Practice Management and EDI Claims Clearinghouse

VENDOR FORM - Attachment B - M/WBE Participation Report: Vendor must download this form, complete it, and upload completed and signed form under "Response Attachments" tab. IMPORTANT: M/WBE documents are a part of Proposer’s evaluation. This documentation is required for your proposal to be evaluated by the district. HISD will determine whether the Proposer’s efforts meet the minimum standards of “Good Faith Effort” consistent with the district’s policy on the participation of M/WBEs. Failure to provide the required M/WBE documentation will be considered non-compliant. If a company is deemed non-compliant, it can lead to disqualification from the provision of goods and services to the district for current and/or future projects.

VENDOR FORM - Certificate of Liability Insurance (ACORD Form) and Insurance Verification Form: All prospective vendors must provide both a Certificate of Liability Insurance (ACORD form) and an Insurance Verification Form signed by the insurance agent/broker. The sample ACORD form provided herein displays the types of coverage and limits required of all vendors by the HISD Risk Management department. Both forms must be uploaded under "Response Attachments" Tab.

VENDOR FORM - IRS Form W-9 (Rev. 3-2024): Vendor must download this form, complete it, and upload the completed and signed form under the "Response Attachments" tab. Vendors must ensure that the Legal Name and the Taxpayer Identification Number (TIN) entered on this form matches exactly with the information referenced in their IRS income tax return.

VENDOR FORM - Conflict of Interest Questionnaire (Form CIQ): Vendors must download this form, complete it, and upload completed and signed form under the "Response Attachments" tab. If the prospective vendor doesn't have any conflict of interest to disclose, then enter your individual or company name on line 1, enter "Not Applicable" or "N/A" on line 3, and then sign and date on line 7.

VENDOR FORM - HISD Fingerprint Appointment Registration: All vendors who may or will have direct contact with students and continuing duties in connection with this contract must be fingerprinted as indicated in the Solicitation. Vendors should provide a copy of this form to their employees and/or subcontractor employees so that they may schedule an appointment to be fingerprinted. All employees/subcontractor requiring to be fingerprinted should not perform services in connection with this contract until HISD has reviewed their criminal history background and cleared them to perform services.