addendum acknowledgement form rfp #11-dc-8339

addendum acknowledgement form rfp #11-dc-8339

ADDENDUM ACKNOWLEDGEMENT FORM
RFP #11-DC-8339
A D DE N D U M #2
Department of Corrections
Bureau Procurement of Supply
4070 Esplanade Way
Tallahassee, Florida 32399-2500
BID NO:
RFP #11-DC-8339
BID TITLE:
Community-Based Therapeutic Community (TC) Beds for Inmates
OPENING DATE:
January 9, 2012
ADDENDUM NO.:
Two (2)
DATE:
December 29, 2011
PLEASE BE ADVISED THAT THE FOLLOWING CHANGES ARE APPLICABLE TO THE ORIGINAL SPECIFICATIONS OF
THE ABOVE-REFERENCED RFP:
This addendum includes the following:
1.
Written Responses to Written Inquiries, inadvertently omitted from Addendum #1.
If you have any difficulty in downloading any of the attached documents, please call or e-mail a request for copies to the
Procurement Manager.
THIS ADDENDUM NOW BECOMES A PART OF THE ORIGINAL RFP.
THE ADDENDUM ACKNOWLEDGMENT FORM SHALL BE SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE, DATED AND
RETURNED WITH THE PROPOSAL AS INSTRUCTED IN SECTION 5, PROPOSAL SUBMISSION REQUIREMENTS. FAILURE TO DO SO
MAY SUBJECT THE PROPOSER TO DISQUALIFICATION.
Failure to file a protest within the time prescribed in Section 120.57(3), Florida Statutes, or failure to post the bond or other security
required by law within the time allowed for filing a bond shall constitute a waiver of proceedings under Chapter 120, Florida
Statutes.
PROPOSER:
BY:
ADDRESS:
PHONE:
CITY, STATE:
DATE:
AUTHORIZED SIGNATURE:
RFP #11-DC-8339
Additional Responses to Written Inquiries
RFP #11-DC-8339
COMMUNITY-BASED THERAPEUTIC COMMUNITY (TC) BEDS FOR INMATES
All written inquiries are reproduced in the same format as submitted by the Proposer.
GOODWILL INDUSTRIES-SUNCOAST, INC
1.
Question #56
Answer #56
Question #57
Answer #57
3.5.4 TRANSPORT…. Non-disciplinary travel to the parent institution or other DC facilities.
QUESTION: Will the contractor be transporting all inmates that required medical services from
the parent institution? Are there any special travel requirements when transporting inmates to the
parent institution…such as staffing requirements, any special equipment on board? Please confirm
that the contractor will not be transporting new arrivals from other institution to the contractor site.
Yes, the Contractor will be responsible for transporting the inmates that require medical services to
and from the parent institution. The transport vehicle must be handicap accessible but does not
require any other special requirements. The Department will initially transport the inmates to the
contracted facility.
2.
3.5.13 … The contractor shall provide the parent institution Senior Registered Nurse
Supervisor with proof of testing prior to the start of the services delivery by the staff member and
annually thereafter.
QUESTION: Once the Contractor sends the TB proof of testing, will there be a requirement that
the Senior Reg. RN communicate back to the contractor PRIOR to the contractor hiring the
individual. We would like to ensure that if communication is required back from the Snr. RN,
that we are not delaying the hiring process waiting for approval from the Snr. RN.
Section 3.5.13 does not require communication back from the Snr. RN. The Contractor should
maintain a copy of what has been submitted for their records. This requirement should not delay
hiring.
3. 3.5.15
Question #58
Answer #58
QUESTION: Will the Department provide all the necessary release forms (sample) under this
section?
Section 3.5.15 requires the Contractor to ensure that all inmates sign appropriate Release of
Information Forms…., the attached DC4-711B in English and Spanish may be used to meet this
requirement.
4. 3.9.7
Question #59
Answer #59
….release of information forms.
WRIMS
QUESTION: Will the Department provide PC’s if WRIMS is required to be operated on it’s own
network? If the Department is providing PC’s what is the number of PC’s per 60 beds that will be
provided? If additional PC’s are required will the contractor be able to add additional PC’s to the
WRIMS network?
The Department will provide one computer per 60 beds. The Contractor may add additional PC’s
if they chose. However, if the additional PC will be used for WRIMS entry, it shall become
property of the Department of Corrections and must meet the minimum standard requirements.
RFP #11-DC-8339
5.
Question #60
Answer #60
3.11. 6 GED testing
QUESTION: Currently the cost to take a GED test is $70 per test. Who will be responsible for
paying for the GED test, the Department, the inmate or the Contractor?
The Contractor is responsible for all costs associated with the GED program.
6.
3.11.10 $4 co-payment …….from inmate’s account.
Question #61
QUESTON: If the inmate is not working and has no funds, will the inability of paying the $4 by
the offender delay medical services? Will the Contractor be responsible for the $4 on behalf of the
inmate?
Answer #61
No, the inability to pay for medical services will not delay the delivery of services. No, the
Contractor will not be responsible for the $4.00 on behalf of the inmate.
8. 3.6.1 …referral of the inmate
Question #62
Answer #62
QUESTION: Please outline the types of inmate criminal record that will exclude an inmate from
this program.
Inmates placed into a community residential programs such as programs outlined in this RFP, are
required to be Community custody level of classification. Convictions for escape, sexual battery,
any sex related offense (with the exception of prostitution) will prohibit inmates from participating
in the services outlined in this RFP.
9.
Work Release.
Question #63
QUESTION: If an agency already operates a work release program within the same location, is
there a possibility of qualifying transitional inmates to transfer to work release before their EOS
date? Typically these may be inmates that have family in the immediate area and are progressing
better than expected.
Answer #63
No. This program is designed as a substance residential therapeutic community and does not
include a work release component.
10. Employment within the agency
Question #64
Answer #64
QUESTION: If the opportunity is available for a transition inmate to work within the Contractors
site (ie retail, warehouse, food services), will this option be considered. The transitional inmate
would receive competitive pay rates just like any other employee. As the inmate progresses
through the program 3.10.4.4.4 and 3.10.4.5 the opportunity to work part time may present itself,
and with that the opportunity to earn an income and save funds for release.
No. See answer to question #63.
RFP #11-DC-8339
FLORIDA DEPARTMENT OF CORRECTIONS
CONSENT AND AUTHORIZATION FOR USE AND DISCLOSURE INSPECTION AND RELEASE
OF CONFIDENTIAL INFORMATION
I,
authorize
(Name, organization or general designation of program making disclosure)
to disclose to
(Name of person(s) or organization(s) and address to which disclosure is to be made)
Purpose of disclosure authorized herein:
The undersigned hereby authorizes the inspection and release of copies of my medical records indicated below by the above-named health
care facility/medical record custodian only to the above-named entity(ies) or persons or their agents. Indicate all of the records authorized
to be inspected/released by initialing in the appropriate box(es) below:
INITIAL BELOW
FOR RELEASE OF
INFORMATION
A.
Release of all medical records except: any information relating to HIV testing, AIDS and AIDS-related
syndromes; psychiatric and psychological information; or alcohol and substance abuse treatment information
related to my condition, care, and confinement (initial box).
B.
Release of any records regarding HIV testing, AIDS and AIDS-related syndromes relating to my condition,
care, and confinement (initial box).
C.
Release of any records of psychiatric and psychological information (mental health records) other than
psychotherapy notes relating to my conditions, care, and confinement (initial box).
D.
Release of all dental records relating to my condition, care and confinement (initial box).
E.
Release of any records regarding alcohol and substance abuse treatment relating to my condition, care, and
confinement. I understand that my records are protected under the federal regulations governing
Confidentiality of Alcohol and Drug Abuse Patient Records, 42 U.S.C. §290 (ee)(2), and cannot be disclosed
without my written consent unless otherwise provided for in the regulations. As to release of
alcohol/substance abuse treatment records, please state the specific information to be released as provided by
42 U.S.C. §290 (ee)(2), Fed rule 42 CFR Part 2 (initial box):
Name of information -- dates of treatment/programs, etc., if possible
NOTE: IF PSYCHOTHERAPY OR SUBSTANCE ABUSE PROGRESS NOTES ARE THE SUBJECT
OF THE RELEASE, OTHER RECORDS CANNOT BE THE SUBJECT OF THE SAME
AUTHORIZATION. RELEASE OF PSYCHOTHERAPY OR SUBSTANCE ABUSE PROGRESS
NOTES IN ADDITION TO THE RECORDS SPECIFIED ABOVE WILL REQUIRE A SEPARATE
AUTHORIZATION (SEE BELOW).
I understand that I may refuse to sign this authorization and my refusal to sign will not affect my access to health care treatment,
eligibility for benefits or enrollment, or payment for or coverage of services. I also understand that once my protected health
information is disclosed pursuant to this authorization, it may be used and/or redisclosed by the recipient unless the recipient is
covered by law which prohibits or limits its use and/or disclosure.
I understand that I may revoke this consent and authorization at any time, provided the revocation is in writing, except to the extent that
action has been taken in reliance on it, and that in any event, this consent and authorization shall be effective for 90 days unless I specify a
different expiration as follows: ____________________________________________________________________________________
(Specification of the date, event, or condition upon which this consent expires if less than six months or greater than 90 days)
In furtherance of this authorization, I (we) do hereby waive all provisions of law and privileges relating to the disclosures hereby
authorized. I acknowledge the extent of my authorization of release as to the records and information denoted in paragraphs A, B, C, D
and E by initialing the appropriate box(es) above.
__________________________________________________________
SIGNATURE OF PATIENT (Guardian or Statutorily Authorized Representative, when required)
_________
Date
AUTHORIZATION FOR RELEASE OF PSYCHOTHERAPHY OR SUBSTANCE ABUSE PROGRESS NOTES
I,
authorize
(Name, organization or general designation of program making disclosure)
to disclose to
(Name of person(s) or organization(s) and address to which disclosure is to be made)
Purpose of disclosure authorized herein:
DC4-711B (English) (Revised 11/27/07)
Incorporated by Reference in Rule 33-601.901, F.A.C.
FLORIDA DEPARTMENT OF CORRECTIONS
CONSENT AND AUTHORIZATION FOR USE AND DISCLOSURE INSPECTION AND RELEASE
OF CONFIDENTIAL INFORMATION
The undersigned hereby authorizes the inspection and release of copies of my psychotherapy progress notes and/or my substance abuse
progress notes as indicated below by the above-named health care facility/medical record custodian only to the above-named entity(ies) or
persons or their agents. Indicate all of the records authorized to be inspected/released by initialing in the appropriate box(es) below:
INITIAL BELOW
FOR RELEASE OF
INFORMATION
A.
Release psychotherapy progress notes (initial box):
B.
Release substance abuse progress notes (initial box):
Name of information -- dates of treatment/programs, etc., if possible
I understand that I may refuse to sign this authorization and my refusal to sign will not affect my access to health care treatment,
eligibility for benefits or enrollment, or payment for or coverage of services. I also understand that once my protected health
information is disclosed pursuant to this authorization, it may be used and/or redisclosed by the recipient unless the recipient is
covered by law which prohibits or limits its use and/or disclosure.
I understand that I may revoke this consent and authorization at any time, provided the revocation is in writing, except to the extent that
action has been taken in reliance on it, and that in any event, this consent and authorization shall be effective for 90 days unless I specify a
different expiration as follows: ____________________________________________________________________________________
(Specification of the date, event, or condition upon which this consent expires if less than six months or greater than 90 days)
In furtherance of this authorization, I (we) do hereby waive all provisions of law and privileges relating to the disclosures hereby
authorized. I acknowledge the extent of my authorization of release as to the records and information denoted in paragraphs A and B
initialing the appropriate box(es) above.
__________________________________________________________
SIGNATURE OF PATIENT (or Next of Kin, Guardian or Authorized Representative, when required)
_________
Date
------------------------------------------------------------------------------------------------------------------------------------------------------COMPLETE NOTARY PORTION ONLY WHEN REQUEST IS NOT FROM CURRENT INMATE/OFFENDER PERSONALLY KNOWN
TO WITNESS OR IS FROM SOURCE EXTERNAL TO DEPARTMENT
STATE OF
COUNTY OF
_____________________________
Sworn to (or affirmed) and subscribed before me this day of
by ____________________________________________________
________________________as identification.
________________________________________________________
Notary Public Signature
Print, type, or stamp commissioned name of Notary Public
My Commission Expires:
who
is
personally
, 20_____,
known to me
or
who
has
SEAL
ACKNOWLEDGEMENT OF RECEIPT OF COPY OF SIGNED AUTHORIZATION(S)
Inmate/Offender Name
DC#
R/S
Date of Birth
SS#
Institution/Office
DC4-711B (English) (Revised 11/27/07)
Witness Name ____________________________________
Witness Signature _________________________________
Date:________________________________
Incorporated by Reference in Rule 33-601.901, F.A.C.
produced
DEPARTAMENTO CORRECCIONAL DE LA FLORIDA
CONSENTIMIENTO Y AUTORIZACIÓN PARA EL USO E INSPECCIÓN DE DIVULGACIÓN
Y LA DIFUSIÓN DE INFORMACIÓN CONFIDENCIAL
Yo,
autorizo a
(Nombre, organización o designación general del programa realizando la divulgación)
a divulgar a
(Nombre de persona(s) u organización(es) y dirección a la cual se realizará la divulgación)
Propósito de la divulgación autorizada por este medio:
El suscrito, por este medio autoriza la inspección y divulgación de copias de mis expedientes médicos indicados abajo por el centro de
salud/custodio de expedientes médicos mencionado anteriormente solamente a la(s) entidad(es) o personas o a sus agentes
mencionados anteriormente. Indique todos los expedientes autorizados a ser inspeccionados/divulgados, escribiendo sus iniciales en
la(s) casilla(s) apropiada(s) a continuación:
COLOQUE SUS INICIALES
ABAJO PARA LA
DIVULAGACIÓN DE
INFORMACIÓN
A.
B.
C.
D.
A.
Divulgación de todo expediente médico exceptuando: cualquier información que se relacione con exámenes de
VIH, SIDA y síndromes relacionados con el SIDA; información psiquiátrica y psicológica; o información sobre mi
tratamiento del abuso de alcohol y sustancias que esté relacionada con mi afección, atención médica y reclusión
(escriba sus iniciales en la casilla).
Divulgación de cualquier expediente que se relacione con exámenes de VIH, SIDA y síndromes relacionados con
el SIDA que se relacione con mi afección, atención médica y reclusión (escriba sus iniciales en la casilla).
Divulgación de cualquier expediente con información psiquiátrica y psicológica (expedientes de salud mental),
aparte de las anotaciones de psicoterapia que se relacionen con mi afección, atención médica y reclusión (escriba
sus iniciales en la casilla).
Divulgación de todo expediente dental relacionado con mi afección, atención médica y reclusión (escriba sus
iniciales en la casilla).
Divulgación de cualquier expediente referente al tratamiento del abuso de alcohol y sustancias que se relacione con
mi afección, atención médica y reclusión. Yo entiendo que mis expedientes están protegidos bajo las
reglamentaciones federales que rigen La Confidencialidad de Expedientes del Abuso de Alcohol y Drogas del
Paciente, 42 U.S.C. §290 (ee)(2), y no pueden ser divulgados sin mi permiso por escrito a menos que sea indicado
de otra manera en las reglamentaciones. Para poder divulgar los expedientes de tratamiento del abuso de alcohol
y/o sustancias, por favor declare la información específica que se pueda divulgar según lo establecido por 42
U.S.C. §290 (ee)(2), Regla Federal 42 CFR Parte 2 (escriba sus iniciales en la casilla):
Nombre de la información -- fechas de tratamiento/ programas, etc., si es posible
NOTA: SI LAS ANOTACIONES DEL PROGRESO EN PSICOTERAPIA O ABUSO DE SUSTANCIAS
CONSTITUYEN EL TEMA DE LA DIVULGACIÓN, OTROS EXPEDIENTES NO PUEDEN CONSTITUIR EL
TEMA DE LA MISMA AUTORIZACIÓN. LA DIVULGACIÓN DE NOTAS DE PROGRESO DE PSICOTERAPIA
O ABUSO DE SUSTANCIAS ADEMÁS DE LOS EXPEDIENTES MENCIONADOS ANTERIORMENTE
REQUERIRÁN UNA AUTORIZACIÓN POR SEPARADO (VER ABAJO).
Yo entiendo que puedo rehusarme a firmar esta autorización y me rehúso a firmar no afectará mi acceso a tratamientos de cuidado de
la salud, elegibilidad para beneficios o inscripción, o pago por o la cobertura de servicios. También entiendo que una vez que mi
información de salud protegida sea divulgada conforme a esta autorización, puede ser utilizada y/o redivulgada por el que la reciba a
menos que el que la reciba esté cubierto por ley que prohíba o limite su utilización y/o divulgación.
Yo entiendo que puedo revocar este permiso y autorización en cualquier momento, con tal que la revocación sea por escrito,
exceptuando hasta el punto de acción que haya sido tomada basada en ello, y que en todo caso, este permiso y autorización estarán en
vigencia por 90 días a menos que yo especifique un vencimiento diferente en el siguiente espacio:
______________________________________________________________________________________________________________
((Especificación de la fecha, evento o condición bajo la cual vence este permiso si es menos de seis meses o más de 90 días)
En promoción de esta autorización, yo (nosotros) por este medio renuncio a todas las disposiciones de leyes y privilegios que se
relacionen con las divulgaciones autorizadas por este medio. Yo reconozco el alcance de mi autorización de divulgación de los
expedientes e información denotados en los párrafos A, B, C, D y E al escribir mis iniciales en la(s) casilla(s) apropiada(s) arriba.
________________________________________________________________
_________
FIRMA DEL PACIENTE (Tutor o Representante Autorizado Estatutorialmente, cuando sea requerido)
Fecha
AUTORIZACIÓN PARA DIVULGACIÓN DE NOTAS DE PROGRESO DE PSICOTERAPIA O ABUSO DE SUSTANCIAS
Yo,
autorizo a
(Nombre, organización o designación general del programa realizando la divulgación)
a divulgar a
(Nombre de persona(s) u organización(es) y dirección a la cual se realizará la divulgación)
Propósito de la divulgación autorizada por este medio:
DC4-711B (Español) (Revisado 3/17/10)
Incorporado por Referencia en Reglamento 33-601.901, F.A.C.
DEPARTAMENTO CORRECCIONAL DE LA FLORIDA
CONSENTIMIENTO Y AUTORIZACIÓN PARA EL USO E INSPECCIÓN DE DIVULGACIÓN
Y LA DIFUSIÓN DE INFORMACIÓN CONFIDENCIAL
El suscrito, por este medio autoriza la inspección y divulgación de copias de mis notas de progreso de psicoterapia y/o mis notas de
progreso de abuso de sustancias indicados abajo por el centro de salud /custodio de expedientes médicos mencionado anteriormente
solamente a la(s) entidad(es) o personas o a sus agentes mencionados anteriormente. Indique todos los expedientes autorizados a ser
inspeccionados/divulgados, escribiendo sus iniciales en la(s) casilla(s) apropiada(s) a continuación:
COLOQUE SUS INICIALES
ABAJO PARA LA
DIVULAGACIÓN DE
INFORMACIÓN
A.
Divulgar notas de progreso de psicoterapia (escriba sus iniciales en la casilla):
B.
Divulgar notas de progreso de abuso de sustancias (escriba sus iniciales en la casilla):
Nombre de la información -- fechas de tratamiento/ programas, etc., si es posible
Yo entiendo que puedo rehusarme a firmar esta autorización y me rehúso a firmar no afectará mi acceso a tratamientos de cuidado de
la salud, elegibilidad para beneficios o inscripción, o pago por o la cobertura de servicios. También entiendo que una vez que mi
información de salud protegida sea divulgada conforme a esta autorización, puede ser utilizada y/o redivulgada por el que la reciba a
menos que el que la reciba esté cubierto por ley que prohíba o limite su utilización y/o divulgación.
Yo entiendo que puedo revocar este permiso y autorización en cualquier momento, con tal que la revocación sea por escrito,
exceptuando hasta el punto de acción que haya sido tomada basada en ello, y que en todo caso, este permiso y autorización estarán en
vigencia por 90 días a menos que yo especifique un vencimiento diferente en el siguiente espacio:
______________________________________________________________________________________________________________
((Especificación de la fecha, evento o condición bajo la cual vence este permiso si es menos de seis meses o más de 90 días)
En promoción de esta autorización, yo (nosotros) por este medio renuncio a todas las disposiciones de leyes y privilegios que se
relacionen con las divulgaciones autorizadas por este medio. Yo reconozco el alcance de mi autorización de divulgación de los
expedientes e información denotados en los párrafos A y B al escribir mis iniciales en la(s) casilla(s) apropiada(s) arriba.
_________________________________________________________________
_________
FIRMA DEL PACIENTE (o Pariente Cercano, Tutor o Representante Autorizado, cuando sea requerido)
Fecha
------------------------------------------------------------------------------------------------------------------------------------------------------COMPLETE NOTARY PORTION ONLY WHEN REQUEST IS NOT FROM CURRENT INMATE/OFFENDER PERSONALLY KNOWN
TO WITNESS OR IS FROM SOURCE EXTERNAL TO DEPARTMENT
STATE OF
COUNTY OF
_____________________________
Sworn to (or affirmed) and subscribed before me this day of
by ____________________________________________________
________________________as identification.
________________________________________________________
Notary Public Signature
Print, type, or stamp commissioned name of Notary Public
My Commission Expires:
who
is
personally
, 20_____,
known to me
or
who
has
SEAL
ACUSO DE RECIBO DE COPIA DE LA(S) AUTORIZACIÓN(ES) FIRMADA(S)
Nombre del Recluso/Infractor
DC#
R/S
Fecha de Nacimiento
Nombre del Testigo ____________________________________
Firma del Testigo _________________________________
Fecha:________________________________
SS#
Institución/Oficina
DC4-711B (Español) (Revisado 3/17/10)
Incorporado por Referencia en Reglamento 33-601.901, F.A.C.
produced