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Office of Procurement Services GOODS AND SERVICES SOLE SOURCE FORM This form is to be used when an agency believes an acquisition is a sole source and the acquisition dollar amount is above $5,000. The Chief Procurement Officer can approve purchases up to $100,000. Board of Supervisors approval is required if the acquisition is over $100,000. This form must be submitted for approval to: Office of Procurement Services I 320 W. Lincoln I Phoenix, AZ 85003. Fax number: 602,258.1573. The signed form must be retained in the purchasing file, DEPARTMENT NAME DEPARTMENT RX# 1Public Health Department Contact Contact Phone Number Machrina Leach +1(602) 506-6662 PROPOSED CONTRACT VENDOR NEED IDENTIFIED Date; January 1,2014 Company: The Arizona Partnership for Immunizations REQUESTED DRIVERY January 1,2014 : Address: 700 E erson Street, Suite 100 Date: : City, State: Phoenix, Arizona QUOTED PRICE: 400,000 1Zip/Postal Code: 85034 1 Phone: Office 755-432-1128 Cell 480- 80-3 84 Accounting String: 265 863 8612 CHIM 0000 0638 00 Fax: 602-262-2654 Contact Nam Jennifer Tinney Material / Service Information Is this a Technology Procurement? (-1 Yes (ii': No Continue to coordinate and provide public health clinics with billing services. This allows Maricopa County to be reimbursed for vaccines administered to clients with Needs Statement: current health insurance. They coordinate with both commercial and the Arizona Describe in detail the material or service to be procured and Health Cost Containment System (AHCCCS) plans reimbursement rates. They assure how only it meets your needs. timely billing and follow-up on all claims. TAPI currently has over 400 private and public partners state wide. They have a direct Features/Requirements: partnership with the Arizona Department of Health Services which houses the official Identify the major features/capabilities that are required. What Arizona State Immunization Registry. They also have partnerships with the commeraa unique design/performance feature(s) make this material or health plans in Arizona that covers the majority of lives, TAPI has the sole contracts vendor the only one that can meet your requirements? Provide with the majority of commercial and all AHCCCS health plans. TAPI currently provides a brief explanation as to why only these features or this vendor billing services for most Arizona County Health Departments. They have been can meet your requirements. Identify the manufacturer/model successfully billing for immunization services for Maricopa County for the last 5 years. or your existing equipment, service or system if applicable. TAPI is the only non-profit of its kind in the State of Arizona. TAPI currently has direct partnerships with the Arizona Department of Health Services, AHCCCS health plans, Competing Brands/Vendors Investigated: commercial health plans and medical providers. Billing for local county health Did you consider other materials or vendors with similar departments is unique compared to health care institutions. TAPI has created the capabilities? Indicate specific competitor's brands/models or contracts and processes that allow us to e successfully reimbursed for immunization vendors that were investigated and describe why they do not services, et your requirements. You need to state that - to the best of your knowledge- these are the only companies making this material, equipment or providing this service, list sales representatives and their phone numbers so the Procurement Officer can contact them to verify that other materials, equipment or services do not meet your requirements. THIS PROCURMENT IS A SOLE SOURCE BECAUSE (attach additional page if needed): TAP! has been successfully biting for Maricopa County Department of Public Health for 5 years. They have established policies and procedures that assure timely reimbursement. They are a non-profit organization that has relationships and partnerships with the immunization community in Arizona They only receive a percentage of total reimbursements for immunization services and only take a percentage of the vaccine cost that is above our cost. There is no other non-profit organization that has the extensive partnerships in Arizona or the contracts in place to assure the timely reimbursement of immunization services. Continuing to utilize TAPI for the billing of immunization services would assure that revenue would continue to be received and Maricopa County would be able to continue to provide immunizations to clients with health insurance, SEARCH MC1-349-A states: Any request by a Using Agency that a Procurement be restricted to one potential Contractor shall be accompanied by an explanation as to why no other would be suitable or acceptable to meet the need. The Using Agency requesting sole source Procurement shall provide written evidence to support a sole source determination. A requirement for a particular proprietary item does not alone justify a sole source Procurement if there is more than one potential Respondent for that itern, A search was conducted consisting of: (check all that apply) RESULTS Market research E Public notice given, list no alternatives were identified 0 Other vendors contacted E Other no alternatives were deemed acceptable because (explain below): I Describe the search from above in detail: PRICE The estimated cost of this Procurement is: !0 , __ $ l ook (.> $lOOk MC1-347 States: The Chief Procurement Officer may make the determination that the sole source method set forth in MC1-349 shall be used if a Commodity or Service is available from only one vendor, and the purchase is estimated to Cost no more than $100,000. , Price has been fairly and reasonably established by: E] Comparison to public sector contract pricing ni Comparison to previous comparable purchases E Discount off published catalog pricing 1---J from a different vendor E Market survey fl Independent estimate [I] Other, explain: Describe methodology and results (attach any written supporting data, e.g., survey or market analysis): CONFLICT OF INTEREST STATEMENT The submitting department agrees that there is no real or potential conflict of interest in recommending this mat erial or service as a sole source procurement, NOTE: If a real or potential conflict exists, contact the Procurement Officer listed on your Requisition. CERTIFICATIONS I certify: 1) I recognize that the Maricopa County Procurement Code requires the use of competitive solicitations unless exempted by law. 1 have reviewed the information and materials relevant to this procurement of goods and services, and am requesting approval of an exception to the competitive process for the reasons described; 2) the price to be paid to the proposed sole source vendor is fair, reasonable, and provides the best value to Maricopa County; and 3) this request for an exception to the competitive solicitation process is not the result of inadequate advance planning or for purposes of securing the services of a preferred vendor, Agency Head or Appointing Authority Signature (Required) Max Porter • A..- .00 , ),- / 27/ i 1) ii. Printed Name ignatre Date Office of Procurement Services 'Approved. Please send a Requisition to OPS to process. E Not Approved, Reasoning: Printed L3E-5\tinL NamL) . Rtn Sianature