WorkSafeBC Section III
Request for Qualifications #011-2014Response Requirements
February 2014Physiotherapy Services
SECTION III. – RESPONSE REQUIREMENTS
It is important that Respondents provide complete information with their submission so they can be readily understood and evaluated. The following minimum information and format should be provided in your submission as it will be an important consideration and it may be rejected without further notice. Supplemental information may be included as an attachment to your submission.
NOTE: This Response Requirements section has been designed to facilitate an efficient response process, particularly for those respondents proposing more than one (1) service location.
Where only one (1) service location is proposed, one (1) response is required to both Part A and Part B below.
Where more than one (1) service location is proposed, one (1) response is required to Part A and one (1) response for each individual service locations proposed is required for Part B.
1.0RESPONSE FORMAT
1.1SEQUENCE:Provide response in the same sequence of topics as below.
1.2NO. OF COPIES:Remit one (1) hard copy and one (1) electronic version[MG1] of
your submission (per Instruction to Respondents 6.2).
1.3BINDING:The hard copy of your response should be bound[MG2]or submitted in a 3-ring binder containing 8½” x 11” papers.
1.4SECTION FORMAT:Title, number, appropriately index and tab each section[MG3]. Content detail of each section should be organized in the sequence stated below.
1.5PAGE NUMBERS:Number each page in sequence.
1.6BROCHURES:Include any standard brochure and company information atthe back of your response. For e-bid responses, you will be required to mail brochures in separately.
2.0SECTION REQUIREMENTS
2.1TITLE PAGE
Should include identification of the following:
Identify the Request for Qualifications # and description of Services requested.
Identify your company name, address, telephone & fax number and email address.
State the name(s) of the company representative(s) responsible for your response.
Date of your response submission.
2.2TABLE OF CONTENTS
List of all topics and associated page numbers.
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WorkSafeBC Section III
Request for Qualifications #011-2014Response Requirements
February 2014Physiotherapy Services
PART A – CORPORATE PROFILERESPOND ONCE TO EACH REQUIREMENT IN THIS SECTION
3.0CORPORATE INFORMATION:
Contact Name and Title[MG4]:
Legal and/or Business name of your company[MG5]:
Other Business Names under which your company operates (if applicable[MG6]):
Affiliated Association/Firms (if applicable[MG7]):
State the name and title of the representative(s) authorized to execute contracts on behalf of the company[MG8]:
3.1Corporate Address Information:
Street Address:
City: / Province: / Country: / Postal Code:
Telephone: / ( ) / Cell Phone: / ( )
Fax: / ( ) / Email:
3.2Is the corporate address also serving as a proposed servicelocation[MG9]? / Yes No
3.3Indicate how long your company has been in operation[MG10]. / # years: ______
3.4PRIOR TO AND AS A CONDITION OF CONTRACT AWARD:
3.4.1WorkSafeBC Assessment Registration[MG11]:
If under the Workers Compensation Act you are required to be registered with WorkSafeBC (this will include all employers), as a condition of contract award you must be registered and in good standing.
If you are already registered and you know your account number, please provide it here.
If yes, provide your WorkSafeBC Account Registration number(s) and include a copy of the Clearance Letter from WorkSafeBC[MG12].
If no:
To determine your eligibility and for registration information to select ‘Register for Coverage’ or if you have any questions, please contact Employer Service Centre toll free 1 (888) 922-2768.
NEW:Please note that you are not required to purchase Personal Optional Protection (POP). / Yes No
Assessment Registration[MG13]
#______
OR[MG14]
If registration is not required under the Workers Compensation Act but you are eligible to purchase Personal Optional Protection (POP) under the Act and your business is awarded a contract by WorkSafeBC, you will be required to purchase POP as a condition of contract award.
Do you agree to purchase POP prior to and as a condition of Contract award?
OR
Where you are not required to register, nor eligible to purchase POP (are exempt from registration), WorkSafeBC will issue a letter to that effect.
If applicable, have you included a copy of the letter from WorkSafeBC?
A copy will be required prior to any contract award. / Yes No N/A
Yes No N/A
3.4.2General Comprehensive Liability Insurance:State[MG15] if your organization is or will be in compliance with the GCL insurance requirements in the minimum amount of $2 million dollars that covers each of the service locations proposed. / Yes No
3.4.3Professional Liability Insurance: State if your organization is or will be in compliance with the professional liability insurance requirements in the minimum amount of $1 million dollars that covers all personnel proposed to deliver the Services. / Yes No
3.4.4Business License: State[MG16] if your company has or will have a current business license for each of the service locations proposed.
If no, state if this is because a business license is not a requirement by your municipalities’ bylaws. / Yes No
Yes No
3.5MANDATORY BUSINESS QUALIFICATIONS:
Indicate ‘Yes’ or ‘No’ to whether your company meets the following mandatory requirements:
3.5.1Absence of Conflict of Interest[MG17]: The proposed service location(s) must not possess a conflict of interest with the provision of the Services to WorkSafeBC.
Are there any potential areas of conflict of interest that may exist with the provision of these Services to WorkSafeBC?
If there is a potential conflict, provide a description and nature of such, as an attachment to your submission.
WorkSafeBC reserves the right to reject submissions from Respondents who in the opinion of WorkSafeBC are in conflict in relation to the services provided in this RFQ.
For additional information on this please refer to:
/ Yes No
If Yes:
Have you included this
information with your
submission?
Yes No
3.5.2Protection of Information and Personal Privacy:
The proposed service location(s) must currently possess an established system for the storage, access and disclosure of personal information obtained from WorkSafeBC that is compliant with the Freedom of Information and Privacy Act R.S.B.C. 1996c.165 (FIPPA) and if successful, the Contractor agrees to a contract that includes Attachment 1 – Confidentiality Agreement Form and Schedule C[MG18] – Privacy Protection in Appendix A - Sample Contract.
Additional information regarding FIPPA may be obtained through the WorkSafeBC website by accessing "Health Care Providers" under Customer Centres, then choose the quick link for "Freedom of Information and Protection of Privacy”.
3.5.2.1 For each service location you are proposing, state if you currently possess an established system for the storage, access and disclosure of personal information obtained from WorkSafeBC that is compliant with the Freedom of Information and Privacy Act R.S.B.C 1996c.165 (FIPPA).
3.5.2.2State if you will agree to a contract that includes Attachment 1 – Confidentiality Agreement Form and Schedule C – Privacy Protection in the sample contract, if successful. / Yes No
Yes No
Yes No
3.6PROTECTION OF INFORMATION AND PERSONAL PRIVACY:
3.6.1Protection of Information and Personal Privacy:The[MG19] Freedom of Information and Protection of Privacy Act (FIPPA) requires that WorkSafeBC, and any Service Provider to it, to ensure personal information in its custody or under its control is stored or accessed only in Canada except in limited circumstances. Further information is available regarding this requirement at:.
Additional information regarding FIPPA may be obtained through the WorkSafeBC website by accessing "Health Care Providers" under “Customer Centres,” then choosing the quick link for "Freedom of Information and Protection of Privacy".
Submit the following information as[MG20] an attachment to your submission:
3.6.2a)State if your company is a subsidiary and/or has any affiliation of any type with any entity outside of Canada[MG21].
b)If ‘yes’, state their names and relationships. / a) Yes No
b)Have you included this information with your submission?
3.6.3State the legal status of the business. E.g. Sole proprietor, partnership or limited company.
3.6.3.1If the business is a partnership, state the countries where the partners reside;
3.6.3.2If the business is a limited company, state the countries where the directors reside. / 3.6.3 Legal status[MG22]:
______
3.6.3.1 & 3.6.3.2:
Have you included this information with your submission?
Yes No
3.6.4a)State if your company is wholly owned by a Canadian entity.
b)If ‘no’, state the nature of the foreign ownership[MG23]. / a) Yes No
b)Have you included this information with your submission?
3.6.5a)State if your company is controlled and operated by a Canadian entity.
b)If ‘no’, state the nature of the foreign control and operations[MG24]. / a) Yes No
b)Have you included this information with your submission?
3.6.6Provide a description of current employee procedures and rules relating to disclosure, access and control of personal information (e.g. levels of access, circumstances, frequency, and familiarity with FIPPA, security clearance requirements[MG25]). / Have you included this information with your submission?
Yes No
3.6.7Provide a description of an existing operational privacy plan in the event of a security or privacy breach relating to personal information (e.g. email breach, home invasion, theft[MG26]). / Have you included this information with your submission?
Yes No
3.6.8Subcontracting[MG27]: If you propose to subcontract any portion or all of the work under the contract, in the event you are awarded a contract, state where and to whom you intend to subcontract with, and answer 3.6.1 to 3.6.7 in relation to the proposed subcontractor. / Have you included this information with your submission?
Yes No
Note:Questions 3.6.1 to 3.6.7 must be completed whether you are subcontracting or not.
3.7CONTRACT TERMS AND CONDITIONS:
Terms and Conditions: Do you agree to execute a contract containing all the terms and conditions as stated in Appendix A, Sample Contract: Physiotherapy Services[MG28]?
If no, describe the stated exception(s) and applicable clause number.
WorkSafeBC reserves the right to determine the materiality of any stated exception to the contract terms and conditions. The Respondent’s willingness to agree to the general terms and conditions is an evaluation criterion upon which the Provider may be evaluated. / Yes No
If No:
Have you included this
information with your
submission?
Yes No
PART B – SERVICE LOCATION & QUALIFICATIONS
COMPLETE ONE (1) PART B FOR EACH
SERVICE LOCATION PROPOSED[MG29]
4.0LOCATION OF EXISTING AND OPERATIONAL SERVICE LOCATION (CLINIC / FACILITY):
StreetAddress[MG30]:
City: / Province: / Postal Code:
Telephone: / ( ) / Cell Phone: / ( )
Fax: / ( ) / Email:
Contact Name and Title:
4.1 State the number of years thisClinic has been in operation[MG31]. / # of Years:______
4.2Do you currently deliver any WorkSafeBC servicesfrom this Service Location? If so, please list the program name(s) as an attachment to this submission[MG32]. / Is this information included with your submission?
Yes No
5.0PROTECTION OF INFORMATION AND PERSONAL PRIVACY (site specific[MG33]):
5.1For this Clinic, state the location* where personal information (both hard and soft copies) is currently stored, by whom and who would have access to this information. / Have you included this information with your submission[MG34]?
Yes No
5.2For this Clinic, state the location* and how you propose to store and access personal information (both hard and soft copies) you obtain from WorkSafeBC and the Injured Worker, in the event you are awarded a contract[MG35]. / Have you included this information with your submission?
Yes No
5.3For this Clinic, state who provides systems & equipment maintenance and data recovery services for your data systems and state their location*. If it is not an employee, answer 5.1 to 5.2 in relation to the proposed subcontractor[MG36]. / Have you included this information with your submission?
Yes No
* ‘Location’ means the exact physical location including an address.
NOTE: Questions 5.1 to 5.3 must be completed whether you are subcontracting or not[MG37].
6.0MANDATORY SERVICE LOCATION QUALIFICATION REQUIREMENTS:
Indicate ‘Yes’ or ‘No’ to whether thisClinic/Service Location meets the following mandatory requirements:
6.1Successful Contractorsmust invoice WorkSafeBC electronically through the Medical Services Plan (MSP) Teleplan system.
State youractive MSP billing number. / MSP Billing No[MG38]#:
______
6.2Absence of Conflict of Interest: The[MG39] proposed Clinic(s) must not possess a conflict of interest with the provision of the Services to WorkSafeBC.
State that there are nopotential areas of conflict of interest that may exist with the provision of these Services to WorkSafeBC.
If there is a conflict, provide a description and nature of such, as an attachment to your submission.
WorkSafeBC reserves the right to reject submissions from Respondents who in the opinion of WorkSafeBC are in conflict in relation to the services provided in this RFQ. / Yes No
If No, have you included this information with your submission?
Yes No
6.3Protection of Information and Personal Privacy[MG40]: The proposed Clinic(s) must currently possess an established system for the storage, access and disclosure of personal information obtained from WorkSafeBC that is compliant with the Freedom of Information and Privacy Act R.S.B.C. 1996c.165 (FIPPA) and if successful, the Contractor agrees to a contract that includes Attachment 1 – Confidentiality Agreement Form and ScheduleC – Privacy Protection in Appendix A - Sample Contract.
Additional information regarding FIPPA may be obtained through the WorkSafeBC website by accessing "Health Care Providers" under Customer Centres, then choose the quick link for "Freedom of Information and Protection of Privacy”.
6.3.1 For each Clinic you are proposing, state if you currently possess an established system for the storage, access and disclosure of personal information obtained from WorkSafeBC that is compliant with the Freedom of Information and Privacy Act R.S.B.C 1996c.165 (FIPPA).
6.3.2State if you will agree to a contract that includes Attachment 1 – Confidentiality Agreement Form and Schedule C – Privacy Protection in the sample contract, if successful. / Yes No
Yes No
7.0MANDATORY PHYSICAL THERAPIST QUALIFICATION REQUIREMENTS:
Indicate ‘Yes’ or ‘No’ to whether you possess the following mandatory Physical Therapist qualifications at this Clinic/Service Location:
7.1Do you possess a minimum of one (1) Physical Therapist that is a full (not interim or student) registrant and in good standing with the College of Physical Therapists of British Columbia[MG41]? / Yes No
Name:
CPTBC Registration Number[MG42]:
7.2Are there any current restrictions or limitations on the practice for the Physical Therapist named above? / Yes No
7.3If yes, please state the restrictions or limitations and the expected end date:
8.0ADDITIONAL PERSONNEL REQUIRMENTS:
8.1Identify a designated key contact person who is responsible for the day-to-day delivery of services (e.g. clinic manager[MG43]).
Name:
8.2Name(s) of other additional proposed Registered Physical Therapist and their College of Physical Therapists of British Columbia registration number, if applicable[MG44]:
If insufficient space, please attach additional pages with your response.
NAME: / Registration Number #::
(1)
(2)
(3)
(4)
9.0SUBMISSION OF INFORMATION:
State if the information contained in your submission is accurate and true to the best of your knowledge[MG45]. / Yes No
Authorization of Information
I/We wish to present this submission as a potential qualified Provider of Physiotherapy Services for WorkSafeBC Injured Workers and certify that the information contained in this document is accurate and true to the best of our knowledge.
Respondent’s and/or Business Name:Authorized Signature: / Title:
Print Name: / Date:
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[MG1]
- Hard copy is a printed copy of your response
- Electronic copy is a copy saved onto a CD or DVD or USB flash drive
[MG2]WorkSafeBC requires the RFQ response to be in a format that is easy to read. Bound & 3-ring binder is not a requirement.
[MG3]WorkSafeBC requires the RFQ response to be in a format that ensures we are able to review your response fully. (Tabs assist in the review of your RFQ response and ensure information is not overlooked)
[MG4]Enter the name of the person who is the main contact for your company.
[MG5]Enter the name of the legal entity of your company/clinic.
[MG6]If applicable, enter the DBA (doing business as) name. Otherwise, leave blank.
[MG7]If applicable, enter the name of any associated company (this assists in WorkSafeBC understanding your organizational structure).
Otherwise, leave blank.
[MG8]Enter the name of the person(s) that will be signing the contract for your business.
[MG9]Check “yes” if this address is the same address for your service location and you are proposing only 1 service location.
[MG10]Enter the # years under the current ownership.
[MG11]This is not a new requirement – if you are required to be registered this assists WorkSafeBC in confirming that this requirement is met.
[MG12]A clearance letter is not required at this time.
[MG13]This is your WorkSafeBC account/payroll # .
If you don’t know it, leave blank.
[MG14]IGNORE this box
[MG15]For 3.4.2 & 3.4.3:
- Check your insurance with the Canadian Physiotherapy Association (where applicable) as it may be covered
- If you do not have general comprehensive or professional liability insurance and/or in the minimal amount, you may indicate this in the “no” checkbox. You will still be eligible to be considered for a contract.
- You do not need to provide a copy of your insurance with your submission.
- However, if you are notified by WorkSafeBC that you will be awarded a contract then you must provide proof that you meet the insurance requirements.
[MG16]
- Indicate if you have a business license where it is required by the municipality where your business is or not.
- You do not need to provide a copy of your business license with your submission.
[MG17]
- If there is no potential areas of conflict, then check the “NO” box.
- If there is any potential conflict of interest, then check the “YES” box, and attach a brief description to your submission.
[MG18] Please note that this is for reference only.
You are not required to sign & return at this time.
[MG19]
- WorkSafeBC needs you to confirm that you have policies and procedures to ensure you are complying with FIPPA regulations.
- For instance, what happens if you discover there is a breach of privacy with a worker’s medical records?
[MG20]Copies of documentation e.g. incorporation papers, is not required. You are only required to provide the specific information requested e.g. names, relationships, countries, etc asked in the following section.
[MG21]This helps with the FIPPA risk assessment.
[MG22]Sole proprietor, partnership or limited company.
[MG23]Provide a brief description of ownership structure.
[MG24]Provide a brief description of how operational directions are provided & implemented.
[MG25]Provide information about your privacy policy as an attachment.
{the FIPPA website can be used for reference:
[MG26]provide information about your privacy plan in the event personal information is inadvertently disclosed.
{the following link can be used for reference:
and includes a sample breach checklist}
[MG27]Subcontracting refers to anyone who is not an employee and has access to personal information.
If you subcontract (e.g. contractors or computer support) WorkSafeBC needs to understand the potential risks of your subcontracting (i.e. that your subcontractors too have the appropriate policies and procedures in place).