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					         County of San Mateo

 Integration of Family Health Systems
                   RFP # 1185

               Purchasing Division
               455 County Center, 5th Floor, EPS121
               Redwood City, CA 94063-1663

               Contact person: Peter Tocchini
                               (650) 363-4408

     Proposals must be submitted and received
     by 4:00 PM, Monday, December 11, 2006
                                 Table of Contents
Section I: Introduction, Background, and Event Schedule ................ 3
Section II: Terms, Conditions, and RFP Process Details .................... 5
Section III: Requirements and Service Specifications ........................ 9
Section IV: Evaluation Criteria ........................................................... 16
Attachment A: Description of Existing Programs and Systems ....... 17
Attachment B: Program Metrics ........................................................ 19
Attachment C: Edit Tables .................................................................. 20
Attachment D: Sample County contract ............................................ 21

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                         REQUEST FOR PROPOSALS FOR

                          Integration of Family Health Systems

                              Proposals must be submitted to:

                                 Peter Tocchini, Buyer
                                 County of San Mateo
                              455 County Center – EPS121
                             Redwood City, California 94063

                       by 4:00 p.m. Monday, December 11, 2006


This Request for Proposals (RFP) is not a commitment or contract of any kind. The
County of San Mateo reserves the right to pursue any and/or all ideas generated by this
request. Costs for developing the proposals are entirely the responsibility of the
applicants and shall not be reimbursed. The County reserves the right to reject any and
all proposals, and to waive any requirements of this RFP when it determines that
waiving a requirement is in the best interest of the County. All materials submitted in
response to this RFP will become the property of the County.

Government Code Sections 6550 et. Seq., the ―Public Record Act‖ defines public
record as any writing containing information relating to the conduct of the public
business. The Public Record Act provides that public records shall be disclosed upon
written request, and that any citizen has a right to inspect any public record, unless the
document is exempted from disclosure.

The County of San Mateo cannot represent or guarantee that any information
submitted in response to this RFP will be confidential. If the County receives a
request for any document submitted in response to this request, it will not assert any
privileges that may exist on behalf of the person or business entity submitting the
proposal. It is the responsibility of the person or business entity submitting the
proposal to assert any applicable privileges or reasons why the document should not be

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A. Introduction
   The Public Health Division protects, maintains, and improves the health of the people of
   San Mateo County. The Division is responsible for monitoring and assessing the health
   status of the community, and identifying and preventing potential health problems.
   Family Health Services (FHS) focuses on the monitoring, assessing and preventing health
   problems in children and families.

   FHS promotes and improves the health and well-being of children and families by joining
   with individuals, organizations, and communities to provide case management, prevention
   and treatment services, outreach and education.

   The San Mateo County Health Department seeks a qualified company/organization to
   provide and support a Family Health Integrated System. This system must meet the
   requirements as outlined in Section III of this document.

   The selected contractor will work primarily with staff from Family Health Services and
   the County Information Services Department.

B. Background
   Each program of Family Health Services that is addressed by this RFP was created to
   focus on specific public health problems. Each program was funded separately and
   separate data collection processes were put in place (sometimes mandated by the state
   funding authority) to manage data collected by that program. Over time, it has become
   apparent that clients are often involved with multiple programs and that it is in the
   County‘s interest to be aware of those multiple involvements. It has also become apparent
   that data integration will allow these programs to be managed more efficiently and
   effectively. The objectives of this integration initiative are:

               1) To provide on-line real time capability to a central client index or
               combined database, which gives the ability to track clients across all
               Family Health programs;
               2) To reduce redundant data entry and applications throughout the Family
               Health Services programs by incorporating a single database structure;
               3) To improve medical data retrieval efficiency for all Public Health users;
               4) To provide a single source of data to assist in monitoring the needs of the
               community and the types of services provided;
               5) To allow greater coordination of programs and services to improve
               outcomes and efficiency of care;
               6) To potentially increase revenue generation through better service

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C. Event Schedule
   Listed below are the target dates for the events to occur. All target dates are predicated on
   the issue date of the RFP. The County reserves the right to change any or all of these

                             EVENT                                 TARGET DATE
         Send RFP to potential contractors                          October 19, 2006
         Pre-Proposal Conference                                    November 9, 2006
         Last date for questions to be submitted                   November 22, 2006
         Answers to all questions published                         December 1, 2006
         Last date to submit proposals                             December 11, 2006
         RFP review                                                   January 2007
         Product review                                              February 2007
         Vendor selection                                          February 20 , 2007
         Review/Approval by the Board of                          February-March, 2007
         Supervisors, CMO, County Counsel
         Contract begins                                              April, 2007

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A. Proposal Terms and Conditions
   If a proposer fails to satisfy any of the requirements identified in this RFP, the proposal
   may be considered non-responsive and the proposal may be rejected. As of the issuance
   date of this RFP and continuing until the final date of proposals, all County personnel are
   specifically directed not to hold meetings, conferences or technical discussions with any
   proposer for the purposes of responding to this RFP. Any proposer found to be acting any
   way contrary to this directive shall be disqualified from entering into any contract that
   may result from this RFP.

   If a proposer discovers any ambiguity, conflict, discrepancy, omission, or other error in
   the RFP, he/she shall immediately notify the County of such error in writing and request
   modification or clarification of the document. Modifications will be made by addenda
   issued as stated below. Clarifications will be given by written notice to all parties who
   have been furnished an RFP for proposal purposes, without divulging the source of the
   request for same. Insofar as practical, the County will give such notices to other interested
   parties, but the County shall not be responsible therefore.

   If a proposer fails to notify the County of an error in the RFP prior to the date fixed for
   submission, he/she shall propose at his/her own risk, and if he/she is awarded the contract,
   he/she shall not be entitled to additional compensation or time by reason of the error or its
   later correction.

   The County may modify the RFP prior to the fixed date for submission of proposals by
   issuance of an addendum to all parties who have received the RFP. The County reserves
   the right to accept other than the lowest price and to negotiate with proposer on a fair and
   equal basis when the best interests of the County are served by so doing. The County
   reserves the right to cancel the RFP in part, or in its entirety, at any time.

   All proposals shall be firm offers, and will be so considered by the County. Proposals
   shall be considered valid offers for a period of six months following the close of the RFP
   on December 11, 2006.

   The County reserves the right to waive any irregularities and technicalities within a
   proposal and may, at its sole discretion, request a clarification or other information to
   evaluate any or all proposals. The County reserves the right to accept the proposals of any
   or all of the items it deems, at its sole discretion, to be in the best interest of the County.
   The County reserves the right to reject any and/or all items proposed.

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B. RFP Process Details

   1. Proposal Clarification and Questions
   Any questions regarding clarification or intent of the RFP should be directed, in writing,
   by e-mail to: The County will publish questions and

   2. Pre-Proposal Conference (November 9, 2006, 1:00 PM, COB-101)
   Prospective proposers will have an opportunity to ask questions at a pre-proposal
   conference to be held on November 9, 2006, at 1:00 P.M. (Pacific Time) in Room 101 on
   the first floor of 455 County Center, Redwood City, CA. This conference will offer an
   opportunity to discuss the County‘s business needs and to clarify issues in this RFP.
   Proposers are encouraged to attend. County answers to questions will be documented in
   writing and e-mailed to parties who have requested copies of the RFP or have requested in
   writing to receive such notices. Any contact regarding the pre-proposal conference should
   be directed to Mr. Peter Tocchini, Purchasing Division by email: or by US mail using the address below.

   3. Proposal Submission Process
   Proposals received shall be used to determine the proposer‘s capability of rendering the
   services to be provided.
       a) Proposal Preparation
             Each proposer shall prepare a proposal on company letterhead that addresses all
             the requirements and specifications in Section III in the same order as listed in
             the Section. Each proposer shall submit one original proposal and seven (7)
             complete duplicate proposals. One copy of the entire proposal shall be
             duplicated electronically on CD-ROM and submitted along with the hard copies.
             All proposals must be signed with the firm name, and by a responsible officer or
             employee. Obligations assumed by such signature must be fulfilled. An
             unsigned proposal may be rejected.

             Proposers shall adhere to the specified content and sequence of information used
             in this RFP. Proposal should specifically address each of the items listed under
             Section III.B ―Product and Service Specifications.‖ Materials and data not
             specifically requested for evaluation should appear under Section III.F
             ―Additional Data‖ and not be interwoven throughout each section.

             Proposals should include a one-page cover letter that includes the address, tax
             identification number, firm voice and fax phone numbers, email address of the
             person or persons to be used for contact and name of person who is authorized to
             represent the proposer.

             Proposals should include current certificates of insurance indicating liability
             insurance of a minimum of $1,000,000 for each of the following: comprehensive
             general, motor vehicle, professional, and Workers‘ Compensation. Note the
             County must be named as additional insured.

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       b)    Proposal Delivery
               1) Address or deliver proposals to:
                  Peter Tocchini, Buyer
                  County of San Mateo
                  455 County Center, 5th Floor, EPS 121
                  Redwood City, CA 94063
                  Phone (650) 363-4408
               2) Proposals must be received no later than 4:00 P.M. on Monday, December
                  11, 2006. All copies of the proposal must be under sealed cover and
                  plainly identified as a proposal for Family Health Integrated System.
                  Proposals not submitted under sealed cover may be rejected. Proposals
                  submitted under improperly marked covers may be rejected. Proposals
                  received after stated due date and time will not be considered.
               3) Proposals transmitted via e-mail, facsimile, or any other electronic
                  means shall not be considered.

   4. Evaluation Process
   County will put each proposal through a process of evaluation to determine the proposer‘s
   responsiveness to County‘s needs. Part of the process is an evaluation and
   recommendation by an RFP committee. A list of some of the evaluation criteria can be
   found in Section IV. Proposals will be screened and a group of finalists selected for
   additional review. Additional review may include a product demonstration, one or more
   panel interviews, and/or site visit. The County may require the presence of a proposer‘s
   representative for answering specific questions, orally and/or in writing. The Committee‘s
   recommendation may be rejected or accepted by the Health Department Director.

   5. Award Process
   The County reserves the right, before awarding the contract, to require proposer(s) to
   submit evidence of qualifications or any other information the County may deem
   necessary. A contract, if awarded, will be negotiated with the proposer who can best meet
   the County‘s needs.

   If the proposer chooses not to accept the County‘s Contract, the proposer is requested to
   explain, in writing, its objections to accepting the County‘s Contract as written.

   For the services requested, the County will execute a contract upon approval by the Board
   of Supervisors. The contract shall be interpreted, construed and given effect in all
   respects according to the laws of the State of California. All the terms, conditions and
   technical specifications stated in the RFP shall be construed to be a condition of the

   6. Inability to Negotiate a Contract
   The successful proposer(s) and the County will negotiate a contract for submission to the
   County‘s Board of Supervisors for consideration and possible approval. If a satisfactory

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   contract cannot be negotiated, the County may begin, at its sole discretion, contract
   negotiations with one or more of the remaining proposers.

   7. Protest Process
   A proposer must submit a written protest to the Health Department Director at the address
   listed below within five (5) business days after receipt of a letter informing such proposer
   that their proposal has not been selected. Protests shall state the specific grounds for the
   protest. Address protests to:

               Charlene A. Silva, Director
               San Mateo County Health Department
               225 37th Avenue
               San Mateo, CA 94403

   The Health Department Director will respond to the protest within seven (7) business days
   of its receipt. The decision of the Health Department Director is final.

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A. General Requirements
      1. Financial Condition and References
         Each proposer shall submit with their RFP response five client references,
         including company name, mailing address, contact person name and phone
         number. Please note that additional items may be required to assist the County in
         making a final determination, such as: financial records in the form of a completed
         statement of financial condition, which should consist of an independently audited
         income statement and balance sheet from your last complete fiscal year; your
         Dunn-Bradstreet rating (if available); and/or an executive summary, not to exceed
         three pages, on the history of your firm, including pertinent financial, managerial
         and technical aspects.

       2. County’s Standard Contract
          The County‘s standard contract and required forms are attached and hereby
          incorporated by reference as Attachment D. All proposers are expected to be able
          to comply with all provisions therein. If there are any terms or partial terms that
          are unacceptable, please indicate them. For each indicated term or partial term,
          please specify why the term or partial term is not acceptable, and provide
          alternative language that you would suggest to replace the same. The County may
          or may not agree to this language

B. Product and Service Specifications
The successful proposer will be able to provide and support a system that meets the following
       1. Functional Requirements(General):
           System will provide Case Management for various programs within Family
           Health Services including, but not limited to, the following:
                      Child Health and Disability Prevention (CHDP)
                      Prenatal-to-Three
                      Field Nursing (Global)
                      Adolescent Family Life (AFLP), Federal AFLP, Cal-Learn, Older
                       Teens, Siblings, At Risk Teens
                      Black Infant Health (BIH)
                      Lead Poisoning Prevention Program (RASSCLE)
                      California Children Services (CCS )
                      Women, Infants, Children (WIC)
            1.1 The system should provide multi-level security and administration.
                  Desired features include, but are not limited to, the following:
                          Client Demographic data will be available to all program users
                              with proper access.

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                              Case Management data for a client will be attached to the
                               particular program where the client has enrolled. Only staff
                               from that program will have access to Case Management data
                               that is part of that program.
                            It should be assumed that case management data regarding a
                               client in one program would not be available to users/groups
                               from a different program.
                            Within a program, access levels by roles/groups will determine
                               whether a user can view or update data about a client.
                            Individual user ids will determine membership in groups.
             1.2   The system should provide import/export functionality.
             1.3   The system should be straightforward and easy to use by all Family Health
             1.4   The system should provide archiving functionality. A search for clients of
                   a particular program should only retrieve ‗active‘ status clients unless the
                   user performing the search requests clients of a different status.
             1.5   System will provide capability of edit tables whose values will be
                   determined by user. See Attachment ‗C‘ to this document for a list of
                   proposed tables.

       2.   Intake/Registration
             2.1 Each person in the system must have a unique identifying value that allows
                  him/her to be tracked across and among the various programs.
             2.2 Each program that a client is involved with will have a case identifying
                  number, which may be unique to that program.
             2.3 System will provide for multiple alias names for client and will keep
                  history of other names used by client.
             2.4 System will permit historical instances of
                           Address Data
                           Date of Birth
                           Aliases
                           Driver‘s License #
                           Social Security Number
                           Medi-Cal Number
                           Medical Record Number and associated facility
             2.5 System must hold /time of client initial entry into the system, the date/time
                  of entry into the program, date/time assigned to a case manager and first
                  contact date/time by program staff.
             2.6 System will provide the ability to search and locate clients using data based
                  on name and/or DOB and/or program case number and/or Medi-Cal
             2.7 System will provide a function to be able to merge the data of two clients
                  in system in the event that the clients are found to be the same person.
             2.8 Primary display of data about a singular client should include the following
                  information about programs the client is involved in: Program name, case

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                  manager & phone #, current status and latest activity date within that
             2.9 Client demographic data displayed will be that demographic data captured
                  by the latest program contact.
             2.10 Changes to demographic data will be audited so that user can trace which
                  earlier data was changed, the date of the change and which user made the

       3.   Case Management
             3.1 When client is to be referred to another agency or program for service,
                 system will automatically generate an email message to the proper referred
                 agency or program. Referents will be able to track the status of the referral
                 and will receive email confirmation that the referral is being acted on.
             3.2 Assessment, treatment plan, outcome data, time keeping, consent forms
                 and progress notes forms concerning the various programs are made a part
                 of this RFP through the RFP Program Appendix document. System should
                 be able to capture and manage similar data for each program.
             3.3 Program data is not changeable except by program manager (or designated
                 staff) and changes must be tracked as to what changes were made and
             3.4 System should have capability of changes to program workflow without
                 requiring programming changes.
             3.5 Calendaring function would include automated generation of reminder
                 letter to client (at option of the user making the entry) when appointment
                 with client is entered.
             3.6 When client appointment is on calendar, user should be able to click on
                 appointment and open that client's case directly (presuming security access
                 permits) without leaving calendar function to separate 'open case' function.
             3.7 System calendar should have ability to synchronize with Groupwise
                 (County standard email system). Program manager should have option to
                 decide how strictly system calendar will be synchronized with Groupwise.
             3.8 Consent forms should be electronic, verifiable and stored in system.
             3.9 System should have the capability to automatically print standard letters to
                 clients, other agencies or departments.

       4.   Reporting
             4.1 Client report for case manager.
             4.2 Reports that give program level counts of contact, clients, client
                 descriptions and outcomes.
             4.3 Report on length of time taken to respond to client request/referral for
                          By client
                          By case manager
                          By program
             4.4 How long has referral been outstanding without activity (aging)?

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             4.5    For all assigned cases, how many are open/active, refused, no activity
                    taken, referred, etc;
             4.6    For referrals, numbers of actual open, closed, not acted on, denied;
             4.7    Number of cases by problem/diagnosis/reasons for referral.
             4.8    Number of closed cases by reason for closure
             4.9    Reports that make use of Predictive Modeling techniques so that staff
                    resources are focused on client populations that appear to carry more risk.
             4.10   Number of clients served compared to total possible clients (e.g., number
                    of pregnant teens in program vs. total number of pregnant teens in county
                    (at some point in time)).
             4.11   Number of cases re-opened, re-referred.
             4.12   Reports and searches should allow flexibility in viewing/printing data with
                    the presumed client status to be ‗active‘ but with the option of selecting
                    clients with other status types.
             4.13   System shall permit the easy creation of ad-hoc reports.

       5.   Interfaces with other systems
             5.1 System should have the capability to integrate with the following San
                  Mateo County systems:
                           County Payroll System
                           San Mateo County Medical Center System (Siemens Invision
                           Public Health Lab System
                           County Groupwise (E-Mail)
                           County CALWIN
                           CWS-CMS (Foster Care)
                           Health Plan San Mateo (HPSM)
                           IEAP (Childhood Health Initiative)
                           WELL (Adult Wellness check)
             5.2 System should be able to integrate with the following systems from the
                  State of California:
                           Meds (Medi-Cal): to obtain client eligibility data
                           Healthy Families
                           Targeted Case Management (TCM)
                           Child Health and Disability Prevention(CHDP)
                           Immunization Registry (CAIR)
                           CMSNET (CCS)
                           ISIS (WIC)
                           EDSNET

       6.   Time Keeping/Billing
             6.1 System should permit entry by all staff of all time incurred during a
                 workday, including time spent on such items as vacation, sick leave, and
             6.2 System must permit export of data to external payroll system.

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             6.3   System must include ability to bill client directly and acceptance of
                   payment by client for fees.
             6.4   System must include real-time access to obtain Medi-Cal eligibility for a
             6.5   System should include ability to generate data for state mandated time-
                   study reports.
             6.6   System should include ability to generate data for state mandated time-
                   study reports.
             6.7   System should be able to accommodate staff time keeping of group
                   activities that are not attributable to any specific client, for example,
                   education classes given to groups of clients.

       7.   Implementation
             7.1 System will be implemented one program at a time over an estimated
                 period of 18 months. The order of implementation is presumed to be as
                          Child Health and Disability Prevention (CHDP)
                          Prenatal -to-Three
                          Field Nursing (Global)
                          Adolescent Family Life (AFLP), Federal AFLP, Cal-Learn,
                             Older Teens.
                          Black Infant Health (BIH)
                          Lead Poison Program (RASSCLE )
                          California Children Services (CCS )
                          Women, Infants, Children (WIC)
             7.2 The implementation of each Family Health program (with the exception of
                 CHDP) will require the import of data from an existing system and/or the
                 building of an interface with the system currently being used by that
                 program. See Attachment ‗A‘ of this document for a description of the
                 existing system(s) used by each program.
             7.3 System will be set up to include
                              a development/test system
                              a training system and
                              a production/live system.
                 Program implementation will initially be done on the development system.
                 After sufficient testing, the program will be migrated to the production
             7.4 Program implementation schedule: Provide a proposed implementation
                 plan outlining proposer and County roles and responsibilities and a high-
                 level timeline with major milestones.
             7.5 Personnel list: Provide a complete list of personnel assigned to this project.
                 Describe proposed staff and their duties, including disciplines and degrees
                 as appropriate. Name the person responsible for overseeing the County
                 account and provide the level of education, background and areas of
                 expertise this person has, and include this person‘s availability.

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       8.   Technical Requirements and Preferences
             8.1 It is preferred that the system be browser-based with a single server
                  installation and no installation on the user workstation other than browser.
             8.2 If browser-based, the system must be compatible with Internet Explorer,
                  Netscape, and Mozilla Firefox.
             8.3 System could be hosted on a San Mateo County server.
             8.4 The system must interface with Novell Groupwise, the County Email
                  System and must be IMAPI compliant.
             8.5 System must provide customization/expansion options – must be a scalable
                  system. Proposal should include a discussion of how a new Family Health
                  program would be integrated into the system. Customizations must be
                  fully supported by future updates to the product without additional cost to
                  San Mateo County.
             8.6 Proposal should include mobile access of system either through
                  distribution /synchronization of the application to a laptop/PDA or access
                  via wireless connectivity.
             8.7 The system should have an open system architecture. The system must
                  utilize ODBO interoperable standards and ODBC access. The system must
                  interface with other databases such as Oracle or SQL Server. Additionally,
                  the system should be CCOW compliant.
             8.8 Vendor must provide technical support and documentation.
                  Documentation to be available as hard copies as well as electronic copies.
             8.9 System must support current County IT Standards (see
             8.10 System must be Windows-based server architecture.
             8.11 Vendor will provide training for end-users.
             8.12 Vendor will provide training for system maintenance and training for any
                  customization to the software package.
             8.13 Identify any required downtime for the system and its frequency.
             8.14 Please address whether or not the County will need to purchase any Third
                  Party Software (TPS) to use the proposed system and/or sign any TPS
                  agreements. If yes, please provide copies of TPS agreements.

       9.    Additional Suggested Features
            In addition to the requirements as listed above, the County will consider proposals
            that suggest additional services that the proposer has reason to believe would
            benefit the County.

C. Pricing & Support
   Please provide a detailed explanation of the cost to be charged to the County for all
   products and services as listed above. The explanation should clearly identify the cost of
   all products and services defined in your proposal.

   Describe the overall support services you intend to provide and include response times.
   Include a copy of the terms and conditions of your maintenance and support with your
   RFP response.

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   Proposals that offer additional preferred services or additional suggested services, in
   addition to the requirements as listed above, should separately detail any additional cost.
   As it is presumed that some phases of implementation will involve custom interfaces with
   existing systems, include with the proposal estimates for the cost of providing those

   In any instance where a stated requirement is not a part of the base software system, the
   proposal should indicate that additional custom programming will be required and an
   estimate of the cost of such customization should be included with the proposal.

   Pricing should include training of County designated staff to provide routine/daily
   maintenance and user training.

D. Firm’s Experience
   Please provide a summary of relevant experience and qualifications of the firm. Please
   include an organizational chart. Include a narrative that includes the history of the
   company, length of time in business, and experience working with public agencies on
   projects similar in size/scope. Describe the firm‘s products and services, administration
   structure and experience providing similar services. If the proposed system or a similar
   system is installed anywhere, please include name, location and date installed.

E. Overall Approach and Philosophy
     1. Provide a definition of the Contractor‘s role, responsibilities and activities and
         how they will integrate with the County.
     2. Explain your customer service philosophy.
     3. Describe what advantages your training management system has over those of
         your competitors.

F. Additional Data
   Please provide any additional data deemed essential to the evaluation of the proposal.

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A. Evaluation Criteria
   An RFP Review Committee composed of representatives of the Health Department and
   Information Services Department will evaluate proposals. Selection will not be based
   solely on lowest price. Evaluation criteria include, but are not limited to, the following:
       1. Philosophy and Values
           There is a clear commitment to timely response and support for a Family Health
           Integrated System.
       2. Applicant’s Experience
           a. Experience providing Family Health system products and services.
           b. Capability and experience of key personnel.
       3. Program Description
           a. There is a clear understanding of the scope of services and products to be
           b. There is sufficient staffing proposed to provide the services.
           c. Proposed mandatory user requirements listed in the RFP are met.
           d. Proposed service delivery, availability and experience providing technical
               support and maintenance are sufficient to provide services.
       4. Organizational Capacity
           a. History of successfully providing similar services.
           b. History of successfully managing other contracts with public agencies similar
               in size/scope.
           c. History of company and length of time in business.
       5. Financial Narrative
           a. Net cost to County, which will include cost of installation, training and other
               incidental costs.

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Note: Please see the Appendix to this RFP ( ) for
forms and documents associated with each of these programs.

A. Prenatal-to-Three
The Pre-to-3 program serves prenatal mothers and children to age 5. Funding is a
combination of local (county based) and state/federal-based sources. The Pre-to-3
Registration Database is an MS Access application using an Oracle database to register clients
into the program and to track the status of the clients. This program uses a TeleForm form to
facilitate time keeping. See copy of form in Appendix.

B. Field Nursing (Global)
Field Nursing serves all age groups in the county. ‗Global‘ is Global Health Information
System (GHiS). This system is used for registration (BIH, AFLP, FAFLP, Cal-Learn), lab
orders and results, billing, dailies (time keeping), accounts receivable, and reporting. This
system is MUMPS based. Approximately 16 users enter data. There is staff from within the
department, hospital and clinics that have access via an Attachmate session to look up lab
results on this system.

C. Child Health & Disability Prevention (CHDP)
This state-funded system is designed to perform follow-up case management on children
identified with health and/or disability problems. Referrals for this program come from
medical providers who complete a form, PM160, which is forwarded to program staff. Most
of the referrals do not result in an active case. Currently there is no automated system for
CHDP; case tracking/management is completely paper-based.

D. Black Infant Health (BIH)
The Black Infant Health program tracks and manages health problems of African-American
infants. The state supplies a system, BIH-MIS (Black Infant Health Management Information
System). This system is used to collect and analyze data, and produce reports on clients
served by the Black Infant Health Program. This software is provided by the state and is
managed by Branaugh Information Systems. It is Foxpro based. Registration of clients uses

E. Lead Poisoning Prevention Program (RASSCLE)
The state Department of Health Services mandates childhood lead poisoning prevention
activities be established within each county, including identification and selection of target
areas for childhood lead screening programs, field trials of alternative lead abatement
technologies, implementation of a program to identify and follow-up high risk children,
provision of environmental abatement and continued programs to reduce the incidence of
excessive childhood lead exposure. Each county reports data to the state concerning these
activities, RASSCLE being the software used to facilitate that reporting.

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F. California Children Services (CCS)
CMSNET is a web-based state system used by CCS for all case management activity.
Currently, Business Objects is used to extract data from CMSNET for analysis and reporting
purposes. CMSNET has the functionality to register clients, open and close cases, check
Medi-Cal, type authorizations, enter Patient Therapy Records for payment, record payments
from parents, send letters to families, enter narratives, and other case management activities.
The use of this system is mandated by the state. It is presumed that integrating this system
will require an import of data from the CMSNET system into the selected system.

G. Adolescent Family Life (AFLP), FAFLP, Cal-Learn, Older Teens
AFLP focuses on teen family with a focus on teen pregnancy. The LodeStar system was
created by the State of California Department of Health Services (CHDS) to collect data and
conduct analysis of a program serving teen parents (State AFLP). We have added data on
clients in other related programs into this system (Federal AFLP; Cal-Learn; and Older Teen
Program). This software is provided by the state, managed by Branaugh Information
Systems. Registration of clients uses GHiS.

H. Women, Infants, Children (WIC)
The WIC program is a program focusing on the nutritional needs of pregnant women and
women with small children. The state-provided, state-mandated system used is ISIS. The
ISIS system provides an automated record, which stores comprehensive client information
required by the WIC program during the length of their participation in the program. ISIS has
a MEDS interface to see if client has active Medi-Cal, Food Stamps or TANF - to assess
adjunctive eligibility for WIC. It is presumed that integrating this system will require an
import of data from the CMSNET system into the selected system.

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Program Name: Pre-to-3 Field Nursing CHDP(Ma AFLP                  California Black        Lead       Women
                                             in case               Children Infant         Poisonin   Infant
                                             managem               Services( Health        g          Children
                                             ent)                  CCS)                    (RASSCL    (WIC)
    number of
    active clients    1385             585        57         350          1914        68        200      25000
    # of clients
    closed per
    month              45 26(approx)              47 25-35                 51                                 300
    # new
    clients per
    month             200 30(approx)              64 35-45                 52    15-Oct                       300
      office visits   970                                          none               15                 12800
      home visits     461                                                   1         60                         0
      phone calls
                      198                         55                      6200        60              500approx
#  Staff with
clients                28              11          2         13            51         6           3           26
Number of PCs
used by program        34               5          2           8           33         8           2           30
# of office sites       3               1          1          1             3         2           1              6

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The following tables are known to Family Health Services staff.
       1. Type of client contact
       2. Reason why case was closed
       3. Reason given for refusing service
       4. Type of case activity
       5. Office site
       6. Referral source
       7. Referral Type
       8. Referral Result
       9. Reason given for referral failure
       10. Clinic Name/address
       11. Language(primary)
       12. Language(secondary)
       13. Risk level/Acuity
       14. Medical problem
       15. Education level
       16. Income level
       17. Income Source
       18. Private Insurance
       19. Employment status
       20. Employ occupation
       21. Case status
       22. Housing type
       23. Immigration status
       24. Literacy
       25. Outcome
       26. Ethnicity
       27. Service Component
       28. Vaccination
       29. Pregnancy Outcome
       30. Type of Delivery
       31. Delivery Complications
       32. Delivery Attendant
       33. Birth Control Used

Time keeping (current Global tables)
      34. T Code
      35. Region
      36. Category
      37. Activities

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                            [Contractor name]

       THIS AGREEMENT, entered into this _____ day of _______________ , 20_____, by
       and between the COUNTY OF SAN MATEO, hereinafter called "County," and
       [Contractor name here], hereinafter called "Contractor";

                                       W I T N E S S E T H:

        WHEREAS, pursuant to Government Code, Section 31000, County may contract with
independent contractors for the furnishing of such services to or for County or any Department

        WHEREAS, it is necessary and desirable that Contractor be retained for the purpose of
[Enter information here].

1. Exhibits and Attachments
The following exhibits and attachments are included hereto and incorporated by reference

Exhibit A—Services
Exhibit B—Payments and rates
Attachment H—HIPAA Business Associate requirements
Attachment I—§ 504 Compliance
2. Services to be Performed by Contractor
In consideration of the payments set forth herein and in Exhibit ―B,‖ Contractor shall perform
services for County in accordance with the terms, conditions and specifications set forth herein
and in Exhibit ―A.‖

3.    Payments
In consideration of the services provided by Contractor in accordance with all terms, conditions
and specifications set forth herein and in Exhibit "A," County shall make payment to
Contractor based on the rates and in the manner specified in Exhibit "B." The County reserves
the right to withhold payment if the County determines that the quantity or quality of the work
performed is unacceptable. In no event shall the County‘s total fiscal obligation under this
Agreement exceed [Write out amount], [$Amount].

4.    Term and Termination

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Subject to compliance with all terms and conditions, the term of this Agreement shall be from
[Month and day], 20[Last 2 digits of year] through [Month and day], 20[Last 2 digits of year].

This Agreement may be terminated by Contractor, the [Name of County Department Head] or
his/her designee at any time without a requirement of good cause upon thirty (30) days‘ written
notice to the other party.

In the event of termination, all finished or unfinished documents, data, studies, maps,
photographs, reports, and materials (hereafter referred to as materials) prepared by Contractor
under this Agreement shall become the property of the County and shall be promptly delivered
to the County. Upon termination, the Contractor may make and retain a copy of such
materials. Subject to availability of funding, Contractor shall be entitled to receive payment for
work/services provided prior to termination of the Agreement. Such payment shall be that
portion of the full payment which is determined by comparing the work/services completed to
the work/services required by the Agreement.

5. Availability of Funds
The County may terminate this Agreement or a portion of the services referenced in the
Attachments and Exhibits based upon unavailability of Federal, State, or County funds, by
providing written notice to Contractor as soon as is reasonably possible after the county learns
of said unavailability of outside funding.

6. Relationship of Parties
Contractor agrees and understands that the work/services performed under this Agreement are
performed as an independent Contractor and not as an employee of the County and that
Contractor acquires none of the rights, privileges, powers, or advantages of County employees.

7.    Hold Harmless
Contractor shall indemnify and save harmless County, its officers, agents, employees, and
servants from all claims, suits, or actions of every name, kind, and description, brought for, or
on account of: (A) injuries to or death of any person, including Contractor, or (B) damage to
any property of any kind whatsoever and to whomsoever belonging, (C) any sanctions,
penalties, or claims of damages resulting from Contractor‘s failure to comply with the
requirements set forth in the Health Insurance Portability and Accountability Act of 1996
(HIPAA) and all Federal regulations promulgated thereunder, as amended, or (D) any other
loss or cost, including but not limited to that caused by the concurrent active or passive
negligence of County, its officers, agents, employees, or servants, resulting from the
performance of any work required of Contractor or payments made pursuant to this Agreement,
provided that this shall not apply to injuries or damage for which County has been found in a
court of competent jurisdiction to be solely liable by reason of its own negligence or willful

The duty of Contractor to indemnify and save harmless as set forth herein, shall include the
duty to defend as set forth in Section 2778 of the California Civil Code.

8.    Assignability and Subcontracting

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Contractor shall not assign this Agreement or any portion thereof to a third party or subcontract
with a third party to provide services required by contractor under this Agreement without the
prior written consent of County. Any such assignment or subcontract without the County‘s
prior written consent shall give County the right to automatically and immediately terminate
this Agreement.

9.     Insurance
The Contractor shall not commence work or be required to commence work under this
Agreement unless and until all insurance required under this paragraph has been obtained and
such insurance has been approved by Risk Management, and Contractor shall use diligence to
obtain such insurance and to obtain such approval. The Contractor shall furnish the
Department/Division with certificates of insurance evidencing the required coverage, and there
shall be a specific contractual liability endorsement extending the Contractor's coverage to
include the contractual liability assumed by the Contractor pursuant to this Agreement. These
certificates shall specify or be endorsed to provide that thirty (30) days' notice must be given, in
writing, to the Department/Division of any pending change in the limits of liability or of any
cancellation or modification of the policy.

 (1) Worker's Compensation and Employer's Liability Insurance The Contractor shall
     have in effect during the entire life of this Agreement Workers' Compensation and
     Employer's Liability Insurance providing full statutory coverage. In signing this
     Agreement, the Contractor certifies, as required by Section 1861 of the California Labor
     Code, that it is aware of the provisions of Section 3700 of the California Labor Code
     which requires every employer to be insured against liability for Worker's Compensation
     or to undertake self-insurance in accordance with the provisions of the Code, and will
     comply with such provisions before commencing the performance of the work of this

 (2) Liability Insurance The Contractor shall take out and maintain during the life of this
     Agreement such Bodily Injury Liability and Property Damage Liability Insurance as
     shall protect him/her while performing work covered by this Agreement from any and
     all claims for damages for bodily injury, including accidental death, as well as any and
     all claims for property damage which may arise from contractors operations under this
     Agreement, whether such operations be by himself/herself or by any sub-contractor or
     by anyone directly or indirectly employed by either of them. Such insurance shall be
     combined single limit bodily injury and property damage for each occurrence and shall
     be not less than the amount specified below.

       Such insurance shall include:
       (a) Comprehensive General Liability . . . . . . . . . . . . . . . . . .              $1,000,000
       (b) Motor Vehicle Liability Insurance . . . . . . . . . . . . . . . . . .            $1,000,000
       (c) Professional Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . .   $1,000,000

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County and its officers, agents, employees and servants shall be named as additional insured on
any such policies of insurance, which shall also contain a provision that the insurance afforded
thereby to the County, its officers, agents, employees and servants shall be primary insurance
to the full limits of liability of the policy, and that if the County or its officers and employees
have other insurance against the loss covered by such a policy, such other insurance shall be
excess insurance only.

In the event of the breach of any provision of this section, or in the event any notice is received
which indicates any required insurance coverage will be diminished or canceled, the County of
San Mateo at its option, may, notwithstanding any other provision of this Agreement to the
contrary, immediately declare a material breach of this Agreement and suspend all further work
pursuant to this Agreement.

10. Compliance with laws; Payment of Permits/Licenses
All services to be performed by Contractor pursuant to this Agreement shall be performed in
accordance with all applicable Federal, State, County, and municipal laws, ordinances and
regulations, including, but not limited to, the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), and the Federal Regulations promulgated thereunder, as amended, and
will comply with the Business Associate requirements set forth in Attachment ―H,‖ and the
Americans with Disabilities Act of 1990, as amended, and Section 504 of the Rehabilitation
Act of 1973, as amended and attached hereto and incorporated by reference herein as
Attachment ―I,‖ which prohibits discrimination on the basis of handicap in programs and
activities receiving any Federal or County financial assistance. Such services shall also be
performed in accordance with all applicable ordinances and regulations, including, but not
limited to, appropriate licensure, certification regulations, provisions pertaining to confiden-
tiality of records, and applicable quality assurance regulations. In the event of a conflict
between the terms of this Agreement and State, Federal, County, or municipal law or
regulations, the requirements of the applicable law will take precedence over the requirements
set forth in this Agreement.

Contractor will timely and accurately complete, sign, and submit all necessary documentation
of compliance.

11. Non-Discrimination and Other Requirements
A. Section 504 applies only to Contractors who are providing services to members of the
    public. Contractor shall comply with § 504 of the Rehabilitation Act of 1973, which
    provides that no otherwise qualified handicapped individual shall, solely by reason of a
    disability, be excluded from the participation in, be denied the benefits of, or be subjected
    to discrimination in the performance of this Agreement.
B. General non-discrimination. No person shall, on the grounds of race, color, religion,
    ancestry, gender, age (over 40), national origin, medical condition (cancer), physical or
    mental disability, sexual orientation, pregnancy, childbirth or related medical condition,
    marital status, or political affiliation be denied any benefits or subject to discrimination
    under this Agreement.

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C. Equal employment opportunity. Contractor shall ensure equal employment opportunity
   based on objective standards of recruitment, classification, selection, promotion,
   compensation, performance evaluation, and management relations for all employees under
   this Agreement. Contractor‘s equal employment policies shall be made available to
   County of San Mateo upon request.
D. Violation of Non-discrimination provisions.        Violation of the non-discrimination
   provisions of this Agreement shall be considered a breach of this Agreement and subject
   the Contractor to penalties, to be determined by the County Manager, including but not
   limited to
       i)    termination of this Agreement;
       ii) disqualification of the Contractor from bidding on or being awarded a County
             contract for a period of up to 3 years;
       iii) liquidated damages of $2,500 per violation;
       iv) imposition of other appropriate contractual and civil remedies and sanctions, as
             determined by the County Manager.

To effectuate the provisions of this section, the County Manager shall have the authority to
examine Contractor‘s employment records with respect to compliance with this paragraph
and/or to set off all or any portion of the amount described in this paragraph against amounts
due to Contractor under the Contract or any other Contract between Contractor and County.

Contractor shall report to the County Manager the filing by any person in any court of any
complaint of discrimination or the filing by any person of any and all charges with the Equal
Employment Opportunity Commission, the Fair Employment and Housing Commission or any
other entity charged with the investigation of allegations within 30 days of such filing,
provided that within such 30 days such entity has not notified Contractor that such charges are
dismissed or otherwise unfounded. Such notification shall include the name of the complainant,
a copy of such complaint, and a description of the circumstance. Contractor shall provide
County with a copy of their response to the Complaint when filed.

E.   Compliance with Equal Benefits Ordinance. With respect to the provision of employee
     benefits, Contractor shall comply with the County Ordinance which prohibits contractors
     from discriminating in the provision of employee benefits between an employee with a
     domestic partner and an employee with a spouse.
F. EThe Contractor shall comply fully with the non-discrimination requirements required by
   . 41 CFR 60-741.5(a), which is incorporated herein as if fully set forth.

12. Compliance with Contractor Employee Jury Service Ordinance
Contractor shall comply with the County Ordinance with respect to provision of jury duty pay
to employees and have and adhere to a written policy that provides that its employees shall
receive from the contractor, on an annual basis, no less than five days of regular pay for actual
jury service in San Mateo County. The policy may provide that employees deposit any fees
received for such jury service with the contractor or that the contractor deduct from the
employees‘ regular pay the fees received for jury service.

13.   Retention of Records, Right to Monitor and Audit

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(a) CONTRACTOR shall maintain all required records for three (3) years after the COUNTY
makes final payment and all other pending matters are closed, and shall be subject to the
examination and/or audit of the County, a Federal grantor agency, and the State of California.

(b) Reporting and Record Keeping: CONTRACTOR shall comply with all program and fiscal
reporting requirements set forth by appropriate Federal, State and local agencies, and as
required by the COUNTY.

(c) CONTRACTOR agrees to provide to COUNTY, to any Federal or State department having
monitoring or review authority, to COUNTY's authorized representatives, and/or their
appropriate audit agencies upon reasonable notice, access to and the right to examine all
records and documents necessary to determine compliance with relevant Federal, State, and
local statutes, rules and regulations, and this Agreement, and to evaluate the quality,
appropriateness and timeliness of services performed.

14. Merger Clause
This Agreement, including the Exhibits attached hereto and incorporated herein by reference,
constitutes the sole Agreement of the parties hereto and correctly states the rights, duties, and
obligations of each party as of this document's date. In the event that any term, condition,
provision, requirement or specification set forth in this body of the agreement conflicts with or
is inconsistent with any term, condition, provision, requirement or specification in any exhibit
and/or attachment to this agreement, the provisions of this body of the agreement shall prevail.
Any prior agreement, promises, negotiations, or representations between the parties not
expressly stated in this document are not binding. All subsequent modifications shall be in
writing and signed by the parties.

15. Controlling Law
The validity of this Agreement and of its terms or provisions, as well as the rights and duties of
the parties hereunder, the interpretation, and performance of this Agreement shall be governed
by the laws of the State of California.

16.   Notices
      Any notice, request, demand, or other communication required or permitted hereunder
      shall be deemed to be properly given when deposited in the United State mail, postage
      prepaid, or when deposited with a public telegraph company for transmittal, charges
      prepaid, addressed to:
                  In the case of County, to:

                  In the case of Contractor, to:

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IN WITNESS WHEREOF, the parties hereto, by their duly authorized representatives, have
affixed their hands.

                                           COUNTY OF SAN MATEO

                                           President, Board of Supervisors, San Mateo County



Clerk of Said Board

[Contractor Name Here]

Contractor‘s Signature

                                                                  Long Form Agreement/Business Associate v 6/28/06

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                                           Exhibit ―A‖

In consideration of the payments set forth in Exhibit ―B‖, Contractor shall provide the
following services:

                                         Exhibit ―B‖
In consideration of the services provided by Contractor in Exhibit ―A‖, County shall pay
Contractor based on the following fee schedule:

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                                     Attachment H
               Health Insurance Portability and Accountability Act (HIPAA)
                            Business Associate Requirements


        Terms used, but not otherwise defined, in this Schedule shall have the same meaning as
those terms are defined in 45 Code of Federal Regulations section 160.103 164.304 and
164.501. (All regulatory references in this Schedule are to Title 45 of the Code of Federal
Regulations unless otherwise specified.)

       a. Designated Record Set. ―Designated Record Set‖ shall have the same meaning as
          the term ―designated record set‖ in Section 164.501.
       b. Electronic Protected Health Information. ―Electronic Protected Health
          Information‖ (―EPHI‖) means individually identifiable health information that is
          transmitted or maintained in electronic media, limited to the information created,
          received, maintained or transmitted by Business Associate from or on behalf of
          Covered Entity.
       c. Individual. ―Individual‖ shall have the same meaning as the term ―individual‖ in
          Section 164.501 and shall include a person who qualifies as a personal
          representative in accordance with Section 164.502(g).
       d. Privacy Rule. ―Privacy Rule‖ shall mean the Standards for Privacy of Individually
          Identifiable Health Information at 45 Code of Federal Regulations Part 160 and Part
          164, Subparts A and E.
       e. Protected Health Information. ―Protected Health Information‖ shall have the same
          meaning as the term ―protected health information‖ in Section 164.501 and is
          limited to the information created or received by Contractor from or on behalf of
       f. Required By Law. ―Required by law‖ shall have the same meaning as the term
          ―required by law‖ in Section 164.501.
       g. Secretary. ―Secretary‖ shall mean the Secretary of the United States Department of
          Health and Human Services or his or her designee.
       h. Security Incident. ―Security Incident‖ shall mean the attempted or successful
          unauthorized access, use, disclosure, modification, or destruction of information or
          interference with systems operations in an information system, but does not include
          minor incidents that occur on a daily basis, such as scans, ―pings‖, or unsuccessful
          random attempts to penetrate computer networks or servers maintained by Business
       i. Security Rule. ―Security Rule‖ shall mean the Standards for the Protection of
          Electronic Protected Health Information at 45 CFR Part 160 and Part 164, Subparts
          A and C.

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Obligations and Activities of Contractor

       a. Contractor agrees to not use or further disclose Protected Health Information other
          than as permitted or required by the Agreement or as required by law.
       b. Contractor agrees to use appropriate safeguards to prevent the use or disclosure of
          the Protected Health Information other than as provided for by this Agreement.
       c. Contractor agrees to mitigate, to the extent practicable, any harmful effect that is
          known to Contractor of a use or disclosure of Protected Health Information by
          Contractor in violation of the requirements of this Agreement.
       d. Contractor agrees to report to County any use or disclosure of the Protected Health
          Information not provided for by this Agreement.
       e. Contractor agrees to ensure that any agent, including a subcontractor, to whom it
          provides Protected Health Information received from, or created or received by
          Contractor on behalf of County, agrees to the same restrictions and conditions that
          apply through this Agreement to Contractor with respect to such information.
       f. If Contractor has protected health information in a designated record set, Contractor
          agrees to provide access, at the request of County, and in the time and manner
          designated by County, to Protected Health Information in a Designated Record Set,
          to County or, as directed by County, to an Individual in order to meet the
          requirements under Section 164.524.
       g. If Contractor has protected health information in a designated record set, Contractor
          agrees to make any amendment(s) to Protected Health Information in a Designated
          Record Set that the County directs or agrees to make pursuant to Section 164.526 at
          the request of County or an Individual, and in the time and manner designed by
       h. Contractor agrees to make internal practices, books, and records relating to the use
          and disclosure of Protected Health Information received from, or created or received
          by Contractor on behalf of, County available to the County, or at the request of the
          County to the Secretary, in a time and manner designated by the County or the
          Secretary, for purposes of the Secretary determining County‘s compliance with the
          Privacy Rule.
       i. Contractor agrees to document such disclosures of Protected Health Information and
          information related to such disclosures as would be required for County to respond
          to a request by an Individual for an accounting of disclosures of Protected Health
          Information in accordance with Section 164.528.

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       j. Contractor agrees to provide to County or an Individual in the time and manner
          designated by County, information collected in accordance with Section (i) of this
          Schedule, to permit County to respond to a request by an Individual for an
          accounting of disclosures of Protected Health Information in accordance with
          Section 164.528.
       k. Contractor shall implement administrative, physical, and technical safeguards that
          reasonably and appropriately protect the confidentiality, integrity, and availability
          of EPHI that Contractor creates, receives, maintains, or transmits on behalf of
       l. Contractor shall conform to generally accepted system security principles and the
          requirements of the final HIPAA rule pertaining to the security of health
       m. Contractor shall ensure that any agent to whom it provides EPHI, including a
          subcontractor, agrees to implement reasonable and appropriate safeguards to protect
          such EPHI.
       n. Contractor shall report to County any Security Incident within 5 business days of
          becoming aware of such incident.
       o. Contractor shall makes its policies, procedures, and documentation relating to the
          security and privacy of protected health information, including EPHI, available to
          the Secretary of the U.S. Department of Health and Human Services and, at
          County‘s request, to the County for purposes of the Secretary determining County‘s
          compliance with the HIPAA privacy and security regulations.

Permitted Uses and Disclosures by Contractor

        Except as otherwise limited in this Schedule, Contractor may use or disclose Protected
Health Information to perform functions, activities, or services for, or on behalf of, County as
specified in the Agreement; provided that such use or disclosure would not violate the Privacy
Rule if done by County.

Obligations of County

       a. County shall provide Contractor with the notice of privacy practices that County
          produces in accordance with Section 164.520, as well as any changes to such notice.
       b. County shall provide Contractor with any changes in, or revocation of, permission
          by Individual to use or disclose Protected Health Information, if such changes affect
          Contractor‘s permitted or required uses and disclosures.
       c. County shall notify Contractor of any restriction to the use or disclosure of
          Protected Health Information that County has agreed to in accordance with Section

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Permissible Requests by County

        County shall not request Contractor to use or disclose Protected Health Information in
any manner that would not be permissible under the Privacy Rule if done by County, unless the
Contractor will use or disclose Protected Health Information for, and if the Agreement provides
for, data aggregation or management and administrative activities of Contractor.

Duties Upon Termination of Agreement

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


       a. Regulatory References. A reference in this Schedule to a section in the Privacy
          Rule means the section as in effect or as amended, and for which compliance is
       b. Amendment. The Parties agree to take such action as is necessary to amend this
          Schedule from time to time as is necessary for County to comply with the
          requirements of the Privacy Rule and the Health Insurance Portability and
          Accountability Act, Public Law 104-191.
       c. Survival. The respective rights and obligations of Contractor under this Schedule
          shall survive the termination of the Agreement.
       d. Interpretation. Any ambiguity in this Schedule shall be resolved in favor of a
          meaning that permits County to comply with the Privacy Rule.
       e. Reservation of Right to Monitor Activities. County reserves the right to monitor the
          security policies and procedures of Contractor

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                                              County of San Mateo
Contractor’s Declaration Form


     Contractor Name:                                              Phone:
      Contact Person:                                                Fax:

II. EQUAL BENEFITS (check one or more boxes)
Contractors with contracts in excess of $5,000 must treat spouses and domestic partners equally as to employee
        Contractor complies with the County’s Equal Benefits Ordinance by:
                offering equal benefits to employees with spouses and employees with domestic partners.
                offering a cash equivalent payment to eligible employees in lieu of equal benefits.
          Contractor does not comply with the County’s Equal Benefits Ordinance.
       Contractor is exempt from this requirement because:
              Contractor has no employees, does not provide benefits to employees’ spouses, or the
              contract is for $5,000 or less.
              Contractor is a party to a collective bargaining agreement that began on            (date) and
              expires on         (date), and intends to offer equal benefits when said agreement expires.
III. NON-DISCRIMINATION (check appropriate box)
       Finding(s) of discrimination have been issued against Contractor within the past year by the Equal
       Employment Opportunity Commission, Fair Employment and Housing Commission, or other
       investigative entity. Please see attached sheet of paper explaining the outcome(s) or remedy for the
       No finding of discrimination has been issued in the past year against the Contractor by the Equal
       Employment Opportunity Commission, Fair Employment and Housing Commission, or any other entity.

IV. EMPLOYEE JURY SERVICE (check one or more boxes)
Contractors with original or amended contracts in excess of $100,000 must have and adhere to a written policy
that provides its employees living in San Mateo County up to five days regular pay for actual jury service in the
          Contractor complies with the County’s Employee Jury Service Ordinance.
          Contractor does not comply with the County’s Employee Jury Service Ordinance.
          Contractor is exempt from this requirement because:
                 the contract is for $100,000 or less.
                Contractor is a party to a collective bargaining agreement that began on          (date) and
                expires on           (date), and intends to comply when the collective bargaining agreement
I declare under penalty of perjury under the laws of the State of California that the foregoing
is true and correct, and that I am authorized to bind this entity contractually.
________________________________________                             ________________________________
Signature                                                            Name
________________________________________                             ________________________________
Date                                                                 Title

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