITEMS         COST           such as vendor          REQUESTED          AVAILABLE        (explain in       $$
                                      work orders, etc.)                                          narrative)
    Software
    acquisition
    Hardware
    acquisition

    New Personnel

    Technical
    support for
    implementation
    Connectivity
    (T1, Cable
    Service)
    Other
    consulting
    support
    Other (explain
    in narrative)
    TOTAL
    PROJECT
    COSTS                                                     Must be 50%
                                                              or less of Total
                                                              Project Costs:
                                                              Total $$


Enter Total Number of FTEs: ___ Physicians ___ Physician Assistants                           ___ Nurse Practitioners

Lead Applicant Signature: ___________________________________ Date: _______________

    Note: Prior to award of grants, applicants may be asked to provide details in support of requested budget amounts.
    Before actual funding is provided, grant award recipients will be required to provide documentation of project costs.


                                                                27
                                        ATTACHMENT 6: Project Budget Detail

     PROJECT NAME:                                               REGION:
     Lead Applicant:

     Please list the detail of project costs here and provide additional explanation of project budget in a
     narrative and attached to this Submission Packet. This form must be completed and signed by each
     partner applicant. Lead applicant should copy this page and distribute to each partner applicant for that
     partner’s detail budget information. If a Budget Line Item is entered, a justification must also be
     entered.

     This Budget Detail is for: ____LEAD APPLICANT or ____PARTNER APPLICANT

     NAME OF APPLICANT THIS BUDGET IS FOR: _________________________________

                                       LINE ITEM                                                   SOURCE(S)
                                       JUSTIFICATION                                               OF OTHER
                                                                                                   $$
                        LINE           (Please attach                                              AVAILABLE,
                        ITEM           supporting              HIT GRANT                           including in-
     BUDGET             ACTUAL         documentation           $$                OTHER $$          kind services     TOTAL
     LINE ITEMS         COST           such as vendor          REQUESTED         AVAILABLE         (explain in       $$
                                       work orders, etc.)                                          narrative)
     Software
     acquisition
     Hardware
     acquisition

     New Personnel

     Technical
     support for
     implementation
     Connectivity
     (T1, Cable
     Service)
     Other
     consulting
     support
     Other (explain
     in narrative)
     TOTAL
     PROJECT
     COSTS


Enter Number of FTEs: ___ Physicians              ___ Physician Assistants            ___ Nurse Practitioners

Applicant Signature: ________________________________ Date: _______________
Note: This must be signed by the applicant that this budget detail is for.

     Note: Prior to award of grants, applicants may be asked to provide details in support of requested budget amounts.
     Before actual funding is provided, grant award recipients will be required to provide documentation of project costs.


                                                                 28
                     ATTACHMENT 7: Project Budget Disbursement and Allocation

    PROJECT NAME:                                              REGION:
    Lead Applicant:

    Please list the proposed allocation of the requested grant funding to the lead applicant and all partner
    applicants. Indicate the names of all partners receiving funds listed here. Where funds will be paid to
    a third party, e.g., a vendor, in the implementation of this project, the applicant who will have
    contractual responsibility for paying the third party, and who thus will directly receive the grant funds
    to be paid to the third party, should be listed as receiving that allocation. Please copy and attach
    additional sheets for additional partner applicants, as needed.

    COSTS               HIT GRANT $$ to lead $$ to                  $$ to        $$ to       $$ to
                        $$        applicant partner                 partner      partner     partner
                        REQUESTED            applicant              applicant    applicant   applicant
                                             #1                     #2           #3          #4
    Software
    acquisition
    Hardware
    acquisition
    New Personnel

    Technical
    support for
    implementation
    Connectivity
    (T1, Cable
    Service)
    Other
    consulting
    support
    Other (explain
    in narrative)
    TOTAL
    PROJECT
    COSTS

    Indicate names of all applicants included in this table:
    Lead applicant: ________________________
    Partner applicant #1___________________________
    Partner applicant #2___________________________
    Partner applicant #3___________________________
    Partner applicant #4___________________________
    Partner applicant #5___________________________


Lead Applicant Signature: ___________________________________ Date: _______________


                                                        29
                           Attachment 8: Sample Project Work Plan


PROJECT NAME:                                           REGION:
Project Member Applicant Name:




This must be completed by successful applicants as part of the contracting process. It is not
required for submitting an initial application in response to the RFA.


Reported By: _________________________________           Week Ending: ________________




Task/                    Start Date       End Date       Status* Issues/Impediments/
Milestone                MM/DD/YY        MM/DD/YY                Comments
Assessment/Gaps
identified
Workflow Analysis
Vendor Evaluation
Select Vendor
Initiate Pilot
Test System
Accept System
Convert Data/ Scan
Charts
Go Live



*Status Codes: C=Completed, OS=On Schedule, BS=Behind Schedule, IP=In Progress




                                               30
                       Attachment 9: Frequently Asked Questions (FAQs)

This attachment is intended to answer common questions about the HIT Pilot Program RFA and the
Application Process. Please review to see if your question is addressed.

The FAQ categories are:
Program Objectives and Priorities
Applicants and Eligibility
Project Costs
Application Process
Implementation

Program Objectives and Priorities
Q:    What are examples of “demonstrated efforts by applicants to educate themselves about
      health information technology (HIT) and/or take steps towards initial implementation of
      HIT in relevant aspects of practices?”

A:     For physicians, participation in DOQ-IT, attendance at HIT physician education programs
       (such as Health Information and Management Systems/HIMSS or other health information
       organization programs), or evidence that practice is “on the verge” of HIT adoption and that
       this grant would help overcome remaining barriers are examples of “demonstrated efforts.”

Q.     Does it matter which of the HIT Pilot Project Objectives our proposal seeks to
       accomplish?

A.     Each of the three Pilot Project Objectives (Section III) is important to the goals of this
       program, so each of them is a valid area for your project to address. Under the grant award
       scoring process, no advantage will be given to projects in one area versus another. However,
       because all of these are important objectives, some consideration may be given in the final
       grant award process to funding projects in each if these areas, if possible.

Q:     What are some examples of projects that small practices could propose that would be
       eligible to receive a grant under this Pilot Program?

A:     Possible projects for small practices within the Pilot Program Objectives would include ones to
       help them purchase and implement electronic prescribing and/or electronic medical records
       systems as part of larger project.

Applicants and Eligibility
Q:    Is a hospital owned physician practice eligible for funding?

A:     No, hospital based and/or subsidized physician practices are not eligible to receive funding
       either as a lead applicant or as a partner applicant..

Q:     Will software to be used in our proposal for outpatient electronic health records have to
       be CCHIT-certified?

A:     For projects that propose to implement or expand EHR, a preference will be given to applicants
       who intend to utilize vendors of ambulatory EHR products that have received CCHIT
                                                  31
             certification or have indicated their vendor(s) has/have applied for certification by the
             Certification Committee for Health Information Technology (CCHIT) and have submitted
             documentary proof from said vendor(s). CCHIT is a common, private sector pathway to
             software interoperability. Its parent bodies are HIMSS, AHIMA, and the Alliance. It will
             certify outpatient EHRs, and eventually inpatient EHRs, and network components. About two
             dozen software packages are being reviewed against a 200-item checklist.

             The Certification Commission for Healthcare Information Technology (CCHIT) announced the
             CCHIT Certified Ambulatory Electronic Health Record (EHR) products. Announcements were
             made in July, and again in October of 2006. The current list includes the following products:
         CCHIT Certified Products by Company
                                                                                                              
              Product                   Company                      Product               Company
     ABELMed PM - EMR            ABELSoft Corp                 Med & PM Suite        LSS Data Systems
     AcerMed                     AcerMed, Inc.                 Med Practice EMR      CPSI
     Allscripts - Healthmatics   Allscripts                    MediNotes             MediNotes Corp
     Allscripts - Touchworks     Allscripts                    MedPlexus EHR         MedPlexus, Inc.
     Avatar                      Netsmart Technologies         MISYS EMR             MISYS Healthcare
     Bond Clinician EHR          Bond Technologies             mMD.Net EHR           Medical Comm Sys
     CareRevolution              EHS                           MyNightingale PW      Nightingale Informatix
     Centricity EMR              GE Healthcare                 NextGen EMR           NextGen Hlth Info Sys
     Companion EMR               Companion Technologies        Noteworthy EHR        Noteworthy Med Sys
     eClinical Works             eClinical Works               PowerChart            Cerner Corporation
     eMDS Solution               EMDs                          Practice Partner9     Practice Partner Corp
     EpicCare Ambulatory         Epic Systems                  Praxis EMR            Infor-Med Corp
     EncounterPro EHR            JMJ Technologies              PrimeSuite            Greenway Med Tech
     Horizon Ambulatory          McKesson                      Record 2006           MedcomSoft
     iMedica PRM                 iMedica Corporation           Sunrise Ambulatory    Eclipsys
     Intergy                     Sage Software                 Streamline MD         ProPractica, Inc.
     Medent                      Community Comp Svc            WebChart              Med Informatics Engin.


    The CCHIT certification process is ongoing as additional products are intended to be announced on a
    quarterly basis moving forward. More details can be found at www.cchit.org, including upcoming
    dates for ambulatory electronic health record (EHR) certification and additional CCHIT certified
    products. THIS IS NOT A FINAL PRODUCT LIST. ALL APPLICANTS ARE ADVISED TO
    CHECK THE CCHIT WEBSITE FOR ADDED PRODUCTS.

    Q:       Will standalone ePrescribing software to be used in our proposal have to be SureScripts-
             certified?

    A.       For projects that propose to implement standalone ePrescribing components, a preference will
             be given to applicants who intend to utilize vendors of eRx products that have received
             SureScripts certification or have indicated their vendor(s) has/have applied for certification by
             SureScripts and have submitted documentary proof from said vendor(s).

             The following table provides a listing of all SureScripts Certified Solution Providers and the
             services for which they have been certified (i.e, E-Prescribing and E-Refills).

                                                         32
Providers                Product                        Sys-Type   E-Prescribing     E-Refills
A4 Health Sys            Healthmatics® EMR            EMR            Certified       Certified
Allscripts               TouchWorks                   eRx/EMR        Certified       Certified
Allscripts/NEPSI         eRx NOW™                     eRx/EMR        Certified       Certified
ASP.MD                   ASP.MD                       EMR            Certified       Certified
athenahealth             athenahealth                 EMR            Certified       Certified
Axolotl                  Axolotl                      eRx/EMR        Certified       Certified
BCBS of Alabama          InfoSolutions                eRx            Certified       Certified
Bond Medical             BondMedical, Inc             EMR            Certified       Certified
Cerner                   Community Hlth Rec           eRx            Certified     Not Certified
ChartConnect             MedManager                   eRx/EMR        Certified       Certified
DAW Systems              ScriptSure                   eRx            Certified       Certified
SOAPware                 SOAPware                     EMR            Certified       Certified
DrFirst                  DrFirst Rcopia               eRx            Certified       Certified
eClinicalWorks, Inc.     eClinicalWorks               EMR            Certified       Certified
eHealthSolutions         eHealthSolutions             eRx            Certified       Certified
e-MDs                    e-MDs Solution Series        EMR            Certified       Certified
Epic                     Epicare Ambulatory EMR       EMR            Certified       Certified
Gold Standard            eMPOWERx                     eRx            Certified       Certified
Health Sys Rsch, Inc.    Clinipath                    EMR            Certified       Certified
iSALUS                   OfficeEMR™                   EMR            Certified       Certified
InstantDx                OnCallData                   eRx            Certified       Certified
                         Providing connectivity for
Kryptiq                                               EMR            Certified       Certified
                         GE Centricity EMR
LighthouseMD             CareTracker                  eRx            Certified       Certified
McKesson                 Horizon Ambul Care           EMR            Certified       Certified
Medent                   MEDENT                       EMR            Certified       Certified
Medical Comm Sys         mMD.net EMR                  EMR            Certified       Certified
MedicWare                MedicWare EMR                EMR            Certified       Certified
MedNet System            emr4MD                       EMR            Certified       Certified
MedPlexus                MedPlexus                    EMR            Certified       Certified
MedPlus                  Care360                      eRx            Certified       Certified
NaviMedix                NaviNet                      e-refills    Not Certified     Certified
Netsmart - InfoScriber   InfoScriber                  eRx            Certified       Certified
NewCrop                  NewCrop                      eRx            Certified       Certified
NextGen®                 NextGen EMR                  EMR            Certified       Certified
OA Systems               Rx Cure                      eRx            Certified       Certified


                                                         33
Polaris – Epichart      EpiChart                 EMR             Certified        Certified
Practice Partner        Practice Partner         EMR             Certified        Certified
RelayHealth             eScript™                 eRx             Certified        Certified
RxNT                    RxNT                     eRx             Certified        Certified
SynaMed                 SmartEMR                 EMR             Certified        Certified
VipaHealth Solutions    SynaMed                  EMR             Certified        Certified
                                                                Certified but   Certified but
SSIMED                  EMRge                    EMR
                                                                not available   not available
SynaMed                 SmartEMR                 EMR             Certified        Certified
ZixCorp                 PocketScript             eRx             Certified        Certified
Wellogic                Consult                  EMR             Certified        Certified


More details can be found at http://www.surescripts.com/get-practice-connected.htm.

Q.     What if a project focuses on implementing a process other than EHR or ePrescribing, for
       example, using a web-based Medical Reconciliation program?

A.      Other types of proposed projects will be considered for grant awards provided that these
        Projects and programs follow the interoperability standards set by CCHIT. In this case, the
        program must use NCPDP Script 4.2 or later. Please visit www.cchit.org to review the
        interoperability criteria for ambulatory EHRs.

Q:      Why are some entities, such as hospitals, not eligible to receive funding in a project even
        if they are a partner applicant?

        A: Hospitals have been a significant beneficiary of the HEAL NY grant program. The second
        cycle of HEAL NY grants, announced in May of 2006, made available more than $269 million
        in grant funding for hospitals and nursing homes to further strengthen New York’s health care
        system. The funding will be dedicated to those health care facilities that demonstrate a
        commitment to investing in the restructuring and reconfiguration of their facilities to further
        improve the delivery of quality care to patients. Certainly. entities such as hospitals are valued
        partners within the context of our health care system. They are already, receiving significant
        financial assistance to establish their HIT infrastructure. That is why the focus of this grant
        program must be on physician practices, particularly those solo and small group practices that
        lack the resources necessary to invest in and embrace health information technology.

Q:      Can an individual physician practice apply for a grant to connect to an existing RHIO or
        other ongoing initiative?

A:      An individual physician practice could not apply on its own for a grant, but could be part of a
        larger proposal that seeks to pursue an innovative approach to overcoming barriers for a
        number of physicians interested in connecting to a RHIO or other initiative.

Q:      What kinds of groups may collaborate to help solo or small practices apply?


                                                    34
A:    Projects that focus on small and solo physician practices as applicants are a funding priority for
      this program, and so are entities that encourage and allow open membership to these types of
      practices, so small practices are encouraged to apply through such organizations. These
      organizations may include local medical or specialty societies, professional and other similar
      organizations, and multi-site group practices. Small practices can work with the existing
      organizations or can come together in their own group, for example as a buyers’ collaborative.

Q:    Do physicians have to be members of MSSNY to be assisted by this initiative?

A:    No, any practicing physician in the state who is part of a project meeting the priorities listed in
      the RFA is eligible to apply.

Q:    Are non-physician entities eligible for grant funding?

A:    The focus of the grant program is overcoming real barriers, including financial ones, which are
      faced in adoption of HIT, particularly by small physician practices, so it is expected that the
      majority of funding would go to support physician practices in these projects. However, non-
      physician entities may receive funding where appropriate in projects. For example, the
      physician practices in an area may be interested in initiating or participating in a project, but
      may not have the resources and capabilities to coordinate the project and manage the
      implementation, so a non-physician entity could fill that role, with agreement of all parties, and
      receive funding.

Q:    Could a hospital or a hospital-supported physician practice be a partner applicant if it
      did not receive funding from the grant?

A:    If the participation of the hospital or hospital-supported physician practice is an integral part of
      the project, it could be partner applicant, but it could not be a lead applicant or receive funding
      from the grant.

Q:    Could a RHIO be a lead or partner applicant?

A:    Yes, a RHIO could be lead or partner applicant, subject to RFA restrictions stated elsewhere.

Q:    Does the lead applicant have to have not-for-profit (501c3) tax status?

A:    No, such NFP tax status is not required, as long as the lead applicant meets the eligibility
      specifications outlined in the RFA.

Project Costs
Q:     Can a lead applicant receive funding to support its coordination and implementation of
       the project?

A:    Yes. Such costs should be included as a line item in the budget.

Q:    What are acceptable sources of other funds to cover the portion of the project costs not
      covered by the grant funding?

A:    Lead and partner applicants should provide their own funds to cover those project costs not
                                                   35
       covered in the grant. They may also apply any other grant funding that they have available, so
       long as it is consistent with the Pilot Project objectives and the funding priorities outlined in
       the RFA. Other sources which can be used include grants received by the applicant from a
       private foundation or a federal agency. Funding from the state, including monies received as a
       part of the HEAL NY initiative, may complement the work of the proposed project, but are not
       eligible to apply as matching funds.

Application Process
Q:    What education or assistance is available to support responding to the RFA?

A:     MSSNY will provide telephone assistance for interested potential applicants to ask questions
       about the RFA process. This assistance will be available to during the RFA application period
       for specific application process questions that are not answered in these FAQ’s.

Q:     Is there technical assistance or grant-writing assistance available to assist with writing
       the response to the RFA?

A:     No, applicants must respond to the RFA using their own resources.

Q:     How will proposals be evaluated?

A:     Applications will be scored separately on a Financial as well as a Technical basis. The
       Technical will be evaluated based on the category of the proposal within a region and scored
       on how well the proposed project:
       -      achieves one or more of the HIT Pilot Program Objectives;
       -      meets Project Expectations, including viability and sustainability of the proposal;
       -      meets Minimum Applicant Eligibility Requirements, Preferred Applicant Target
              Efforts, and Project Characteristics Priorities.

       The Financial will be evaluated based on the category of the proposal within a region and the
       score will be derived using a normalization formula based on lowest cost per FTE.

       In selecting the successful grant applicants, efforts will be made to fund a diversity of projects,
       varied according to geographic locations, settings, applicants, project objectives, etc.

Implementation
Q:    Is there any technical assistance available for project implementation after grants are
      awarded?

A:     Yes, MSSNY will provide limited technical support for implementation.

If your question is not addressed there, additional questions about the RFA process may be directed in
writing or by e-mail to:
                               Ron Pucherelli (518-465-8085)
                               HIT Project Administrator – MSSNY
                               rpucherelli@mssny.org




                                                   36
                             ATTACHMENT 10:
             STANDARD GRANT CONTRACT WITH APPENDICES A, C, D, X

                                 GRANT CONTRACT

                                                      .   NYS COMPTROLLER’S NUMBER:
______
The Medical Society of the State of New York          .
                                                      . ORIGINATING AGENCY CODE:
_______________________________________               .
                                                      ___________________________________
CONTRACTOR (Name and Address):                        . TYPE OF PROGRAM(S)
                                                      .
                                                      .
_______________________________________               .
                                                      ___________________________________
FEDERAL TAX IDENTIFICATION NUMBER:                    . INITIAL CONTRACT PERIOD

                                                      . FROM:
MUNICIPALITY NO. (if applicable):                     .
                                                      . TO:
                                                      .
                                                      ___________________________________
                                                      . MULTI-YEAR TERM (if applicable):
_______________________________________               . FROM:
                                                      . TO:



APPENDICES ATTACHED AND PART OF THIS AGREEMENT

_____    APPENDIX A             Standard clauses as required by the Attorney General for all
                                State contracts.
_____    APPENDIX B             Budget
_____    APPENDIX C             Payment and Reporting Schedule
_____    APPENDIX D             Program Workplan
_____    APPENDIX X             Modification Agreement Form (to accompany modified
                                appendices for changes in term or consideration on an existing
                                period or for renewal periods)


                                     OTHER APPENDICES

_____    APPENDIX A-2           Program-Specific Clauses
_____    APPENDIX E-1           Proof of Workers’ Compensation Coverage
_____    APPENDIX E-2           Proof of Disability Insurance Coverage
_____    APPENDIX H             Federal Health Insurance Portability and Accountability Act
                                Business Associate Agreement




                                                37
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the
dates below their signatures.

Contract No. _______________________               Contract No. ___      _____________________


By: ____________________________________ By: ____________________________________
                 (Print Name)                                           (Print Name)


   ____________________________________                ____________________________________
                 (Signature)                                             (Signature)



Title: ___________________________________ Title: _____________                __________________


Date: ___________________________________ Date: ______________________________




STATE OF NEW YORK         )
                          ) SS:
County of _______________ )

On the ____ day of ________20__, before me personally appeared _________________________,
to me known, who being by me duly sworn, did depose and say that he/she resides at
______________________, that he/she is the ______________________________ of the
____________________________________, the corporation described herein which executed the
foregoing instrument; and that he/she signed his/her name thereto by order of the board of directors
of said corporation.
(Notary) _______________________________________________________________________

ATTORNEY GENERAL’S SIGNATURE                .       STATE COMPTROLLER’S SIGNATURE


___________________________________                . __________________________________




Title: __________________________________          Title: ___________________________________




Date: ___________________________________ Date: ______________________________


                                                 38
                                  STATE OF NEW YORK

                                       AGREEMENT

This AGREEMENT is hereby made by and between the Medical Society of the State of New
York (MSSNY) and the public or private agency (CONTRACTOR) identified on the face page
hereof.

                                     WITNESSETH:
   WHEREAS, MSSNY has the authority to regulate and provide funding for the
establishment and operation of program services and desires to contract with skilled parties
possessing the necessary resources to provide such services; and

    WHEREAS, the CONTRACTOR is ready, willing and able to provide such program
services and possesses or can make available all necessary qualified personnel, licenses,
facilities and expertise to perform or have performed the services required pursuant to the
terms of this AGREEMENT;

   NOW THEREFORE, in consideration of the promises, responsibilities and convenants
herein, MSSNY and the CONTRACTOR agree as follows:

I.    Conditions of Agreement

      A.     This AGREEMENT may consist of successive periods (PERIOD), as specified
             within the AGREEMENT or within a subsequent Modification Agreement(s)
             (Appendix X). Each additional or superseding PERIOD shall be on the forms
             specified by MSSNY, and shall be incorporated into this AGREEMENT.

      B.     Funding for the first PERIOD shall not exceed the funding amount specified on
             the face page hereof. Funding for each subsequent PERIOD, if any, shall not
             exceed the amount specified in the appropriate appendix for that PERIOD.

      C.     This AGREEMENT incorporates the face pages attached and all of the marked
             appendices identified on the face page hereof.

      D.     For each succeeding PERIOD of this AGREEMENT, the parties shall prepare
             new appendices, to the extent that any require modification, and a Modification
             Agreement (the attached Appendix X is the blank form to be used). Any terms
             of this AGREEMENT not modified shall remain in effect for each PERIOD of the
             AGREEMENT.

             To modify the AGREEMENT within an existing PERIOD, the parties shall revise
             or complete the appropriate appendix form(s). Any change in the amount of
             consideration to be paid, or change in the term, is subject to the approval of the
             Office of the State Comptroller.

             The CONTRACTOR shall perform all services to the satisfaction of MSSNY.
             The CONTRACTOR shall provide services and meet the program objectives
             summarized in the Program Workplan (Appendix D) in accordance with:
                                             39
             provisions of the AGREEMENT; relevant laws, rules and regulations.

       E.    If the CONTRACTOR enters into subcontracts for the performance of work
             pursuant to this AGREEMENT, the CONTRACTOR shall take full responsibility
             for the acts and omissions of its subcontractors. Nothing in the subcontract
             shall impair the rights of MSSNY under this AGREEMENT. No contractual
             relationship shall be deemed to exist between the subcontractor and MSSNY.

       F.    Appendix A (Standard Clauses as required by the Attorney General for all State
             contracts) takes precedence over all other parts of the AGREEMENT.

II.    Payment and Reporting

       A.    The CONTRACTOR, to be eligible for payment, shall submit to MSSNY’s
             designated payment office (identified in Appendix C) any appropriate
             documentation as required by the Payment and Reporting Schedule (Appendix
             C) and by agency fiscal guidelines, in a manner acceptable to MSSNY.

       B.    MSSNY shall make payments and any reconciliations in accordance with the
             Payment and Reporting Schedule (Appendix C). MSSNY shall pay the
             CONTRACTOR, in consideration of contract services for a given PERIOD, a
             sum not to exceed the amount noted on the face page hereof or in the
             respective Appendix designating the payment amount for that given PERIOD.
             This sum shall not duplicate reimbursement from other sources for
             CONTRACTOR costs and services provided pursuant to this AGREEMENT.

       C.    The CONTRACTOR shall meet the audit requirements specified by MSSNY.

III.   Terminations

       A.    This AGREEMENT may be terminated at any time upon mutual written consent
             of MSSNY and the CONTRACTOR.

       B.    MSSNY may terminate the AGREEMENT immediately, upon written notice of
             termination to the CONTRACTOR, if the CONTRACTOR fails to comply with
             the terms and conditions of this AGREEMENT and/or with any laws, rules and
             regulations, policies or procedures affecting this AGREEMENT.

       C.    MSSNY may also terminate this AGREEMENT for any reason in accordance
             with provisions set forth in Appendix A-1.

       D.    Written notice of termination, where required, shall be sent by personal
             messenger service or by certified mail, return receipt requested. The
             termination shall be effective in accordance with the terms of the notice.

       E.    Upon receipt of notice of termination, the CONTRACTOR agrees to cancel,
             prior to the effective date of any prospective termination, as many outstanding
             obligations as possible, and agrees not to incur any new obligations after
             receipt of the notice without approval by MSSNY.
                                            40
      F.    MSSNY shall be responsible for payment on claims pursuant to services
            provided and costs incurred pursuant to terms of the AGREEMENT. In no
            event shall MSSNY be liable for expenses and obligations arising from the
            program(s) in this AGREEMENT after the termination date.

IV.   Indemnification

      A.    The CONTRACTOR shall be solely responsible and answerable in damages for
            any and all accidents and/or injuries to persons (including death) or property
            arising out of or related to the services to be rendered by the CONTRACTOR or
            its subcontractors pursuant to this AGREMENT. The CONTRACTOR shall
            indemnify and hold harmless MSSNY and its officers and employees from
            claims, suits, actions, damages and costs of every nature arising out of the
            provision of services pursuant to this AGREEMENT.

      B.    The CONTRACTOR is an independent contractor and may neither hold itself
            out nor claim to be an officer, employee or subdivision of MSSNY nor make any
            claims, demand or application to or for any right based upon any different
            status.




                                           41
                                     APPENDIX A

     STANDARD CLAUSES FOR THIRD-PARTY CONTRACTS FOR NEW YORK STATE

             PLEASE RETAIN THIS DOCUMENT FOR FUTURE REFERENCE.

                                TABLE OF CONTENTS

1. Limitation of State’s Liability

2. Non-Assignment Clause

3. Comptroller’s Approval

4. Workers’ Compensation Benefits

5. Non-Discrimination Requirements

6. Wage and Hours Provisions

7. Non-Collusive Bidding Certification

8. International Boycott Prohibition

9. Records

10. Equal Employment Opportunities For Minorities and Women

11. Conflicting Terms

12. Governing Law

13. No Arbitration

14. Service of Process

15. Prohibition on Purchase of Tropical Hardwoods

16. MacBride Fair Employment Principles

17. Omnibus Procurement Act of 1992

18. Reciprocity and Sanctions Provisions

19. Purchases of Apparel



                                         42
   STANDARD CLAUSES FOR THIRD-PARTY CONTRACTS FOR NEW YORK STATE

The attached contract (“the Contract” or “this Contract”) has been determined to
be a contract “for” the State of New York (“the State”) . The Contract is between
an entity acting for the State pursuant to an agreement with the State (the “State
Contractor”) and another entity (the “Third-Party Contractor”, which refers to any
party other than the State Contractor or the State, whether a contractor, licenser,
licensee, lessor, lessee or any other party). In light of the foregoing, the parties to
the Contract (whether it may be a license, lease, amendment or other agreement
of any kind) agree to be bound by the following clauses which are hereby made a
part of the Contract:

1. LIMITATION OF STATE’S LIABILITY. The State shall have no liability hereunder
to the Third-Party Contractor. The State’s liability, if any, is to the State
Contractor pursuant to an agreement between the State and the State Contractor
(“the Agreement”) which is separate and apart from this Contract, and, in
accordance with the executory clause to the Agreement the State’s liability is
limited to the funds appropriated and available for such Agreement.

2. NON-ASSIGNMENT CLAUSE. Consistent with the provisions of Section 138 of the
State Finance Law, this Contract may not be assigned by the Third-Party Contractor
or its right, title or interest therein assigned, transferred, conveyed, sublet or
otherwise disposed of without the previous consent, in writing, of the State
Contractor and the State and any attempts to assign the Contract without the
State's written consent are null and void. The Third-Party Contractor may,
however, assign its right to receive payment without the State Contractor’s and the
State's prior written consent unless this Contract concerns Certificates of
Participation pursuant to Article 5-A of the State Finance Law.

3. COMPTROLLER'S APPROVAL. In accordance with Section 112 of the State
Finance Law, if this Contract exceeds $15,000 (or, if this Contract is for the State
University or City University of New York, Section 355 or Section 6218 of the
Education Law and exceeds the minimum thresholds agreed to by the Office of the
State Comptroller for certain S.U.N.Y. and C.U.N.Y. contracts), or if this is an
amendment for any amount to a contract which, as so amended, exceeds said
statutory amount, or if the Contract involves consideration other than the payment
of money for the State and the consideration being given for the State has a value
or reasonably estimated value that exceeds $10,000, it shall not be valid, effective
or binding until it has been approved by the State Comptroller and filed in his
office. Comptroller's approval of Contracts let for the Office of General Services is
required when such Contracts exceed $30,000 (State Finance Law Section 163.6.a).
Failure to obtain the Comptroller’s approval of this Contract, where required, will
preclude any payment by the State to the State Contractor under the Agreement
which would be used to fund this Contract.

4. WORKERS' COMPENSATION BENEFITS. Consistent with the provisions of Section
142 of the State Finance Law, this Contract shall be void and of no force and effect

                                          43
unless the Third-Party Contractor shall provide and maintain coverage during the
life of this Contract for the benefit of such employees as are required to be
covered by the provisions of the Workers' Compensation Law.

5. NON-DISCRIMINATION REQUIREMENTS. To the extent required by Article 15 of
the Executive Law (also known as the Human Rights Law) and all other State and
Federal statutory and constitutional non-discrimination provisions, the Third-Party
Contractor will not discriminate against any employee or applicant for employment
because of race, creed, color, sex, national origin, sexual orientation, age,
disability, genetic predisposition or carrier status, or marital status. Furthermore,
in accordance with Section 220-e of the Labor Law, if this is a contract for the
construction, alteration or repair of any public building or public work or for the
manufacture, sale or distribution of materials, equipment or supplies, and to the
extent that this Contract shall be performed within the State of New York, the
Third-Party Contractor agrees that neither it nor its subcontractors shall, by reason
of race, creed, color, disability, sex, or national origin: (a) discriminate in hiring
against any New York State citizen who is qualified and available to perform the
work; or (b) discriminate against or intimidate any employee hired for the
performance of work under this Contract. If this is a building service contract as
defined in Section 230 of the Labor Law, then, in accordance with Section 239
thereof, the Third-Party Contractor agrees that neither it nor its subcontractors
shall by reason of race, creed, color, national origin, age, sex or disability: (a)
discriminate in hiring against any New York State citizen who is qualified and
available to perform the work; or (b) discriminate against or intimidate any
employee hired for the performance of work under this Contract. The Third-Party
Contractor is subject to fines of $50.00 per person per day for any violation of
Section 220-e or Section 239 as well as possible termination of this Contract and
forfeiture of all moneys due hereunder for a second or subsequent violation.

6. WAGE AND HOURS PROVISIONS. If this is a public work contract covered by
Article 8 of the Labor Law or a building service contract covered by Article 9
thereof, neither the Third-Party Contractor's employees nor the employees of its
subcontractors may be required or permitted to work more than the number of
hours or days stated in said statutes, except as otherwise provided in the Labor
Law and as set forth in prevailing wage and supplement schedules issued by the
State Labor Department. Furthermore, the Third-Party Contractor and its
subcontractors must pay at least the prevailing wage rate and pay or provide the
prevailing supplements, including the premium rates for overtime pay, as
determined by the State Labor Department in accordance with the Labor Law.

7. NON-COLLUSIVE BIDDING CERTIFICATION. Consistent with the provisions of
Section 139-d of the State Finance Law, if this Contract was awarded based upon
the submission of bids, the Third-Party Contractor warrants, under penalty of
perjury, that its bid was arrived at independently and without collusion aimed at
restricting competition. The Third-Party Contractor further warrants that, at the
time the Third-Party Contractor submitted its bid, an authorized and responsible
person executed and delivered to the State Contractor or the State a non-collusive

                                          44
bidding certification on the Third-Party Contractor's behalf.

8. INTERNATIONAL BOYCOTT PROHIBITION . Consistent with the provisions of
Section 220-f of the Labor Law and Section 139-h of the State Finance Law, if this
Contract exceeds $5,000, the Third-Party Contractor agrees, as a material
condition of the Contract, that neither the Third-Party Contractor nor any
substantially owned or affiliated person, firm, partnership or corporation has
participated, is participating, or shall participate in an international boycott in
violation of the federal Export Administration Act of 1979 (50 USC App. Sections
2401 et seq.) or regulations thereunder. If such Third-Party Contractor, or any of
the aforesaid affiliates of Third-Party Contractor, is convicted or is otherwise found
to have violated said laws or regulations upon the final determination of the United
States Commerce Department or any other appropriate agency of the United States
subsequent to the Contract's execution, such Contract, amendment or modification
thereto shall be rendered forfeit and void. The Third-Party Contractor shall so
notify the State Comptroller within five (5) business days of such conviction,
determination or disposition of appeal (2NYCRR 105.4).

9. RECORDS. The Third-Party Contractor shall establish and maintain complete and
accurate books, records, documents, accounts and other evidence directly
pertinent to performance under this Contract (hereinafter, collectively, "the
Records"). The Records must be kept for the balance of the calendar year in which
they were made and for six (6) additional years thereafter. The State Comptroller,
the Attorney General and any other person or entity authorized to conduct an
examination, as well as the agency or agencies involved in this Contract, shall have
access to the Records during normal business hours at an office of the Third-Party
Contractor within the State of New York or, if no such office is available, at a
mutually agreeable and reasonable venue within the State, for the term specified
above for the purposes of inspection, auditing and copying. The State shall take
reasonable steps to protect from public disclosure any of the Records which are
exempt from disclosure under Section 87 of the Public Officers Law (the "Statute")
provided that: (i) the Third-Party Contractor shall timely inform an appropriate
State official, in writing, that said records should not be disclosed; and (ii) said
records shall be sufficiently identified; and (iii) designation of said records as
exempt under the Statute is reasonable. Nothing contained herein shall diminish, or
in any way adversely affect, the State's right to discovery in any pending or future
litigation.

10. EQUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN.
Consistent with the provisions of Section 312 of the Executive Law, if this Contract
is: (i) a written agreement or purchase order instrument, providing for a total
expenditure in excess of $25,000.00, whereby the State Contractor is committed to
expend or does expend funds in return for labor, services, supplies, equipment,
materials or any combination of the foregoing, to be performed for, or rendered or
furnished to the State Contractor; or (ii) a written agreement in excess of
$100,000.00 whereby the State Contractor is committed to expend or does expend
funds for the acquisition, construction, demolition, replacement, major repair or

                                          45
renovation of real property and improvements thereon; or (iii) a written agreement
in excess of $100,000.00 whereby the owner of a State assisted housing project is
committed to expend or does expend funds for the acquisition, construction,
demolition, replacement, major repair or renovation of real property and
improvements thereon for such project, then:

(a) The Third-Party Contractor will not discriminate against employees or
applicants for employment because of race, creed, color, national origin, sex, age,
disability or marital status, and will undertake or continue existing programs of
affirmative action to ensure that minority group members and women are afforded
equal employment opportunities without discrimination. Affirmative action shall
mean recruitment, employment, job assignment, promotion, upgradings, demotion,
transfer, layoff, or termination and rates of pay or other forms of compensation;

(b) at the request of the State, the Third-Party Contractor shall request each
employment agency, labor union, or authorized representative of workers with
which it has a collective bargaining or other agreement or understanding, to furnish
a written statement that such employment agency, labor union or representative
will not discriminate on the basis of race, creed, color, national origin, sex, age,
disability or marital status and that such union or representative will affirmatively
cooperate in the implementation of the Third-Party Contractor's obligations herein;
and

(c) the Third-Party Contractor shall state, in all solicitations or advertisements for
employees, that, in the performance of the Contract, all qualified applicants will
be afforded equal employment opportunities without discrimination because of
race, creed, color, national origin, sex, age, disability or marital status.

The Third-Party Contractor will include the provisions of "a", "b", and "c" above, in
every subcontract over $25,000.00 for the construction, demolition, replacement,
major repair, renovation, planning or design of real property and improvements
thereon (the "Work") except where the Work is for the beneficial use of the Third-
Party Contractor. Section 312 does not apply to: (i) work, goods or services
unrelated to this Contract; or (ii) employment outside New York State ; or (iii)
banking services, insurance policies or the sale of securities. The State shall
consider compliance by a Third-Party Contractor or subcontractor with the
requirements of any federal law concerning equal employment opportunity which
effectuates the purpose of this section. The State shall determine whether the
imposition of the requirements of the provisions hereof duplicate or conflict with
any such federal law and if such duplication or conflict exists, the State shall waive
the applicability of Section 312 to the extent of such duplication or conflict. The
Third-Party Contractor will comply with all duly promulgated and lawful rules and
regulations of the Governor's Office of Minority and Women's Business Development
pertaining hereto.

11. CONFLICTING TERMS. In the event of a conflict between the terms of the
Contract (including any and all attachments thereto and amendments thereof) and

                                          46
the terms of this Appendix A, the terms of this Appendix A shall control.

12. GOVERNING LAW. This Contract shall be governed by the laws of the State of
New York except where the Federal supremacy clause requires otherwise.

13. NO ARBITRATION. Disputes involving this Contract, including the breach or
alleged breach thereof, may not be submitted to binding arbitration (except where
statutorily authorized), but must, instead, be heard in a court of competent
jurisdiction of the State of New York.

14. SERVICE OF PROCESS. In addition to the methods of service allowed by the
State Civil Practice Law & Rules ("CPLR"), in any litigation arising under or with
respect to this Contract, the Third-Party Contractor hereby consents to service of
process upon it by registered or certified mail, return receipt requested. Service
hereunder shall be complete upon the Third-Party Contractor's actual receipt of
process or upon the receipt, by the entity attempting service on the Third-Party
Contractor, of the return thereof by the United States Postal Service as refused or
undeliverable. The Third-Party Contractor must promptly notify the State
Contractor, in writing, of each and every change of address to which service of
process can be made. Service to the last known address of the Third-Party
Contractor shall be sufficient. The Third-Party Contractor will have thirty (30)
calendar days after service hereunder is complete in which to respond.

 15. PROHIBITION ON PURCHASE OF TROPICAL HARDWOODS. The Third-Party
Contractor certifies and warrants that all wood products to be used under this
Contract award will be consistent with, but not limited to, the provisions of State
Finance Law §165 (Use of Tropical Hardwoods) which prohibits purchase and use of
tropical hardwoods, unless specifically exempted, by the State or any governmental
agency or political subdivision or public benefit corporation. Qualification for an
exemption under this law will be the responsibility of the Third-Party Contractor to
establish to meet with the approval of the State.

In addition, when any portion of this Contract involving the use of woods, whether
supply or installation, is to be performed by any subcontractor, the prime Third-
Party Contractor will indicate and certify in the submitted bid proposal that the
subcontractor has been informed and is in compliance with the language regarding
use of tropical hardwoods as detailed in State Finance Law §165. Any such use must
meet with the approval of the State; otherwise, the bid may not be considered
responsive. Under bidder certifications, proof of qualification for exemption will be
the responsibility of the Third-Party Contractor to meet with the approval of the
State.

 16. MACBRIDE FAIR EMPLOYMENT PRINCIPLES. Consistent with the provisions of
the MacBride Fair Employment Principles (Chapter 807 of the Laws of 1992), the
Third-Party Contractor hereby stipulates that the Third-Party Contractor either (a)
has no business operations in Northern Ireland, or (b) shall take lawful steps in good
faith to conduct any business operations in Northern Ireland in accordance with the

                                         47
MacBride Fair Employment Principles (as described in Section 165 of the New York
State Finance Law), and shall permit independent monitoring of compliance with
such principles.

17. OMNIBUS PROCUREMENT ACT OF 1992. It is the policy of New York State to
maximize opportunities for the participation of New York State business
enterprises, including minority and women-owned business enterprises as bidders,
subcontractors and suppliers on its procurement Contracts.

Information on the availability of New York State subcontractors and suppliers is
available from:

NYS Department of Economic Development
Division for Small Business
30 South Pearl St -- 7 th Floor
Albany , New York 12245
Telephone: 518-292-5220

A directory of certified minority and women-owned business enterprises is available
from:

NYS Department of Economic Development Division of Minority and Women's
Business Development
30 South Pearl St -- 2nd Floor
Albany , New York 12245
http://www.empire.state.ny.us

Consistent with the provisions of Omnibus Procurement Act of 1992, by signing this
bid proposal or Contract, as applicable, Third-Party Contractors certify that
whenever the total bid amount is greater than $1 million:

(a) The Third-Party Contractor has made reasonable efforts to encourage the
participation of New York State Business Enterprises as suppliers and
subcontractors, including certified minority and women-owned business
enterprises, on this project, and has retained the documentation of these efforts to
be provided upon request to the State;

(b) The Third-Party Contractor has acted consistent with the provisions of the
Federal Equal Opportunity Act of 1972 (P.L. 92-261), as amended;

(c) The Third-Party Contractor agrees to make reasonable efforts to provide
notification to New York State residents of employment opportunities on this
project through listing any such positions with the Job Service Division of the New
York State Department of Labor, or providing such notification in such manner as is
consistent with existing collective bargaining contracts or agreements. The Third-
Party Contractor agrees to document these efforts and to provide said


                                         48
documentation to the State upon request; and

(d) The Third-Party Contractor acknowledges notice that the State may seek to
obtain offset credits from foreign countries as a result of this Contract and agrees
to cooperate with the State in these efforts.



18. RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are hereby notified that if
their principal place of business is located in a country, nation, province, state or
political subdivision that penalizes New York State vendors, and if the goods or
services they offer will be substantially produced or performed outside New York
State, consistent with the provisions of the Omnibus Procurement Act 1994 and
2000 amendments (Chapter 684 and Chapter 383, respectively), they will be denied
contracts which they would otherwise obtain. NOTE: As of May 15, 2002 , the list of
discriminatory jurisdictions subject to this provision includes the states of South
Carolina , Alaska , West Virginia , Wyoming , Louisiana and Hawaii . Contact NYS
Department of Economic Development for a current list of jurisdictions subject to
this provision.

19. PURCHASES OF APPAREL. Consistent with the provisions of State Finance Law
§162 (4-a), the State and the State Contractor shall not purchase any apparel from
any vendor unable or unwilling to certify that: (i) such apparel was manufactured
in compliance with all applicable labor and occupational safety laws, including, but
not limited to, child labor laws, wage and hours laws and workplace safety laws,
and (ii) vendor will supply, with its bid (or, if not a bid situation, prior to or at the
time of signing a contract), if known, the names and addresses of each
subcontractor and a list of all manufacturing plants to be utilized by the bidder.




                                           49
                                      APPENDIX C

                      PAYMENT AND REPORTING SCHEDULE


1.   Payment and Reporting Terms and Conditions

     A.    MSSNY may, at its discretion, make an advance payment to the
           CONTRACTOR, during the initial or any subsequent PERIOD, in an amount to
           be determined by MSSNY but not to exceed ______ percent of the maximum
           amount indicated in the budget as set forth in the most recently approved
           Appendix B. If this payment is to be made, it will be due thirty calendar days,
           excluding legal holidays, after the first day of the contract term specified in the
           Initial Contract Period identified on the face page of the AGREEMENT or if
           renewed, in the PERIOD identified in the Appendix X
           provided, however, that a proper voucher for such advance has been received
           in MSSNY’s designated payment office. If no advance payment is to be made,
           the initial payment under this AGREEMENT shall be due thirty calendar days,
           excluding legal holidays, after the end of the first monthly/quarterly period of
           this AGREEMENT; or provided, however, that the proper voucher for this
           payment has been received in MSSNY’s designated payment office.

     B.    No payment under this AGREEMENT, other than advances as authorized
           herein, will be made by MSSNY to the CONTRACTOR unless proof of
           performance of required services or accomplishments is provided.

     C.    Any optional advance payment(s) shall be applied by MSSNY to future
           payments due to the CONTRACTOR for services provided during initial or
           subsequent PERIODS. Should funds for subsequent PERIODS not be
           appropriated or budgeted by the STATE to MSSNY for the purpose herein
           specified, MSSNY shall have no liability under this AGREEMENT to the
           CONTRACTOR, and this AGREEMENT shall be considered terminated and
           cancelled.

     D.    The CONTRACTOR will be entitled to receive payments for work, projects, and
           services rendered as detailed and described in the program workplan,
           Appendix D. All payments shall be in conformance with the rules and
           regulations of the Office of the State Comptroller.

     E.    The CONTRACTOR will provide MSSNY with the reports of progress or other
           specific work products pursuant to this AGREEMENT as described in this
           Appendix below. In addition, a final report must be submitted by the
           CONTRACTOR no later than ____ days after the end of this AGREEMENT. All
           required reports or other work products developed under this AGREEMENT
           must be completed as provided by the agreed upon work schedule in a manner
           satisfactory and acceptable to MSSNY in order for the CONTRACTOR to be
           eligible for payment.



                                            50
      F.    The CONTRACTOR shall submit to MSSNY quarterly voucher claims and
            reports of expenditures on such forms and in such detail as the STATE shall
            require. The CONTRACTOR shall submit vouchers to MSSNY’s designated
            payment office located in the c/o Mr. Phillip Schuh, 420 Lakeville Rd., Lake
            Success New York 11042._________________________________________.

            All vouchers submitted by the CONTRACTOR pursuant to this AGREEMENT
            shall be submitted to MSSNY no later than ___________________ days after
            the end date of the period for which reimbursement is being claimed. In no
            event shall the amount received by the CONTRACTOR exceed the budget
            amount approved by MSSNY, and, if actual expenditures by the
            CONTRACTOR are less than such sum, the amount payable by MSSNY to the
            CONTRACTOR shall not exceed the amount of actual expenditures. All
            contract advances in excess of actual expenditures will be recouped by
            MSSNY prior to the end of the applicable budget period.

II.   Progress and Final Reports

      Organization Name: ___________________________________________________

      Report Type:

      A.    Narrative/Qualitative Report
            ___________________________ (Organization Name) will submit, on a
            quarterly basis, not later than __________ days from the end of the quarter, a
            report, in narrative form, summarizing the services rendered during the quarter.
            This report will detail how the ________________________ (Organization)
            _________________ has progressed toward attaining the qualitative goals
            enumerated in the Program Workplan (Appendix D).

            (Note: This report should address all goals and objectives of the project and
            include a discussion of problems encountered and steps taken to solve them.)

      B.    Statistical/Quantitative Report

            ___________________________ (Organization Name) will submit, on a
            quarterly basis, not later than __________ days from the end of the quarter, a
            detailed report analyzing the quantitative aspects of the program plan, as
            appropriate (e.g., type of technology selected, purchased and installed; number
            of staff and physicians trained; number of records maintained on system; etc.)

      C.    Expenditure Report

            ___________________________ (Organization Name) ______________ will
            submit, on a quarterly basis, not later than __________ days after the end date
            for which reimbursement is being claimed, a detailed expenditure report, by
            object of expense. This report will accompany the voucher submitted for such
            period.

                                              51
D.   Final Report

     ___________________________ (Organization Name) _________________
     will submit a final report, as required by the contract, reporting on all aspects of
     the program, detailing how the use of grant funds were utilized in achieving the
     goals set forth in the program Workplan.




                                      52
                                                APPENDIX D

                                          PROGRAM WORKPLAN
                                             (sample format)

A well written, concise workplan is required to ensure that MSSNY and the contractor are
both clear about what the expectations under the contract are. When a contractor is selected
through an RFA or receives continuing funding based on an application, the proposal
submitted by the contractor may serve as the contract’s work plan if the format is designed
appropriately. The following are suggested elements of an RFA or application designed to
ensure that the minimum necessary information is obtained. Program managers may require
additional information if it is deemed necessary.

I. CORPORATE INFORMATION

              Include the full corporate or business name of the organization as well as the
       address, federal employer identification number and the name and telephone
       number(s) of the person(s) responsible for the plan’s development. An indication as to
       whether the contract is a not-for-profit or governmental organization should also be
       included. All not-for-profit organizations must include their New York State charity
       registration number; if the organization is exempt AN EXPLANATION OF THE
       EXEMPTION MUST BE ATTACHED.

II.    SUMMARY STATEMENT

              This section should include a narrative summary describing the project which
       will be funded by the contract. This overview should be concise and to the point.
       Further details can be included in the section which addresses specific deliverables.

III.   PROGRAM GOALS

              This section should include a listing, in an abbreviated format (i.e., bullets), of
       the goals to be accomplished under the contract. Project goals should be as
       quantifiable as possible, thereby providing a useful measure with which to judge the
       contractor’s performance.

IV.    SPECIFIC DELIVERABLES

               A listing of specific services or work projects should be included. Deliverables
       should be broken down into discrete items which will be performed or delivered as a
       unit (i.e., a report, number of clients served, etc.) Whenever possible a specific date
       should be associated with each deliverable, thus making each expected completion
       date clear to both parties.

              Language contained in Appendix C of the contract states that the contractor is
       not eligible for payment “unless proof of performance of required services or
       accomplishments is provided.” The workplan as a whole should be structured around
       this concept to ensure that MSSNY does not pay for services that have not been
       rendered.
                                               53
                                                  APPENDIX X


                                                                    Contract No. _______________________
                                                                    Period ____________________________
                                                                    Funding Amount for Period ____________


This is an AGREEMENT between having its principal office at _____________________ (hereinafter referred to as
MSSNY), and ___________________________ (hereinafter referred to as the CONTRACTOR), for modification of
Contract Number as amended in attached Appendix(ices)_____________________________________________.

All other provisions of said AGREEMENT shall remain in full force and effect

IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing under
this signatures.

___________________________________.___________________________________


CONTRACTOR SIGNATURE                                          Medical Society of the State of New York

By: ____________________________________.By: _______________________________
_______________________________________ ._________________________________
                    (Printed Name)           .                                 (Printed Name)


Title: ___________________________________Title: ______________________________
Date: ___________________________________Date: _____________________________
                                                                  _________________________________
__
STATE OF NEW YORK                    )
                                     ) SS:   _______________.
County of _______________            )

On the ____ day of ________ 20__, before me personally appeared ___________________________, to me
known, who being by me duly sworn, did depose and say that he/she resides at ______________________,
that he/she is the ______________________________ of the ____________________________________,
the corporation described herein which executed the foregoing instrument; and that he/she signed his/her name
thereto by order of the board of directors of said corporation.
(Notary) _______________________________________________________________________


                                                                    STATE COMPTROLLER’S SIGNATURE


                                                                    __________________________________
                                                                    Title: _____________________________
                                                                    Date:


                                                         54
                                                 ATTACHMENT 11:
                                            STATE OF NEW YORK VENDOR
                                           RESPONSIBILITY QUESTIONNAIRE

1. VENDOR IS:  PRIME CONTRACTOR
                   SUB- CONTRACTOR
2. VENDOR'S LEGAL BUSINESS NAME
                                                                                      3. IDENTIFICATION NUMBERS
                                                                                      a) FEIN #
                                                                                      b) DUNS #
4. D/B/A- Doing Business As (if applicable) & COUNTY FILED:                           5. WEBSITE ADDRESS (if applicable)


6. ADDRESS OF PRIMARY PLACE OF BUSINESS/EXECUTIVE OFFICE                              7. TELEPHONE NUMBER                 8. FAX NUMBER


9. ADDRESS OF PRIMARY PLACE OF BUSINESS/EXECUTIVE OFFICE IN                            10. TELEPHONE NUMBER                11. FAX NUMBER
NEW YORK STATE, if different from above


                                                                                13. AUTHORIZED CONTACT FOR THIS
12. PRIMARY PLACE OF BUSINESS IN NEW YORK STATE IS:                             QUESTIONNAIRE
                                                                                Name
 Owned                          Rented
                                                                                Title
If rented, please provide landlord's name, address, and telephone number below: Telephone Number
                                                                                Fax Number
                                                                                 e-mail
14. VENDOR'S BUSINESS ENTITY IS (please check appropriate box and provide additional information):
a)  Business Corporation                     Date of Incorporation                        State of Incorporation*

b)  Sole Proprietor                          Date Established

e)  General Partnership                      Date Established

d)  Not-for-Profit Corporation               Date of Incorporation                        State of Incorporation*
                                              Charities Registration Number
e)  Limited Liability Company (LLC)          Date Established

f)  Limited Liability Partnership            Date Established

g)  Other -Specify:                          Date Established                            Jurisdiction Filed (if applicable)

                  * If not incorporated in New York State, please provide a copy of authorization to do business in New York.

15. PRIMARY BUSINESS ACTIVITY - (Please identify the primary business categories, products or services provided by your business)


16. NAME OF WORKERS' COMPENSATION INSURANCE CARRIER:

17. LIST ALL OF THE VENDOR'S PRINCIPAL OWNERS AND THE THREE OFFICERS WHO DIRECT THE DAILY
OPERATIONS OF THE VENDOR (Attach additional pages if necessary):
a) NAME (print)               TITLE                              b) NAME (print)   TITLE


c) NAME (print)                         TITLE                                  d) NAME (print)                            TITLE




                                                                    Page 1 of 6


                                                                         55
                               STATE OF NEW YORK VENDOR
                              RESPONSIBILITY QUESTIONNAIRE

                                                                                                    FEIN#


A DETAILED EXPLANATION IS REQUIRED FOR EACH QUESTION ANSWERED WITH A
"YES," AND MUST BE PROVIDED AS AN ATTACHMENT TO THE COMPLETED
QUESTIONNAIRE. YOU MUST PROVIDE ADEQUATE DETAILS OR DOCUMENTS TO
AID THE CONTRACTING AGENCY IN MAKING A DETERMINATION OF VENDOR
RESPONSIBILITY. PLEASE NUMBER EACH RESPONSE TO MATCH THE QUESTION
NUMBER. _____________________________________________________________________________

 18. Is the vendor certified in New York State as a (check please):                       Yes  No
 Minority Business Enterprise (MBE)
 Women's Business Enterprise (WBE)
 Disadvantaged Business Enterprise (DBE)?
____ Please provide a copy of any of the above certifications that apply. __________________________
 19. Does the vendor use, or has it used in the past ten (10) years, any other            Yes No
       Business Name, FEIN, or D/B/A other than those listed in items 2-4 above?
List all other business name(s), Federal Employer Identification Number(s) or any
D/B/A names and the dates that these names or numbers were/are in use. Explain
____ the relationship to the vendor. _______________________________________________________
 20. Are there any individuals now serving in a managerial or consulting capacity to
       the vendor, including principal owners and officers, who now serve or in the
       past three (3) years have served as:
     a) An elected or appointed public official or officer?                                  Yes  No
        List each individual's name, business title, the name of the organization and
        position elected or appointed to, and dates of service.
     b) A full or part-time employee in a New York State agency or as a consultant,         Yes No
        in their individual capacity, to any New York State agency?
        List each individual's name, business title or consulting capacity and the New York
        State agency name, and employment position with applicable service dates.
     c) If yes to item #20b, did this individual perform services related to the            Yes No
        solicitation, negotiation, operation and/or administration of public contracts
        for the contracting agency?
        List each individual's name, business title or consulting capacity and the New York
        State agency name, and consulting/advisory position with applicable service
        dates. List each contract name and assigned NYS number.
     d) An officer of any political party organization in New York State, whether            Yes No
        paid or unpaid?
        List each individual's name, business title or consulting capacity and the official
_______ political party position held with applicable service dates. _______________________________


                                                   Page 2 of 6




                                                  56
               STATE OF NEW YORK VENDOR RESPONSIBILITY QUESTIONNAIRE

                                                                                   FEIN#


21. Within the past five (5) years, has the vendor, any individuals serving in
    managerial or consulting capacity, principal owners, officers, major
    stockholder(s) (10% or more of the voting shares for publicly traded
    companies, 25% or more of the shares for all other companies), affiliate1 or any
    person involved in the bidding or contracting process:
    a) 1. been suspended, debarred or terminated by a local, state or federal Yes No
            authority in connection with a contract or contracting process;
        2. been disqualified for cause as a bidder on any permit, license,
            concession franchise or lease;
        3. entered into an agreement to a voluntary exclusion from
            bidding/contracting;
        4. had a bid rejected on a New York State contract for failure to comply
            with the MacBride Fair Employment Principles;
        5. had a low bid rejected on a local, state or federal contract for failure to
            meet statutory affirmative action or M/WBE requirements on a
            previously held contract;
        6. had status as a Women's Business Enterprise, Minority Business
            Enterprise or Disadvantaged Business Enterprise denied, de-certified,
            revoked or forfeited;
        7. been subject to an administrative proceeding or civil action seeking
            specific performance or restitution in connection with any local, state or
            federal government contract;
        8. been denied an award of a local, state or federal government contract,
            had a contract suspended or had a contract terminated for non -
            responsibility; or
        9. had a local, state or federal government contract suspended or
_________ terminated for cause prior to the completion of the term of the contract? ____________
    b) been indicted, convicted, received a judgment against them or a grant of Yes No
       immunity for any business-related conduct constituting a crime under local,
        state or federal law including but not limited to, fraud, extortion, bribery,
        racketeering, price-fixing, bid collusion or any crime related to truthfulness
______ and/or business conduct? __________________________________________________
    c) been issued a citation, notice, violation order, or are pending an Yes No
       administrative hearing or proceeding or determination for violations of:
       1. federal, state or local health laws, rules or regulations, including but not
            limited to Occupational Safety & Health Administration (OSHA) or
            New York State labor law;
       2. state or federal environmental laws;
       3. unemployment insurance or workers' compensation coverage or claim
            requirements;
       4. Employee Retirement Income Security Act (ERISA);

                                                Page 3 of 6


                                                57
         5.  federal, state or local human rights laws;
         6.  civil rights laws;
         7.  federal or state security laws;
         8.  federal Immigration and Naturalization Services (INS) and Alienage
             laws;
         9. state or federal anti-trust laws; or
         10. charity or consumer laws?
For any of the above, detail the situations), the date(s), the name(s), title(s),
address(es) of any individuals involved and, if applicable, any contracting agency,
specific details related to the situations) and any corrective action(s) taken by the
vendor. ______________________________________________________________________________
22. In the past three (3) years, has the vendor or its affiliates had any claims,        Yes No
    judgments, injunctions, liens, fines or penalties secured by any governmental
    agency?
Indicate if this is applicable to the submitting vendor or affiliate. State whether the
situation(s) was a claim, judgment, injunction, lien or other with an explanation.
Provide the name(s) and address(es) of the agency, the amount of the original
obligation and outstanding balance. If any of these items are open, unsatisfied,
 ____ indicate the status of each item as "open" or "unsatisfied."_________________________________
23. Has the vendor (for profit and not-for profit corporations) or its affiliates , in   Yes No
    the past three (3) years, had any governmental audits that revealed material
weaknesses in its system of internal controls, compliance with contractual
agreements and/or laws and regulations or any material disallowances?
Indicate if this is applicable to the submitting vendor or affiliate. Detail the type of
material weakness found or the situation(s) that gave rise to the disallowance, any
____ corrective action taken by the vendor and the name of the auditing agency. ____________________
 24. Is the vendor exempt from income taxes under the Internal Revenue Code?    Yes No
     Indicate the reason for the exemption and provide a copy of any supporting
____ information. _____________________________________________________________________
 25. During the past three (3) years, has the vendor failed to:
     a) file returns or pay any applicable federal, state or city taxes?        Yes No
        Identify the taxing jurisdiction, type of tax, liability year(s), and tax liability
        amount the vendor failed to file/pay and the current status of the liability.
     b) file returns or pay New York State unemployment insurance?                          Yes No
        Indicate the years the vendor failed to file/pay the insurance and the current
_______ status of the liability.____________________________________________________________
26. Have any bankruptcy proceedings been initiated by or against the vendor or its       Yes No
    affiliates1 within the past seven (7) years (whether or not closed) or is any
    bankruptcy proceeding pending by or against the vendor or its affiliates
    regardless of the date of filing?

Indicate if this is applicable to the submitting vendor or affiliate. If it is an affiliate,
include the affiliate's name and FEIN. Provide the court name, address and docket
number. Indicate if the proceedings have been initiated, remain pending or have
been closed. If closed, provide the date closed. _______________________________________________


                                                     Page 4 of 6


                                                     58
27.   Is the vendor currently insolvent, or does vendor currently have reason to                      Yes No
      believe that an involuntary bankruptcy proceeding may be brought against it?

    Provide financial Information to support the vendor's current position, for example,
    Current Ratio, Debt Ratio, Age of Accounts Payable, Cash Flow and any documents that
    will provide the agency with an understanding of the vendor's situation.
28. Has the vendor been a contractor or subcontractor on any contract with any            Yes No
     New York State agency in the past five (5) years?
    List the agency name, address, and contract effective dates. Also provide state
    contract identification number, if known. _____________________________________________
    In the past five (5) years, has the vendor or any affiliates :                        Yes No
    a) defaulted or been terminated on, or had its surety called upon to complete,
         any contract (public or private) awarded;
    b) received an overall unsatisfactory performance assessment from any
         government agency on any contract; or
    c) had any liens or claims over $25,000 filed against the firm which remain
         undischarged or were unsatisfied for more than 90 days ?
    Indicate if this is applicable to the submitting vendor or affiliate. Detail the
    situations) that gave rise to the negative action, any corrective action taken by the
    vendor and the name of the contracting agency.
      1
        "Affiliate" meaning: (a) any entity in which the vendor owns more than 50% of the voting stock; (b) any
      individual, entity or group of principal owners or officers who own more than 50% of the voting stock of the
      vendor; or (c) any entity whose voting stock is more than 50% owned by the same individual, entity or
      group described in clause (b). In addition, if a vendor owns less than 50% of the voting stock of another
      entity, but directs or has the right to direct such entity's daily operations, that entity will be an "affiliate" for
      purposes of this questionnaire.




Issued: November 1,2004                             Page 5 of 6




                                                            59
                             STATE OF NEW YORK VENDOR RESPONSIBILITY
                                          QUESTIONNAIRE

                                                                                                                FEIN#


State of:                    )
                             ) ss:
County of:                   )

CERTIFICATION:

The undersigned: recognizes that this questionnaire is submitted for the express purpose of assisting the State of New York
or its agencies or political subdivisions in making a determination regarding an award of contract or approval of a subcontract;
acknowledges that the State or its agencies and political subdivisions may in its discretion, by means which it may choose, verify
the truth and accuracy of all statements made herein; acknowledges that intentional submission of false or misleading
information may constitute a felony under Penal Law Section 210.40 or a misdemeanor under Penal Law Section 210.35 or
Section 210.45, and may also be punishable by a fine and/or imprisonment of up to five years under 18 USC Section 1001 and may
result in contract termination; and states that the information submitted in this questionnaire and any attached pages is true, accurate
and complete.

The undersigned certifies that he/she:
• has not altered the content of the questions in the questionnaire in any manner;
• has read and understands all of the items contained in the questionnaire and any pages
    attached by the submitting vendor;
• has supplied full and complete responses to each item therein to the best of his/her
    knowledge, information and belief;
• is knowledgeable about the submitting vendor's business and operations;
• understands that New York State will rely on the information supplied in this questionnaire
    when entering into a contract with the vendor; and
• is under duty to notify the procuring State Agency of any material changes to the vendor's
    responses herein prior to the State Comptroller's approval of the contract.

Name of Business
Signature of Owner/Officer
Address
City, State, Zip
Printed Name of Signatory                                 Title


Sworn to before me this ________ day of ______________________________ , 20_

Notary Public      Print Name ___________________________________________

                   Signature     ___________________________________________

                   Date          ____________________



Issued: November 1, 2004                                  Page 6 of 6


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