AMR v. San Bernardino County Lawsuit

Case 5:24-cv-00267 Document 1 Filed 02/02/24 Page 1 of 27 Page ID #:1
1 Stephen G. Larson (SBN 145225)

[email protected]
2 Jonathan E. Phillips (SBN 233965)
[email protected]
3
Mehrunisa Ranjha (SBN 318399)
4 [email protected]
Benjamin Falstein (SBN 342867)
5 [email protected]
LARSON LLP
6 555 South Flower Street, 30th Floor
Los Angeles, California 90071
7
Telephone: (213) 436-4888
8 Facsimile: (213) 623-2000
9 Attorneys for Petitioner and Plaintiff

10 UNITED STATES DISTRICT COURT
11 CENTRAL DISTRICT OF CALIFORNIA, EASTERN DIVISION
12
13 AMERICAN MEDICAL RESPONSE OF Case No. 5:24-CV-00267

INLAND EMPIRE, a California corporation,
14
15 Petitioner and Plaintiff,

VERIFIED COMPLAINT AND PETITION
FOR:
16 vs.
(1) Violation of Sherman Antitrust Act (15
17 COUNTY OF SAN BERNARDINO, a U.S.C. § 1);
California municipal corporation; COUNTY
18 (2) Writ of Mandamus (CCP §§ 1085,
OF SAN BERNARDINO BOARD OF
1094.5);
19 SUPERVISORS, an elected body; INLAND
COUNTIES EMERGENCY MEDICAL (3) Declaratory Relief – Proposition 26
20 AGENCY, a local emergency medical services (CCP § 1060)
agency; CONSOLIDATED FIRE
21 AGENCIES, a Joint Powers Authority; and
22 DOES 1-10,
23 Defendants and Respondents.
24
25 CONSOLIDATE FIRE AGENCIES, a Joint

Powers Authority,
26
Real Party in Interest.
27
28
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VERIFIED COMPLAINT AND PETITION FOR WRIT OF MANDATE
1 Petitioner and Plaintiff American Medical Response of Inland Empire (“AMR”) alleges as
2 follows:
3 INTRODUCTION
4 1. For over 40 years, AMR has contracted with Defendants and Respondents Inland
5 Counties Emergency Medical Agency (“ICEMA”) and County of San Bernardino (the “County”)
6 as the exclusive “grandfathered” ambulance provider to the County and its residents. In December
7 2022, ICEMA and the County departed from this practice and for the first time published a state-
8 approved Request for Proposals (“RFP”) for the purpose of selecting the ambulance provider for
9 the next exclusive five-year contract with the County.

10 2. Two providers submitted proposals in response to the RFP: AMR and Defendant
11 and Real Party in Interest Consolidated Fire Agencies (“CONFIRE”). The requirements set forth
12 in the RFP were strict. Among other things, the County was required to award the exclusive
13 contract to the bidder with the highest scoring proposal. Moreover, any provider whose proposal
14 failed to meet the minimum qualifications specified in the RFP could not be considered at all.
15 3. These strict requirements in the RFP were not implemented by accident—they were
16 designed to ensure a competitive process for the selection of an exclusive ambulance provider, as
17 required by state law. Strict adherence to this state-approved process is the only basis upon which
18 the County can maintain immunity from federal antitrust liability. Yet, based on the process
19 actually employed by the County, it is clear the County was willing to disregard this mandatory
20 process in order to award the contract to its pre-ordained preferred provider—CONFIRE—
21 regardless of whether it had submitted the best bid. In other words, the process actually employed
22 by the County was not truly competitive at all.
23 4. The independent, non-biased review committee administering the RFP process

24 gave AMR’s proposal a higher score than CONFIRE’s proposal based on scoring criteria set forth
25 in the RFP.
26 5. Despite AMR’s status as the winning bidder, the County notified AMR and
27 CONFIRE that draft contracts from both bidders would be presented to Defendant and Respondent
28 County of San Bernardino Board of Supervisors (the “Board of Supervisors”) for consideration
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1 and ultimate award. Thereafter, at its December 5, 2023 regular meeting, the Board of Supervisors
2 voted to award the contract to the losing bidder, CONFIRE. By negotiating with and ultimately
3 awarding the contract to an ambulance services provider with an inferior bid, the County and its
4 Board of Supervisors acted contrary to the RFP and state law—and, consequently, outside the
5 narrow confines of their antitrust immunity.
6 6. In fact, CONFIRE’s proposal should not have been considered to begin with, as it
7 failed to fulfill basic minimum requirements mandated by the RFP. Nevertheless, the County and
8 Board of Supervisors deliberately disregarded the glaring deficiencies in CONFIRE’s proposal
9 when they allowed it to move forward in the process and ultimately decided to award CONFIRE
10 the next exclusive ambulance services contract.
11 7. As demonstrated by the outright failure to adhere to the mandatory requirements of

12 the state-approved RFP, the County, the Board of Supervisors, and ICEMA clearly never intended
13 for the selection process to be competitive at all. Instead, the decision to award CONFIRE the
14 exclusive ambulance services contract appears to have been carried out for the sole purpose of
15 exploiting additional sources of revenue for which only CONFIRE would be eligible and that
16 would ultimately benefit the County.
17 8. As a result of Defendants’ anti-competitive conduct, AMR will be forced to cease

18 ambulance services it has heretofore diligently provided in the County since the 1970s, thereby
19 jeopardizing the livelihoods of AMR’s employees and the safety of the County’s residents.
20 PARTIES
21 9. AMR is, and at all relevant times was, a corporation formed under the laws of the
22 State of California and doing business in California.
23 10. The County is, and at all relevant times was, a general-law county and political
24 subdivision of the State of California.
25 11. The Board of Supervisors is, and at all relevant times was, the local elected body
26 governing the County.
27 12. Defendant and Respondent ICEMA is, and at all relevant times was, the County’s
28 designated Local Emergency Medical Services Agency (“LEMSA”) under California Health and
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1 Safety Code section 1797.200.
2 13. CONFIRE is, and all relevant times was, a Joint Powers Authority authorized under
3 the laws of California, Government Code section 6500 et seq. CONFIRE primarily provides
4 emergency communications and dispatch services to its members, which consist of thirteen public
5 fire agencies, all located within the County. CONFIRE is named as a real party in interest for the
6 Second Cause of Action alleged herein because it is the recipient of the contract for ambulance
7 services described within to which it may claim an interest. CONFIRE is named as a Defendant
8 only as to the Third Cause of Action.
9 14. AMR is ignorant of the true names and capacities of Defendants and Respondents
10 sued herein as Does 1-10 (“DOES 1-10”), inclusive, and therefore sues these Defendants and
11 Respondents by fictitious names. AMR is informed and believes, and therefore alleges, that DOES
12 1 through 10 are in some manner responsible for the acts and occurrences set forth herein and are
13 legally liable to AMR. AMR will seek leave to amend this Complaint and Petition to allege the
14 true names and capacities of these fictitiously named Defendants and Respondents, together with
15 the appropriate allegations, when ascertained.
16 JURISDICTION AND VENUE

17 15. This case arises under 15 U.S.C. § 1. The Court has jurisdiction over this action
18 pursuant to 28 U.S.C. § 1331. The Court has supplemental jurisdiction over the state law claims
19 pursuant to 28 U.S.C. § 1367.
20 16. Venue in the United States District Court for the Central District of California is
21 proper pursuant to 28 U.S.C. § 1391.
22 FACTUAL ALLEGATIONS
23 17. AMR is an experienced ambulance provider that has faithfully served the County
24 and its citizens since the 1970s, with a focus on delivering the highest quality, cost-effective
25 patient care as the centerpiece of its business model. As testament to its exceptional service, AMR
26 has held an exclusive contract with the County’s designated local emergency medical services
27 authority—ICEMA—as a grandfathered provider of ambulance services under the EMS Act since
28 January 1, 1981. Accordingly, until now, ICEMA had never before utilized a competitive process
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1 for selecting an ambulance provider for the County. AMR’s current contract is set to expire on
2 March 31, 2024.
3 California’s Emergency Medical Services Act and Federal Antitrust Immunity
4 18. Prehospital emergency medical services (“EMS”) in California are governed by the
5 Emergency Medical Services System and Prehospital Emergency Medical Care Personnel Act
6 (1980) (“EMS Act”). The EMS Act is a comprehensive statutory system governing virtually all
7 aspects of EMS, including the provision of ambulance services in situations when individuals need
8 immediate medical care. Health & Safety Code § 1797 et seq.
9 19. The EMS Act established a two-tiered system for EMS regulation. At the state
10 level, the Emergency Medical Services Authority (“EMSA”) oversees and regulates the
11 coordination of state activities involving EMS. Health & Safety Code, §§ 1797.1, 1797.100,
12 1797.107. At the local level, a LEMSA administers the local EMS program and oversees the
13 delivery of EMS within a specified geographic area. Id., §§ 1797.94, 1797.200.
14 20. LEMSAs are responsible for planning, evaluating, and implementing an “EMS
15 system,” which the EMS Act defines as an organized system for provision of personnel, facilities,
16 and equipment—like emergency medical technicians, paramedics, and ambulances—for effective
17 delivery of EMS. See Health & Safety Code, §§ 1797.78, 1797.94, 1797.204.
18 21. For a county to develop an EMS program, it must “designate” a LEMSA. Id., §
19 1797.200. The EMS Act recognizes LEMSAs as agencies distinct from their counties. Id., §§
20 1797.94, 1797.200. As the Act provides, a LEMSA—not the county—is “the agency, department,
21 or office having primary responsibility for administration of emergency medical services in a
22 county.” Id., § 1797.94. Counties and LEMSAs accordingly may not share statutory powers and
23 duties under the EMS Act.
24 22. A LEMSA must also maintain “medical control” of the EMS system and formulate
25 policies and procedures in accordance with the medical standards imposed by EMSA. Health &
26 Safety Code, §§ 1797.94, 1797.202; 1797.204, 1797.220. As part of this responsibility, a LEMSA
27 must have a medical doctor/physician as its medical director. Health & Safety Code, §§ 1797.90,
28 1797.202, 1798. An EMS system must therefore operate under distinctly medical (rather than
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1 political) management.
2 23. As part of its responsibilities, a LEMSA must develop—and submit to EMSA for
3 approval—an annual EMS plan for delivering EMS consistent with California law. Health &
4 Safety Code, §§ 1797.76, 1797.206, 1797.250, 1797.252, 1797.254.
5 24. A LEMSA may create exclusive operating areas when developing its local EMS
6 plan. Id., § 1797.224. An exclusive operating area (“EOA”) is an area within a LEMSA’s
7 geographic jurisdiction, and defined by the local EMS plan, that the LEMSA has restricted to
8 certain emergency ambulance services or providers of emergency services. Id., §§ 1797.74,
9 1797.85.
10 25. The EMS Act only authorizes LEMSAs to create EOAs; Counties “recommend”
11 EOAs, but are nowhere empowered to create them. Id., §§ 1797.74, 1797.85, 1797.224.
12 26. Fundamental to the establishment of an EOA, the LEMSA must use a “competitive
13 process” when selecting the provider(s) to whom the EOA is restricted. Health & Safety Code, §
14 1797.224. The only exception to this is that no competitive process is required if a LEMSA
15 continues the use of an existing EMS provider that has provided EMS without interruption since
16 on or before January 1, 1981. Id.
17 27. If a LEMSA decides to use a competitive process, it must first submit the
18 contemplated process to EMSA for approval. Id. If a county intends to select an exclusive
19 ambulance services provider, its selection process must conform to the process approved by
20 EMSA. Id.
21 28. The mandatory procedure for selecting an exclusive provider under the EMS Act
22 was expressly created for the purpose of ensuring compliance with federal antitrust laws. This is
23 because exclusive contracts for local public services inherently operate as illegal restraints on
24 trade in violation of the Sherman Antitrust Act.
25 29. However, a narrow exception to antitrust liability exists where anticompetitive

26 conduct at the local level is authorized by a state law establishing a clearly articulated and
27 affirmatively expressed state policy to displace competition. As such, immunity will only attach to
28 the activities of local governmental entities if they are undertaken pursuant to this state policy.
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1 30. California’s clearly articulated and affirmatively expressed policy authorizing local
2 governments to confer exclusivity in the provision of ambulance services is set forth in the EMS
3 Act. That is, through the EMS Act, the legislature announced its intent to “ensure the provision of
4 effective and efficient emergency medical care” by prescribing and exercising “the degree of state
5 direction and supervision over emergency medical services as will provide for state action
6 immunity under federal antitrust laws for activities undertaken by local government entities.”
7 Health & Saf. Code, § 1797.6. Specifically, the legislature, through section 1797.224, has clearly
8 expressed a state policy authorizing localities to create EOAs for emergency services, but only on
9 the condition that such exclusivity agreements be reviewed and approved at the state level by
10 EMSA.
11 The County and ICEMA’s Request for Proposals for Exclusive Ambulance Service Provider
12 31. On December 20, 2022, the County and the County’s designated LEMSA—
13 ICEMA—published the RFP, soliciting written proposals for the provision of ground ambulance
14 transportation services, interfacility transports, and critical care transports for an initial five-year
15 contract. (See Exhibit 1, p. 5). Through the RFP, the County and ICEMA sought to award a
16 contract to an exclusive ambulance provider for the EOA established by ICEMA. (Id., p. 5-6).
17 32. The RFP established the required qualifications for EMS providers, the rules for
18 proposals, the procedures for selecting a winning proposal and awarding the contract, and the
19 procedures for protesting and appealing contract decisions. (See generally Id.). In accordance with
20 Health and Safety Code section 1797.224, the County and ICEMA received approval from EMSA
21 on November 29, 2022 for the RFP.
22 33. The RFP provided for the establishment of an independent, non-biased Proposal
23 Review Committee (the “Review Committee”) appointed by the County. (Id., p. 20). Each
24 member of the Review Committee would evaluate and score the proposals based on specified
25 criteria. (Id.). The scores from all the evaluators would be calculated to arrive at a final score for
26 each proposal. (Id.).
27 34. The specified evaluation criteria consisted of the following categories:
28 organizational experience, key leadership experience, reference letters, financial condition, legal
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1 history, evidence of insurance, and evidence of the provider’s ability to provide a performance
2 bond or irrevocable letter of credit. (Id., p. 92). The relevant factors upon which each of these
3 criteria would be evaluated were detailed throughout the RFP.
4 35. The RFP specifies that the Review Committee would only recommend the highest-
5 scoring bidder for final negotiation of contract terms with the County. (Id., p. 20-21). Negotiations
6 may only commence with the next highest-rated bidder if the County terminates negotiations
7 with the highest-scoring bidder for failure to negotiate. (Id.).
8 36. After the completion of contract negotiations with the highest-scoring bidder, the
9 County would then issue a Notice of Intent to Award, and the winning proposal would then be
10 submitted to the Board of Supervisors for ultimate award of the contract. (Id., p. 21).
11 37. In other words, the RFP explicitly provided that a contract would only be awarded
12 to the bidder with the highest scoring proposal. (Id.).
13 38. However, for a proposal to even be considered at all, each bidder was required to
14 fulfill certain minimum qualifications specified in the RFP, along with supporting documentation
15 of its ability to do so. (Id., p. 24). The RFP is explicit: proposals not meeting the minimum
16 qualifications would be disqualified and would not be evaluated by the Review Committee. (Id.).
17 The Selection Process

18 39. The deadline for submitting proposals in response to the RFP was March 23, 2023.
19 AMR and CONFIRE were the only two providers to submit proposals for consideration.
20 40. While AMR has decades of experience in providing ambulance services throughout
21 the County and beyond, CONFIRE itself is not an ambulance provider but is instead a secondary
22 public safety answering point established to provide dispatch and communication services to the
23 public fire agencies comprising its membership. As the RFP itself indicates, none of CONFIRE’s
24 thirteen member agencies are capable of performing the full range of emergency and non-
25 emergency ambulance services currently performed by AMR, including ambulance transport
26 services as well as advanced life support and basic life support response. (Id., p. 10-13). In
27 addition, none of the thirteen member agencies have ever provided ambulance transport in an
28 EMS system of the size and scope of the County—which is the largest county in the United States
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1 and is larger than the states of New Jersey, Connecticut, Delaware, and Rhode Island combined.
2 As a result of these limitations, CONFIRE and its member agencies lack the resources and
3 capabilities to perform the services contemplated in the RFP. CONFIRE’s proposal indicated that
4 it would be able to fulfill the RFP’s requirements by subcontracting with a private ambulance
5 provider, Priority Ambulance, LLC (“Priority")
6 41. As evidenced by CONFIRE’s proposal, while it would be the primary contracting
7 entity, the vast majority of the funding to support the provision of ambulance services would
8 actually come from Priority. Specifically, of the $63,000,000 in total funding, $57,000,000—over
9 90%—would come from Priority. (Ex. 2, p. 276). Moreover, Priority would be the main provider
10 of the services called for in the RFP. In other words, CONFIRE, a government entity, seeks to
11 partner with a private entity, Priority, as a means of making itself a market participant. Although
12 such an arrangement is technically permitted under the RFP, the subcontractor (Priority) is held to
13 the same minimum qualifications enumerated therein. (Ex. 1, p. 24).
14 42. The Review Committee conducted its evaluation of the CONFIRE and AMR
15 proposals over the course of the next several months, which was ultimately completed in or
16 around June 2023.
17 43. AMR’s proposal received the highest score based on the scoring metrics specified
18 in the RFP. And because AMR had the highest scoring proposal, it was the only bidder with whom
19 the County could commence contract negotiations. Notwithstanding this express requirement, the
20 County announced on June 6, 2023 that it would begin contract negotiations with both AMR and
21 CONFIRE and would thereafter make a recommendation to the Board of Supervisors based on the
22 outcome of those negotiations. (Ex. 3).
23 44. On October 27, 2023, the County announced that it had completed its contract
24 negotiations with both bidders. Consistent with the procedures set forth in the RFP, the County
25 issued a Notice of Intent to Award indicating that “AMR received the highest score and will
26 receive the independent evaluation committee’s recommendation for award as stated in the RFP.”
27 (Ex. 4). However, in direct contravention of the state-approved RFP procedures, the County
28 further indicated that, “because the difference in scores is substantially equivalent, draft contracts
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1 from each proposer will be presented to the Board of Supervisors for considerations and ultimate
2 award.” (Id.).
3 45. On November 3, 2023, AMR submitted a protest to the County on the grounds that
4 ICEMA and the County’s failure to adhere to the selection procedures and requirements specified
5 in the RFP subverted the competitive process for contract selection, as mandated by state and
6 federal law. (See Ex. 5).
7 46. By letter dated November 28, 2023, the County notified AMR that its protest was
8 denied. (Ex. 6). The County informed AMR that denial of its protest was justified based on two
9 general provisions in the RFP. First, the County cited the language under the provision in the RFP
10 titled “Scope of Work,” which provided that: “[t]he County intends to award an initial five (5)
11 year contract to the highest scoring Proposer whose proposal conforms to the RFP and whose
12 proposal presents the greatest value to the residents and visitors in the San Bernardino County”
13 EOA. (Id. (emphasis in original), (citing Ex. 1, p. 6)). The County also cited to a different general
14 provision titled “Proposal Process” that similarly indicated the County’s intention to award the
15 contract to the proposal that “receives the highest score” and that “best meets the needs of the
16 County.” (Ex. 6 (emphasis in original), (citing Ex. 1, p. 16)). The County contended that the
17 foregoing emphasized language bestowed on the County and Board of Supervisors the sole
18 discretion to select the contract for ambulance services. (See Ex. 6).
19 47. In essence, the County took the position that the discretion it had asserted entitled
20 the County and Board of Supervisors to disregard the evaluation prepared by the non-biased
21 Review Committee and further empowered the County and Board of Supervisors to disregard the
22 RFP’s mandatory requirement that only the highest scoring proposal would receive consideration
23 for award of the contract. Not only is this mandatory requirement contained in the same general
24 provisions that the County cited in its denial of AMR’s protest, it is also reiterated in the several
25 specific provisions throughout the RFP setting forth the process for negotiating with, and
26 ultimately awarding the contract to, the highest-scoring bidder. (See, e.g., Ex. 1, p. 6, 16, 20-21).
27 48. In compliance with the protest procedures set forth in the RFP, following the
28 County’s denial of the protest, AMR thereafter lodged a formal notice of protest with the clerk of
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1 the Board of Supervisors on November 30, 2023. (Ex. 7). As explained in the RFP, the protests
2 submitted by AMR “constitute[d] the sole administrative remedy available” to it, and “[u]pon
3 exhaustion of this remedy no additional recourse is available.” (Ex. 1, p. 23).
4 49. On December 5, 2023, the Board of Supervisors held its regular meeting during
5 which the higher-scoring draft contract submitted by AMR and the inferior draft contract
6 submitted by CONFIRE were both presented for consideration. Following several rounds of public
7 comments, the Board of Supervisors briefly discussed the two draft contracts. Board of
8 Supervisors Chair Dawn Rowe declared that, notwithstanding the mandatory requirements in the
9 RFP, the Board of Supervisors possessed the sole discretion to determine which draft contract to
10 select. 1 Chair Rowe cited to the same language in the RFP relied on by the County in denying
11 AMR’s protest, which provided that “[t]he County realizes that criteria other than price is
12 important and will award a contract based on the highest scoring proposal that demonstrates the
13 best value and meets the needs of the County.” (Ex. 1, p. 6).
14 50. As did the County, Chair Rowe did not consider the fact that the “highest scoring
15 proposal” is necessarily the proposal that “demonstrates the best value and meets the needs of the
16 County.” In other words, there was already a procedure for selecting the proposal that
17 demonstrates the best value and that meets the needs of the County—and that procedure is
18 established by the criteria set forth in the state-approved RFP. The Board of Supervisors, however,
19 took the position that it was permitted to conduct its own evaluation of these criteria—
20 notwithstanding the non-biased Review Committee already having done precisely that.
21 51. The matter was thereafter put to a vote, and in a unanimous decision the Board of
22 Supervisors voted to deny AMR’s protest, without any discussion of the merits of AMR’s
23 contentions therein. After denying the protest, the Board of Supervisors then unanimously voted to
24 award the exclusive contract for ambulance services to CONFIRE. 2
25
1
San Bernardino County Board of Supervisors, Regular Meeting (Dec. 5, 2023),
26 https://sanbernardino.granicus.com/player/clip/6338?view_id=13&redirect=true&h=3bd94be9759
27 fdb53fabd483e49d037fc
28
2
See source cited supra note 1.
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1 52. The vote by the Board of Supervisors was directly contrary to the mandatory
2 requirement in the RFP that only the highest-scoring proposal would ultimately be awarded the
3 contract.
4 53. Beyond the complete abdication of its duty to adhere to the RFP requirements, the
5 Board of Supervisors’ cursory vote to deny AMR’s protest further violated the requirements of the
6 Brown Act. Cal. Gov. Code § 54950 et seq. Specifically, section 54954.2 of the Act requires the
7 Board of Supervisors to post an agenda in advance of its next regular meeting identifying each
8 distinct item of business to be discussed therein. AMR’s protest, however, was never included in
9 the December 5, 2023 agenda, and yet the Board of Supervisors unanimously voted to deny the
10 protest during that meeting. Accordingly, by letter dated December 19, 2023, AMR demanded that
11 the Board cure the Brown Act violation. (Ex. 8). In response, the Board of Supervisors simply
12 issued a new agenda prior to its next meeting that included AMR’s protest, and the Board
13 thereafter reaffirmed its denial of AMR’s protest—again, without any discussion of the
14 contentions AMR had set forth regarding the deeply flawed, and entirely unlawful, RFP process.
15 CONFIRE Was Unqualified to Participate in the RFP Process

16 54. Based on the confidential nature of the RFP process (Ex. 1, p. 19), AMR was
17 unable to review CONFIRE’s proposal prior to submitting its protest to the County and Board of
18 Supervisors. Following the vote by the Board of Supervisors awarding the contract to CONFIRE,
19 AMR obtained CONFIRE’s proposal through a California Public Records Act request.
20 55. Based on a review of the materials included therein, it is undisputable that
21 CONFIRE, as well as its private subcontractor, Priority, had failed to meet the basic requirements
22 set forth in the RFP. Because of this failure, disqualification was mandatory under the RFP, and
23 CONFIRE’s proposal should never have received consideration by the County, let alone the
24 County’s recommendation for further negotiation and ultimate award.
25 56. Specifically, CONFIRE could not meet the following minimum qualifications:
26 57. First, the RFP mandates that a bidder must demonstrate sufficient “organizational
27 experience,” which requires the bidder to have continuously engaged in the provision of 9-1-1
28 ambulance services under a contract for a large urban area with a population greater than
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1 1,000,000. (Id., p. 24). In addition, the bidder’s contract with the large urban area must include the
2 provision of multiple levels of ambulance services, including advanced life support, interfacility
3 transport, and critical care transport services. (Id.). Further, the bidder must have provided the
4 services continuously for five of the last seven years. (Id.).
5 58. Neither CONFIRE, nor the fire agencies comprising its membership, possessed the
6 organizational experience necessary to meet these requirements. CONFIRE instead attempted to
7 rely on its private subcontractor, Priority, to meet the “organizational experience” standard.
8 Priority is a private ambulance provider established in 2013 that has contracts in several smaller
9 regions throughout the country for various levels of ambulance services. Priority has no California
10 experience. Nevertheless, CONFIRE’s proposal represented that Priority had sufficient
11 organizational experience based on the ambulance services Priority provides in its largest service
12 area, Maricopa County, Arizona. (See Ex. 9). This was false.
13 59. Priority does not have a contract as the primary ambulance provider with Maricopa
14 County itself; instead, Priority contracts with five municipalities that together comprise only a
15 portion of Maricopa County. (Id.).
16 60. Based on the information CONFIRE submitted with its proposal—which includes
17 contract dates, population size for the areas served, and the types of services that Priority performs
18 in these areas—it is readily apparent that the five municipalities with whom Priority currently
19 contracts do not convey on Priority the requisite organizational experience necessary to meet the
20 requirements of the RFP.
21 61. For instance, Priority’s contract with the City of Chandler, Arizona only
22 commenced in or about January 2022 and thus fails to satisfy the durational requirement in the
23 RFP, which requires the bidder to have continuously provided ambulance services for five of the
24 last seven years. (Id.). Additionally, under that contract, Priority only provides the physical
25 ambulance and an EMT driver—whereas the city provides the licensed paramedic on board the
26 ambulance—and thus Priority itself is not capable of providing advanced life support services as
27 required by the RFP. (Id.). Priority’s contract with the City of Scottsdale, Arizona only includes
28 the provision of basic life support services and does not include the provision of advanced life
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1 support services required by the RFP, which are instead provided by the local fire department.
2 (Id.). CONFIRE also represented that Priority has an active contract with the City of Surprise,
3 Arizona, but in actuality, that contract is no longer active and thus should never have been
4 included in CONFIRE’s proposal to begin with. Yet, even if the contract was still active, it only
5 allowed Priority to provide backup 9-1-1 ambulance response—as opposed to the primary 9-1-1
6 ambulance response services required by the RFP. (Id.). At best, then, Priority has only provided
7 primary 9-1-1 ambulance response services for the requisite durational period for two
8 municipalities in Maricopa County: the City of Glendale, Arizona, and the City of Goodyear,
9 Arizona. (Id.). However, based on the population metrics submitted by CONFIRE, the combined
10 population of these two municipalities only amounts to 338,000 residents—a far cry from the
11 service area population of 1,000,000 required under the RFP. (Id.).
12 62. Equally disqualifying for CONFIRE is the fact that none of Priority’s contracts
13 with the five municipalities in Maricopa County include the provision of critical care transport or
14 interfacility transport services—both of which are mandated by the RFP’s organizational
15 experience requirement. (Id.).
16 63. After it submitted its proposal in response to the RFP, CONFIRE received a letter
17 from the County on or about April 7, 2023 wherein the County informed CONFIRE that “[a]fter a
18 thorough review of your RFP submission, we are missing the demonstration of your subcontractor
19 meeting the minimum qualification set forth in [the] RFP” under the organizational experience
20 requirement. (Ex. 10). The County further stated that in order for CONFIRE’s proposal to receive
21 further consideration, it must “submit documentation demonstrating your subcontractor’s ability to
22 meet the minimum qualifications set forth in the RFP, specifically experience providing primary
23 9-1-1 ambulance services for a large urban area with a population greater than 1,000,000.” (Id.).
24 64. On or about April 11, 2023, CONFIRE responded to the County’s letter in an
25 attempt to make the requisite showing of its organizational experience. (Ex. 11). But no additional
26 responsive documentation was provided—CONFIRE instead merely repeated the same
27 information submitted with its initial proposal, again relying on Priority’s limited history of
28 providing ambulance services for the five municipalities in Maricopa County, which, as explained
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1 above, is inadequate. (See id.).
2 65. Notwithstanding CONFIRE’s complete lack of organizational experience—which
3 is itself grounds for mandatory and immediate disqualification—the County never again raised the
4 issue. To the contrary, the County simply ignored this requirement, proceeded to negotiate with
5 CONFIRE, and ultimately recommended its draft contract to the Board of Supervisors for
6 approval. By disregarding these requirements and awarding the contract to an unqualified
7 provider, the County and Board of Supervisors violated the express terms of the RFP and put the
8 safety of the County’s residents at risk.
9 66. Beyond the aforementioned organizational experience requirement, the RFP further
10 included another mandatory provision requiring the recipient of the ambulance services contract to
11 agree to implement services by no later than April 1, 2024 (immediately following the expiration
12 of AMR’s current contract on March 31, 2024). (Ex. 1, p. 2). This requirement is repeated
13 multiple times throughout the RFP, which further indicates that “[t]he County will not accept any
14 modifications to the RFP after the award.” (Id., p. 16).
15 67. Notwithstanding this express language, CONFIRE is not prepared to commence

16 operations under the contract by April 1, 2024, as it is required to do. Instead, CONFIRE indicated
17 that it would not be able to implement services until October 1, 2024, at the earliest—which is six
18 months after the mandatory deadline in the RFP.
19 68. Rather than disqualifying CONFIRE from further participation in the contract
20 selection process, the County, the Board of Supervisors, and ICEMA once again disregarded the
21 RFP and are moving forward with the exclusive contract with CONFIRE. At each step of the RFP
22 process, the Board overlooked the inferiority of CONFIRE’s proposal as well as its inability to
23 meet the RFP’s most basic qualifications.
24 In Awarding the Contract to CONFIRE the County Considered Extraneous Criteria not
Permitted by the RFP
25
69. During the December 5, 2023 regular meeting, in which the Board of Supervisors
26
considered the AMR and CONFIRE proposals, the Board of Supervisors took notice of an alleged
27
funding opportunity that awarding the contract to CONFIRE would purportedly afford.
28
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1 Specifically, Board of Supervisors Chair Dawn Rowe referenced the fact that as a municipal Joint
2 Powers Authority, CONFIRE would be eligible for certain state and federal government funding
3 programs for the provision of ambulance services. Among the available funding programs is the
4 Public Provider Intergovernmental Transfer (“PPIGT”) program established by California
5 Assembly Bill 1705, which entitles publicly operated ground ambulance providers to receive
6 supplemental Medi-Cal reimbursement in addition to the rate of payment the provider would
7 otherwise receive for those services. Private providers are not eligible for this funding. And even
8 though CONFIRE would be relying on Priority—a private subcontractor—to perform the bulk of
9 the services called for in the RFP and to provide over 90% of the funding for those services (Ex. 2,
10 p. 276), CONFIRE would still be eligible for PPIGT funding as the prime contractor under the
11 exclusive ambulance services contract. Indeed, Chair Rowe specifically cited the PPIGT program
12 as the basis for her decision to vote in favor of CONFIRE, adding that “of the two proposers we
13 heard today, CONFIRE JPA may be eligible for this funding. But only CONFIRE JPA.” 3
14 70. Chair Rowe declared that, because CONFIRE was eligible for PPIGT funding,
15 CONFIRE’s proposal demonstrated the best value and would best meet the needs of the County.
16 But the determination of which proposal demonstrated the best value and best met the needs of the
17 County was already accounted for in the evaluation criteria specified in the RFP.
18 71. Nowhere in the various scoring metrics set forth in the RFP for the evaluation of
19 each bidder’s proposal was access to government funding enumerated. Rather, to ensure a
20 meaningfully competitive process as required by state and federal law, the RFP criteria made no
21 distinction between public and private providers, nor their access to government funding
22 programs.
23 FIRST CAUSE OF ACTION
24 Section 1 of the Sherman Anti Trust Act – 15 U.S.C. § 1
25 (Against the County, the Board of Supervisors, and ICEMA)
26 72. AMR realleges and incorporates all paragraphs in this Complaint and Petition as if
27
28
3
See source cited supra note 1.
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1 fully set forth herein.
2 73. Exclusive contracts for local public services inherently operate as illegal restraints
3 on trade in violation of the Sherman Antitrust Act.
4 74. A narrow exemption to antitrust liability for local governmental entities is available
5 where the challenged conduct is undertaken pursuant to a clearly articulated and affirmatively
6 expressed state policy to displace competition.
7 75. California’s clearly articulated and affirmatively expressed policy is set forth in the
8 EMS Act under Health and Safety Code section 1797.224, which authorizes a LEMSA to establish
9 an EOA only on the condition that “a competitive process is utilized to select the provider” and
10 that the competitive process receives approval from EMSA.
11 76. For the purpose of selecting an exclusive ambulance provider, the County and
12 ICEMA established a competitive RFP process, which was subsequently approved by EMSA as
13 required by the EMS Act under Health and Safety Code section 1797.224. As such, the only
14 legally permissible means for the County and ICEMA to adopt an exclusive arrangement for EMS
15 services was through compliance with the procedures set forth in the state-approved RFP. The
16 criteria and procedures contained in the RFP accordingly provide the sole mechanism through
17 which the County, the Board of Supervisors, and ICEMA can select and enter into an exclusive
18 contract for ambulance services.
19 77. Notwithstanding the foregoing legally-mandated procedure, the County, the Board
20 of Supervisors, and ICEMA acted in express violation of the RFP by virtue of the following
21 conduct:
22 a. AMR received the highest score from the non-biased Review Committee.
23 The unambiguous terms of the RFP required that the County and ICEMA
24 enter into contract negotiations only with “the Proposer of the highest-
25 ranked proposal.” (Ex. 1, p. 20). The County and ICEMA therefore had no
26 authority to enter into contract negotiations with CONFIRE. Moreover, the
27 unambiguous terms of the RFP further require that “a contract will be
28 awarded based on the highest scoring proposal received.” (Id., p. 21). But
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1 upon completion of the negotiation process, the County further violated the
2 RFP procedures by submitting the proposed contracts from both AMR and
3 CONFIRE to the Board of Supervisors for ultimate consideration of award,
4 notwithstanding AMR having received the highest score. (Exs. 3-4).
5 b. The Board of Supervisors thereafter violated the RFP procedures by voting
6 to award the exclusive contract to CONFIRE, contrary to the express
7 requirement that the “contract will be awarded” only to the “highest scoring
8 proposal received.” (Ex. 1, p. 21). By disregarding this requirement, the
9 Board of Supervisors exceeded the lawful scope of its discretion and

10 directly contravened the competitive process mandated by the clearly
11 articulated and affirmatively expressed policy established under the EMS
12 Act.
13 c. For similar reasons, reliance on extraneous criteria not enumerated in the
14 RFP for the purpose of selecting an exclusive ambulance provider falls
15 outside the scope of the Board of Supervisors’ discretion. The Board of
16 Supervisors’ discretion is in fact defined solely by the criteria authorized by
17 the competitive process approved by the state. The Board of Supervisors
18 disregarded this statutory prohibition by awarding the exclusive contract for
19 ambulance services based on its own subjective determination of which
20 provider would offer the “best value” to the County.
21 d. The County, the Board of Supervisors, and ICEMA further violated the RFP
22 by failing to enforce—and deliberately disregarding—the minimum
23 qualifications enumerated thereunder. Based on the materials in
24 CONFIRE’s proposal, it was clear that its subcontractor, Priority, did not
25 possess the requisite “Organizational Experience” required under the RFP
26 because it did not continuously engage in the provision of 9-1-1 ambulance
27 services, for five of the last seven years, at the requisite transport levels of
28 care, and for the requisite service area of 1,000,000 residents. (Compare Ex.
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LOS ANGELES 18
1 1, p. 24 with Ex. 9). CONFIRE further failed to satisfy the mandatory
2 requirement that it become operational by no later than April 1, 2024. In
3 light of these glaring deficiencies, CONFIRE was subject to immediate
4 disqualification from the RFP process and its proposal was prohibited from
5 receiving any further consideration. The County, the Board of Supervisors,
6 and ICEMA nevertheless deliberately disregarded these requirements.
7 e. ICEMA further violated the RFP procedures by designating CONFIRE as
8 the County’s new exclusive ambulance provider for the EOA and entering
9 into a contract with CONFIRE for that purpose. CONFIRE was not the
10 winner of the competitive procurement process established by the RFP and
11 it was not qualified under the minimum standards set by the RFP to provide
12 emergency ambulance services.
13 78. Because of the failure to adhere to the procedures and criteria in the RFP, which
14 was established pursuant to California’s clearly articulated and affirmatively expressed policy
15 under the EMS Act, the conduct of the County, the Board of Supervisors, and ICEMA cannot be
16 considered “state action” and consequently falls outside of the narrow exemption from antitrust
17 liability afforded to such action.
18 79. By authorizing CONFIRE to become the exclusive ambulance provider for the
19 County’s EOA, the County, the Board of Supervisors, and ICEMA entered into an agreement or
20 conspiracy to confer exclusivity outside of the requirements mandated by the EMS Act.
21 80. By conferring exclusivity on CONFIRE as the sole ambulance provider permitted

22 to operate in the EOA, the aforementioned conspiracy or agreement was necessarily intended to
23 harm or restrain competition.
24 81. Because CONFIRE will be the exclusive provider of ambulance services, AMR
25 will be prohibited from operating in the EOA and will be forced to cease operations in the County
26 as a result. The significant ensuing financial harm to AMR is the direct result of the conduct of the
27 County, the Board of Supervisors, and ICEMA in conferring exclusivity on CONFIRE.
28 82. The restraint on competition resulting from the aforementioned conspiracy or
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1 agreement has a substantial effect on interstate commerce. AMR provides ambulance
2 transportation services utilizing the channels and instrumentalities of interstate commerce and
3 responds to emergencies on streets and highways throughout the County, including the removal of
4 obstructions from such streets and highways so as to enable commerce to move freely. In addition,
5 AMR is part of a family of companies providing healthcare services in 40 states and the District of
6 Columbia. As such, the County’s illegal restraint on AMR’s ability to participate in a competitive
7 RFP process has a substantial effect on interstate commerce.
8 83. If the County, the Board of Supervisors, and ICEMA are permitted to award an
9 exclusive ambulance services contract to CONFIRE, AMR will be irreparably injured.

10 84. AMR has no plain, speedy, or adequate remedy at law to address the irreparable
11 injury described above.
12 SECOND CAUSE OF ACTION

13 Petition for Peremptory Writ of Mandamus – California Code of Civil Procedure
§§ 1085 and 1094.5
14
(Against the County, the Board of Supervisors, and ICEMA)
15
18 86. The County and ICEMA have a clear and present nondiscretionary duty to conduct
19 the competitive process required by Health and Safety Code section 1797.224 in accordance with
20 the rules and procedures published in the RFP, which was approved by EMSA pursuant to its
21 authority under the EMS Act. The County and ICEMA are accordingly obligated to enforce the
22 requirements of the RFP as written, including the procedures for selecting the highest-scoring
23 proposal and enforcement of the minimum qualifications.
24 87. Because AMR’s proposal received the highest score, as determined by the non-
25 biased Review Committee, the County and ICEMA had a ministerial duty to negotiate only with
26 AMR. (See Ex. 1, p. 20-21). The County and ICEMA failed to adhere to this ministerial duty by
27 negotiating with both AMR and CONFIRE and thereafter submitted draft contracts from both
28 providers to the Board of Supervisors, in further violation of the RFP. (See Exs. 3-4). The County
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1 and ICEMA additionally failed to comply with their ministerial obligations by deliberately
2 disregarding CONFIRE’s demonstrated inability to satisfy the requisite minimum qualifications,
3 including its subcontractor’s lack of organizational experience and its refusal to begin operations
4 within the timeframe required by the RFP.
5 88. The Board of Supervisors similarly has a clear and present ministerial duty to
6 comply with the mandatory procedures established by the RFP. And to the extent that the Board of
7 Supervisors possesses any discretion in determining whether to award an exclusive contract for
8 ambulance services, such discretion is circumscribed by the dictates of the EMS Act. The Board of
9 Supervisors accordingly has a ministerial duty to comply with its statutory obligations, and any
10 discretion it otherwise possesses is limited by the criteria specified in the state-approved RFP.
11 89. The Board of Supervisors therefore abused its discretion by awarding the exclusive
12 contract to CONFIRE. Because AMR was the highest-scoring bidder pursuant to the procedures
13 set forth in the RFP, the Board of Supervisors’ discretion was limited to considering whether to
14 approve AMR’s contract. Conversely, as the lowest-scoring bidder, CONFIRE’s proposal was not
15 eligible for consideration by the Board of Supervisors, and the failure to adhere to this statutory
16 requirement constituted a flagrant abuse of discretion. The Board of Supervisors further abused its
17 discretion by failing to ensure that the County enforced the RFP’s mandatory minimum
18 qualifications necessary for participation in the competitive bidding process—which CONFIRE
19 was indisputably incapable of fulfilling. Nor could the Board of Supervisors select CONFIRE
20 based on its subjective determination that CONFIRE’s proposal would provide the best value to
21 the County. The Board of Supervisors made this determination as a result of CONFIRE’s access to
22 state and federal funding programs; but whether a provider has access to government funding is
23 not among the criteria enumerated in the RFP and is thus an impermissible factor for the Board of
24 Supervisors to consider.
25 90. Because AMR was the highest scoring bidder, once the evaluation process was
26 completed, ICEMA had a ministerial duty to ensure that only AMR would be designated as the
27 exclusive ambulance provider for the EOA. ICEMA failed to carry out this ministerial duty by
28 instead designating CONFIRE as the new exclusive ambulance provider and entering into an
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1 exclusive contract for that purpose.
2 91. Because the County improperly denied AMR’s protest based on the false assertion
3 that the Board of Supervisors possessed the sole discretion to determine which draft contract to
4 select, notwithstanding the mandatory requirements of the RFP that only the highest scoring
5 proposal would receive consideration for award of the contract, the County failed to carry out its
6 mandatory duty to adjudicate any protest in compliance with law and the procedures set forth in
7 the RFP.
8 92. As the highest-scoring bidder in the RFP process, AMR has a clear and present
9 beneficial right to the performance of the mandatory duties owed by the County, the Board of
10 Supervisors, and ICEMA, including a beneficial interest in the receipt of the exclusive ambulance
11 services contract. AMR was denied this right due to the foregoing violations.
12 93. By lodging a formal protest with both the County and the Board of Supervisors,
13 AMR exhausted all applicable legal remedies before commencing this action.
14 94. AMR will suffer irreparable injury from the denial of the exclusive ambulance
15 services contract in that it will be forced to discontinue providing ambulance services upon the
16 expiration of its current contract, despite its more than 40 years of continuous service in the
17 County and the County’s citizens.
18 95. AMR has no other plain, speedy, or adequate remedy at law to redress the denial of
19 the exclusive ambulance services contract and thus must seek this petition for writ to protect its
20 rights.
21 96. AMR therefore requests that this Court issue a writ of mandate compelling the
22 County, the Board of Supervisors, and ICEMA to set aside the decision to grant the exclusive
23 ambulance services contract to CONFIRE. AMR further requests the issuance of a writ of mandate
24 compelling the Board of Supervisors to comply with the procedures set forth in the RFP, which in
25 turn requires awarding the exclusive ambulance services contract to AMR as the sole winner of
26 the competitive bidding process.
27 97. Although the aforementioned conduct challenged by AMR in this action is

28 distinctly legislative in character, thereby warranting relief via a writ of traditional mandate
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1 pursuant to Code of Civil Procedure section 1085, AMR alternatively seeks a writ of
2 administrative mandamus pursuant to Code of Civil Procedure section 1094.5, which provides that
3 in matters involving “any final administrative order or decision made as the result of a proceeding
4 in which by law a hearing is required to be given, evidence is required to be taken, and discretion
5 in the determination of facts is vested in the inferior tribunal . . .,” administrative mandamus shall
6 issue where “respondent has proceeded without, or in excess of, jurisdiction; whether there was a
7 fair trial; and whether there was any prejudicial abuse of discretion.” Cal. Civ. Proc. Code §
8 1094.5(a)-(b).
9 98. To the extent administrative mandamus is appropriate, the conduct alleged herein
10 demonstrates that the County, the Board of Supervisors, and ICEMA acted in clear excess of their
11 jurisdiction be conferring exclusivity on CONFIRE in violation of their authority as authorized
12 under the EMS Act.
13 THIRD CAUSE OF ACTION

14 Declaratory Relief – California Code of Civil Procedure Section 1060
15 (Against All Defendants)
18 100. ICEMA, acting within the control by the County and Board of Supervisors,
19 annually sets the rates that ambulance providers may charge for ambulance transports and related
20 expenses.
21 101. California Constitution section XIII C, as amended by Proposition 26 in 2010, sets
22 forth the requirements for local government-imposed charges. Among other things, these
23 requirements mandate that the “local government” that “impose[s]” fees may not, without voter
24 approval, generate revenues beyond the cost of providing a municipal service.
25 102. In the materials submitted in connection with CONFIRE’s proposal, CONFIRE
26 informed the County that, for the first year alone, it anticipates generating approximately $17.6
27 million in revenue beyond the cost of providing ambulance services in the County. (See Ex. 12)
28 Altogether, CONFIRE expects to generate approximately $63.3 million in excess revenue over the
LARSON
LOS ANGELES 23
1 course of the five-year contract.
2 103. AMR is informed and believes, and on that basis alleges, that should CONFIRE be
3 permitted to begin providing ambulance service under the exclusive contract awarded by the
4 County, CONFIRE has admitted that it will charge ambulance service payors for more than the
5 cost of service it incurs to provide the service. Moreover, on information and belief, CONFIRE’s
6 proposed ambulance rates do not include any rate offset to account for the additional revenue it
7 would generate through government funding sources, such as the PPIGT program. In this regard,
8 CONFIRE will impose a charge that California Constitution Article XIII C deems a “tax”
9 requiring voter approval—which has not been obtained and for which no exception under § 1(e) of
10 the article is provided.
11 104. AMR is informed and believes, and on that basis alleges, that CONFIRE’s
12 representations about the excess revenue it would generate from providing ambulance service was
13 an important and motivating factor in the Board of Supervisors’ decision to disregard the RFP
14 procedures and award CONFIRE the exclusive ambulance services contract.
15 105. AMR is informed and believes, and on that basis alleges, that because of the
16 overlapping governance structures of the County and CONFIRE’s member agencies, the Board of
17 Supervisors had strong incentive to favor—and for revenue-generation reasons, did favor—the
18 selection of CONFIRE as the exclusive ambulance provider notwithstanding it receiving a lower
19 score in the RFP process.
20 106. AMR is injured by CONFIRE’s anticipated violation of Article XIII C in that

21 CONFIRE’s ability to generate revenues beyond its cost of service gave it an unfair competitive
22 advantage over AMR in the Board of Supervisors’ decision in awarding the exclusive ambulance
23 services contract. To the extent AMR would participate in a future competitive bidding process,
24 CONFIRE would continue to be able to tout its ability to generate excess revenue as an advantage
25 for favoring CONFIRE over AMR, making any future RFP submission by AMR futile.
26 107. A present, justiciable controversy exists between AMR and all Defendants as to the
27 lawfulness of ICEMA’s setting of, and CONFIRE’s charging of, ambulance service rates that
28 generate revenue beyond the cost to provide service. Judicial declarations by this Court are
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LOS ANGELES 24
1 accordingly necessary and proper.
2 108. AMR has no plain, speedy, or adequate remedy at law to address the controversies
3 described above.
4 PRAYER FOR RELIEF
5 WHEREFORE, AMR prays for judgment against all Defendants and Respondents as
6 follows:
7 1. Against the County, the Board of Supervisors, and ICEMA: for a declaration that
8 awarding an exclusive contract for ambulance services through a selection process that fails to
9 adhere to the procedures mandated by the state-approved RFP constitutes an illegal restraint on
10 competition in violation of section 1 of the Sherman Antitrust Act;
11 2. Against the County and ICEMA: for an injunction pursuant to 15 U.S.C section 26
12 permanently enjoining the County and ICEMA from proceeding with the exclusive ambulance
13 services contract with CONFIRE;
14 3. Against the Board of Supervisors: for an injunction pursuant to 15 U.S.C section 26
15 permanently enjoining the Board of Supervisors from violating the procedures mandated by the
16 RFP;
17 4. Against the County and ICEMA: for a writ of mandate pursuant to Code of Civil
18 Procedure section 1085, or a writ of administrative mandamus pursuant to Code of Civil
19 Procedure section 1094.5, requiring the County to grant AMR’s protest, and requiring the County
20 and ICEMA to set aside the exclusive ambulance services contract with CONFIRE, and to
21 perform their ministerial duty to present only AMR’s proposal and negotiated contract for
22 ratification by the Board of Supervisors in accordance with the RFP;
23 5. Against the Board of Supervisors: for a writ of mandate pursuant to Code of Civil
24 Procedure section 1085, or a writ of administrative mandamus pursuant to Code of Civil
25 Procedure section 1094.5, requiring the Board of Supervisors to grant AMR’s protest and carry
26 out its ministerial duty to award the exclusive ambulance services contract based solely on the
27 procedures mandated by the state-approved RFP;
28 //
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1 6. Against all Defendants: for a declaration that the Defendants may not set or charge
2 ambulance service rates at amounts that would generate revenues in excess of CONFIRE’s cost to
3 provide ambulance services;
4 7. For attorneys’ fees and costs incurred in bringing this suit; and
5 8. For such other relief as the Court deems just and appropriate.
7 Dated: February 2, 2024 LARSON LLP
9
By:
10 Stephen G. Larson
Jonathan E. Phillips
11 Mehrunisa Ranjha
Benjamin Falstein
12
Attorneys for Petitioner and Plaintiff
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1 VERIFICATION
2 I am the attorney for Plaintiff and Petitioner American Medical Response of Inland Empire
3 (“AMR”) in the above entitled action and am authorized to make this verification on its behalf.
4 AMR and its corporate officers are absent from Los Angeles County, where I have my office, and
5 are therefore unavailable to verify the Verified Complaint and Petition for Writ of Mandate. I have
6 read the foregoing Verified Complaint and Petition for Writ of Mandate and know its contents. I
7 am informed and believe, and on that ground allege, that the matters stated in the Verified
8 Complaint and Petition for Writ of Mandate are true.
9 I declare under penalty of perjury under the laws of the State of California that the
10 foregoing is true and correct.
11 Executed on February 2, 2024, at Los Angeles, California.

12
13
14 .
Stephen G. Larson
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Case 5:24-cv-00267 Document 1-1 Filed 02/02/24 Page 1 of 137 Page ID #:28
EXHIBIT 1
SAN BERNARDINO
COUNTY
Request for Proposal

RFP #: ICEMA23-ICEMA-4811
Advanced Life Support and Basic Life Support Ground Ambulance
Services, Interfacility and Critical Care Transport Services for Exclusive
Operating Areas in San Bernardino County
The Inland Counties Emergency Medical Agency

San Bernardino County
December 20, 2022
Advanced Life Support and Basic Life Support Ground Ambulance Services, Interfacility and Critical Care Transport Services for Exclusive Operating 0
Areas in San Bernardino County RFP#: ICEMA23-ICEMA-4811
The Inland Counties Emergency Medical Agency (ICEMA) and San Bernardino County (County) invites experienced and
qualified organizations to submit proposals to provide ground ambulance transportation services, interfacility and
critical care transports for an Exclusive Operating Area (EOA) as provided for in Section 1797.224 of the California Health
and Safety Code. For the purpose of this RFP, ICEMA is unifying the following existing EOAs (EOA 1, EOA 2, EOA 3, EOA
4, EOA 5b, EOA 6, EOA 7, EOA 8, EOA 9, EOA 11 and EOA 12a), and referring to them as the Comprehensive Service
Area. This is to ensure proposers understand the County will only accept proposals for the entire Comprehensive Service
Area and will not consider proposals that fragment the Comprehensive Service Area. The boundaries of each existing
EOA have not changed. The Comprehensive Service Area included in this Request for Proposal (RFP) is identified in
Exhibit 2.
Proposals and questions must be submitted using the County’s Electronic Procurement Network (ePro). Questions
related to the use of this system should be directed to the person identified below (RFP Contact):
Michelle Churchill, Supervising Buyer

Purchasing Department
777 E. Rialto Avenue
San Bernardino, CA 92415-0760
Email: [email protected]
Phone: (909) 387-2060
Proposals will not be accepted by email or facsimile. Proposals must be submitted electronically through the County
ePro, and via hard copy with original signature submitted to the address indicated above. All Proposers must register
with the ePro system prior to the date and time to submit the proposal or they will be disqualified.
The County is a political subdivision of the State of California. State law confers to the Local Emergency Medical Services
Agency (LEMSA) authority to designate one or more emergency ambulance service providers. The County and ICEMA
are conducting this procurement and are seeking a qualified ambulance service provider to deliver the services
identified under Section IV, Scope of Work.
ICEMA encompasses the jurisdictional boundaries of San Bernardino County and is designated by the San Bernardino
County Board of Supervisors as the LEMSA pursuant to California Health and Safety Code, Section 1797.200. In this role,
the Emergency Medical Services (EMS) Agency has the exclusive authority over and sole responsibility for planning,
implementing, and evaluating the County’s EMS System. This authority includes the power to designate a 911
Ambulance service provider selected through a competitive procurement process. The successful Proposer will be
granted a contract for exclusive operating rights for services within the Comprehensive Service Area for an initial period
of five years. The start date for the service will be negotiated with the awarded Proposer with a start date not to exceed
April 1, 2024, at 00:01 AM, Pacific Time
To the extent achievable, the following schedule shall govern the review, evaluation, and award of the proposal. The
County reserves the right to modify the dates below following its review process.
Event Date Time

Proposal Document Available December 20, 2022 8:00 AM
Mandatory Proposer’s Conference
Located at:
January 17, 2023 10:00 AM
385 N. Arrowhead Ave
San Bernardino, CA 92415
Deadline for Written Questions January 26, 2023 4:00 PM
Letter of Intent to Submit a Proposal
February 23, 2023 1:00 PM
(via ePro)
Proposals Due March 23, 2023 5:00 PM
Time and Place of Response Opening
March 23, 2023 10:30 AM
will be conducted via Zoom
Oral Presentations, Proposal Review,
April 6, 2023 9:00 AM
and Selection
Notice of Intent to Negotiate April 20, 2023 10:00 AM
Notice of Award to Provider May 18, 2023 10:00 AM
Last Day to Protest May 28, 2023 10:00 AM
To be negotiated but not to exceed
Implementation of Service 12:01 AM
April 1, 2024
TABLE OF CONTENTS
SECTION I - INTRODUCTIONS AND BACKGROUND 5
1.1 INVITATION 5
1.2 POLICY GOALS OF PROCUREMENT 5
1.3 SCOPE OF WORK SUMMARY 5
1.4 PROPOSED ENHANCEMENTS TO THE SAN BERNARDINO COUNTY EMS RESPONSE SYSTEM 7
1.5 GENERAL REQUIREMENTS AND GOVERNING DOCUMENTS 7
1.6 DESCRIPTION OF SAN BERNARDINO COUNTY 7
1.7 DESCRIPTION OF THE EMS SYSTEM 9
SECTION II - INSTRUCTIONS FOR PROPOSERS 16
2.1 PROPOSAL PROCESS 16
2.2 PRE-SUBMITTAL ACTIVITIES 16
2.3 PROPOSERS’ CONFERENCE 16
2.4 PROPOSAL CONTENT AND ORGANIZATIONAL REQUIREMENTS 17
2.5 PROPOSAL SUBMISSION 18
2.6 ERRORS IN PROPOSAL 18
2.7 CONFIDENTIALITY OF PROPOSALS 19
2.8 CONTACT WITH COUNTY EMPLOYEES 19
2.9 WITHDRAWAL OF PROPOSALS 20
2.10 NO COMMITMENT 20
2.11 ESTIMATED QUANTITY 20
2.12 SELECTION 20
2.13 NEGOTIATIONS AND NOTICE OF INTENT TO AWARD 20
2.14 PROTESTS (APPEAL AND AWARD) 21
2.15 PUBLIC RECORDS ACT 23
SECTION III - QUALIFICATIONS, EXPERIENCE, AND EVALUATION CRITERIA 24
3.1 MINIMUM QUALIFICATIONS 24
3.2 EVIDENCE OF INSURANCE OR ABILITY TO OBTAIN INSURANCE 28
3.3 EVALUATION CRITERIA 28
SECTION IV - SCOPE OF WORK AND SCORING CRITERIA 29
4.1 SUMMARY 29
4.2 SYSTEM REQUIREMENTS 29
4.3 RESPONSE TIME STANDARDS 30
4.4 CLINICAL PERFORMANCE STANDARDS 31
4.5 AMBULANCE DEPLOYMENT AND SYSTEM STATUS PLAN 31
4.6 VEHICLES 32
4.7 MEDICAL SUPPLIES AND EQUIPMENT 34
4.8 PERSONNEL 35
4.9 HOSPITAL AND COMMUNITY REQUIREMENTS 40
4.10 DISASTER PREPAREDNESS/RESOPNSE 41
4.11 QUALITY MANAGEMENT 42
4.12 ELECTRONIC PATIENT CARE (EPCR) REQUIREMENTS 43
4.13 CENTRALIZED EMERGENCY MEDICAL DISPATCH (EMD) CENTER 44
4.14 FINANCIAL AND ADMINISTRATIVE REQUIREMENTS 45

4.15 FUTURE SYSTEM ENHANCEMENTS 47
EXHIBIT 1 - REQUIRED TABLE OF CONTENTS 49
EXHIBIT 2 – COMPREHENSIVE SERVICE AREA MAPS OF SAN BERNARDINO COUNTY 51
EXHIBIT 3 - HISTORICAL CALL DATA 64
EXHIBIT 4 - CONTRACT TEMPLATE 65
EXHIBIT 5 - PROPOSER SCORING SHEET 92
EXHIBIT 6 - RESPONSE TIMES AND LIQUIDATED DAMAGES 98
EXHIBIT 7 - CLINICAL PERFORMANCE STANDARDS, EXEMPTION, AND LIQUIDATED DAMAGES 104
EXHIBIT 8 - FINANCIAL REPORTING EXCEL SPREADSHEET 110
EXHIBIT 9 - INVESTIGATIVE AUTHORIZATION - COMPANY 115
EXHIBIT 10 - INVESTIGATIVE AUTHORIZATION - INDIVIDUAL 117
EXHIBIT 11 - EMD CENTRALIZED DISPATCH CENTER & COMMUNICATION EQUIPMENT REQUIREMENTS 118
EXHIBIT 12 - CURRENT SAN BERNARDINO COUNTY AMBULANCE RATES 121
EXHIBIT 13 - ASSURANCE OF COMPLIANCE WITH SECTION 504 OF THE REHABILITATION ACT OF 1973 122
EXHIBIT 14 - FINANCIAL REQUIREMENTS 123
EXHIBIT 15 - INSURANCE 125
EXHIBIT 16 - ATTESTATION 128
EXHIBIT 17 - DEFINITIONS 129
EXHIBIT 18 – PUBLIC RECORDS ACT EXCEPTION FORM 135
SECTION I - INTRODUCTIONS AND BACKGROUND

1.1 INVITATION
The Inland Counties Emergency Medical Agency (ICEMA) and San Bernardino County (County) invite experienced and
qualified organizations to submit a proposal to provide 911 Advanced Life Support (ALS) and Basic Life Support (BLS)
Ambulance Transport Services, Interfacility Transport (IFT) and Critical Care Transport (CCT) in the Comprehensive
Service Area.
Each Proposer responding to this Request for Proposals (RFP) must submit a written proposal setting forth the Proposer
qualifications and plans for meeting or exceeding the performance expectations for the entire Comprehensive Service
Area. Proposals must be organized to address each requirement in a format structure that is easy to follow as identified
in Exhibit 1.
The outcome of this RFP will be the selection of one Proposer (Contractor) with whom the County will contract for an
exclusive, performance-based contract for the provision of services. The performance expectations and commitments
identified in the selected Proposal will be incorporated in the contract as mandatory performance standards. The initial
term of the contract will be for five (5) years, beginning on April 1, 2024, and continue through March 31, 2029. There
will be an option of one (1) extension of the contract of five (5) years based on the Contractor's performance.
1.2 POLICY GOALS OF PROCUREMENT
The County's overarching goals in conducting this procurement process are to:
1. Improve services delivery to customers and external partners;
2. Establish a more efficient system, through transparent and outcome-based service; and
3. Make investments back into the EMS system.
1.3 SCOPE OF WORK SUMMARY
This RFP and its provisions, attachments, addendums, and exhibits constitute the RFP for the selection of a single
provider of ambulance services for the Comprehensive Service Area. The operation of ambulance services in this area
shall be consistent with the provisions of this procurement process. The Comprehensive Service Area is delineated in
the map entitled Exclusive Operating Areas (EOAs) for the purposes of this RFP. Proposers must agree to provide the
services referred above for the entire Comprehensive Service Area without any qualification or variation other than as
expressly outlined in this RFP.
All the ambulance requests originating in the Comprehensive Service Area shall be referred to the holder of the
contract. The holder of this exclusive contract shall provide all responses and ground ambulance transport including:
● All ALS and BLS 911 requests for ambulance service,
● Requests for emergency ambulance service made directly to an ambulance service provider without going
through an authorized dispatch center including a seven-digit phone number,
● Ambulance transport to an emergency department from the scene of an emergency,
● Ambulance transports to an emergency department originating from a skilled nursing facility, physician's office,
medical clinic, residential care facility, or other medical facilities,
● Potential non-transport response with treatment and referral,
● Potential transport to an alternative destination,
● All ALS, BLS, IFT and CCT requests directed to Contractor,
● Requests for mutual aid by the Centralized EMD Center,
● Requests for ambulance stand-by services such as working fires, hazardous materials incidents,
hostage/Special Weapons and Tactics (SWAT) events, special events, including disaster drills or other requests
by ICEMA.
The Contractor's scope of work is summarized as follows:
A. The County has determined that the highest level of county-wide emergency medical response is to be
provided by a system utilizing ALS or BLS ambulance services. The County intends to award an initial five (5)
year contract to the highest scoring Proposer whose proposal conforms to the RFP and whose proposal
presents the greatest value to the residents and visitors in the San Bernardino County Comprehensive Service
Area. The Proposal Review Committee (Committee) will evaluate all proposals based on the evaluation criteria
score sheet as established in this RFP. The County realizes that criteria other than price is important and will
award a contract based on the highest scoring proposal that demonstrates the best value and meets the needs
of the County.
B. The County may extend the Contractor's contract for one additional five (5) year term. The extension will be
based on the Contractor's performance in meeting and or exceeding the performance standards outlined in
the contract over the initial term.
C. The Contractor shall respond, upon notification from the ICEMA Authorized Emergency Medical Services (EMS)
Dispatch Center, 24 hours a day, 365 days a year with an appropriately staffed and equipped ALS, BLS or IFT/CCT
ambulance. The Contractor’s response shall be in a manner consistent with the specific requirements of the
request. Such requirements shall vary depending upon whether the request for ambulance service is in
response to a 911 medical emergency, non-emergency, or the need to post an ambulance to provide optimum
coverage to the Comprehensive Service Area or an adjacent area.
D. Ambulance response times must meet the response-time standards set forth herein, and every ambulance unit
must be at the appropriate staffing and equipment level as determined following ICEMA Emergency Medical
Dispatch (EMD) Policy 4090. The RFP requires the Contractor to meet specified response times within each
EOA in the Comprehensive Service Area. Services will be provided according to ICEMA’s Policies and Procedures
as they are or may be established or as developed or promulgated.
E. Clinical performance must be consistent with all ICEMA’s policies and approved medical standards. Medical
care must meet the Clinical Performance Measures established jointly at contract award, further details are
set forth herein. Services and care delivered must be evaluated by the Contractor's internal quality
improvement program as approved by ICEMA and incorporated into the County’s EMS system quality
improvement program to improve and maintain effective clinical performance. The Contractor must make a
persistent effort to detect and correct performance deficiencies and to continuously upgrade the performance
and reliability of the EMS system. Clinical and response-time performance must be extremely reliable, with
equipment failure and human error held to an absolute minimum through constant attention to performance,
protocol, procedure, performance auditing, and prompt and definitive corrective action.
F. This procurement process requires the highest levels of performance and reliability, and mere demonstration
of effort, even diligent and well-intentioned effort, shall not substitute for performance results. The holder of
an exclusive contract that fails to perform to the standards required may be found to be in breach of their
contract and promptly replaced to protect the public health and safety of San Bernardino County visitors and
residents.
G. The Contractor will be expected to participate in a countywide Master Mutual Aid Response Plan focusing on
ensuring coverage in the remote and wilderness areas of the county.
1.4 PROPOSED ENHANCEMENTS TO THE SAN BERNARDINO COUNTY EMS RESPONSE SYSTEM
San Bernardino County and ICEMA reviewed the current EMS system and recognizes this procurement process is
designed to move the EMS System, and the 911 ambulance service provided therein, away from the traditional mindset
that quicker is always better and toward a new paradigm of providing the right resource, to the right patient, at the
right time. This concept is supported by clinical research. ICEMA also highly values data-driven, and evidence-based
practice from all EMS providers. Other key considerations are the sustainability of the system through quality patient
care, provider financial stability, compliance with state and local laws and ICEMA physician medical control/direction.
This RFP is an opportunity to improve systems of care including, but not limited to:
● Fully utilize Medical Priority Dispatch System (MPDS) or other ICEMA approved emergency medical dispatch
process to identify patients who require immediate care and ensure callers receive the appropriate level of
response, right care at the right time through the ICEMA approved EMD center,
● Innovations in Prehospital care, including ALS or BLS ambulance response, alternative ambulance destination,
Nurse Triage at Dispatch, Community Paramedicine and Telemedicine,
● Implementation of a transparent system,
● Innovations to improve system deployment and economic efficiency,
● Foster a collaborative working relationship among all system participants.
ICEMA is focused on scientific evidence-based clinical initiatives to enhance patient care. This RFP and any subsequent
contract intend to implement a system dedicated to improving patient outcomes. The contract will require sufficient
staff for performance improvement activities at all levels of patient interaction, including inter-agency education and
training. ICEMA will require the successful Proposer to purchase and implement data analytic programs, including but
not limited to mandatory participation in the County’s FirstWatch/First Pass surveillance platform. The Contractor shall
be an active participant in the Cardiac Arrest Registry for Enhanced Survival (CARES) program, EMS Authority's Core
Measures program, and other national clinical care standards as directed by ICEMA’s Medical Director.
1.5 GENERAL REQUIREMENTS AND GOVERNING DOCUMENTS
ICEMA has established exclusive ambulance operating areas and provides system oversight and medical control of the
EMS system. They establish policies, procedures, and protocols that govern ambulance services within the County. The
requirements for service to the Comprehensive Service Area include the following: California Statutes and Regulations;
Contractual standards as stipulated in this RFP and future addendum; County resolutions and ordinances; and published
ICEMA Policy and Protocol Manual and any amendments thereto, which may be found at www.sbcounty.gov/icema.
Collectively, these requirements for service are referred to as the "Governing Documents" in this RFP.
The County makes no representation, promises, or guarantees concerning the actual number of ambulance transports,
number of patients, or distance of transports associated with this procurement. Every effort has been made to provide
accurate information, but Proposers will need to use their professional judgment and expertise to develop estimates,
economic models, operational plans, and proposals.
1.6 DESCRIPTION OF SAN BERNARDINO COUNTY
San Bernardino County (County) is the largest county by area in the contiguous United States, covering more than
20,000 square miles. The County borders Riverside, Los Angeles, Orange, Kern, and Inyo counties, as well as the states
of Arizona and Nevada. The County comprises both urban and rural communities containing 24 incorporated cities and
towns.
More than 93% of the County’s land area is within the desert region with the remaining areas in mountain and valley
expanse. According to the 2020 U.S. Census, the population is 2,180,537 with a projected growth of 16% between 2020
and 2045. Seniors, ages 65 and older, are experiencing the highest rate of growth at 70%. Forty-three percent (43%) of
residents speak a language other than English in their home.
The cost of living is lower in San Bernardino County compared to its Southern California neighbors. In 2019, median
household income in San Bernardino County was $67,903, a 21% increase since the 10-year low in 2014.
REAL M ED IAN INCOM E HAS INCREA SED OVER THE LAST FIVE YEARS
Median Househo ld Income (Inflation Adj usted to 2019 Do llars) in San Bernardino County, Californ ia, and the United States,
2010-2019
- San Bernardino County - California - United Stat es
$90,000 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
$80,440
$50,000 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
2010 20 11 2012 2013 20 14 2015 2016 2017 2018 2019
Sources: U.S. Census Bureau. 2010.2019 American Community Survey. 1-Year Estimates. Table B19013; U.S. Inflation Calculator. based on U.S. Bureau of u,bor Statistics Consume,
Price Index (www.usinflationcalcufator.com)
San Bernardino County participates in the California Community Health Assessment program, which tracks critical
health indicators. Chronic diseases are costly and contributes to approximately 70% of the United States’ deaths every
year, 75% of healthcare costs. The chart below illustrates the percentage of adults diagnosed with heart disease,
diabetes and high blood pressure compared to neighboring counties. San Bernardino County’s prevalence rate for heart
disease was the lowest among neighboring counties and the state. However, for diabetes prevalence, at 10.8% in 2018,
San Bernardino County had a rate of adults diagnosed with diabetes that was in the middle among counties compared
and higher than the California rate. Also in 2018, 29.5% of adults in San Bernardino County had high blood pressure,
second lowest among neighboring counties compared and lower than California.
COUNTY HAS LOWEST RATE OF HEART DISEASE BUT HIGHEST RATE OF HIGH BLOOD PRESSURE
County Comparison of the Percentage Ever Diagnosed with Diabetes, High Blood Pressure, or Heart Disease, 2018
Heart Disease: Diabet es: High Blood Pressure:
■ County ■ County ■ County
- Californ ia (6.8%) - California (10.1%) - California (29.8%)
40%
20%
0%
San Bernardino Los Angeles Orange San Diego Riverside
Source: California Health Interview Survey
1.7 DESCRIPTION OF THE EMS SYSTEM
A. Local EMS Agency Responsibilities
ICEMA is a Joint Powers Authority (JPA) responsible for administering Emergency Medical Services (EMS) in San
Bernardino, Inyo, and Mono Counties. ICEMA is designated as the local EMS Agency for San Bernardino County.
ICEMA has the regulatory responsibility to plan, implement, monitor, and evaluate the local EMS system. This is
accomplished through the establishment of policies and medical control. ICEMA is responsible for ensuring an effective
method of quality patient care and coordinated emergency medical response by planning, implementing, and
evaluating an effective emergency medical system that includes fire departments, public and private ambulances,
prehospital providers, hospitals, and specialty hospitals such as trauma, stroke, and cardiac care hospitals.
Section 1797.224 of the California Health and Safety Code provides for the creation of Exclusive Operating Areas (EOAs)
for ambulance services and the designation of providers to serve EOAs through one of two ways. The local EMS Agency
may conduct a competitive process approved by the California Emergency Medical Services Authority (EMSA) and
award a contract to the winning Proposer or, if the local EMS Agency develops or implements a local plan that continues
the use of existing ambulance providers that have been providing services within a local EMS area in the same manner
and scope since January 1, 1981 without interruption, the Local EMS Agency may negotiate an contract without a
competitive process.
American Medical Response (AMR), through its predecessor companies, has been providing ALS emergency ambulance
services under contract with San Bernardino County since the late 1970s. AMR has been a grandfathered ALS
ambulance transport provider under Section 1797.224 of the California Health & Safety Code. San Bernardino County
has not utilized the competitive process for any of the 26 Operational Areas (OAs) since their inception. This will be the
first RFP the County and ICEMA has conducted for ground ambulance transport services for this area of the County.
ICEMA, in coordination with the County, established an EMS plan that includes EOAs for ground ambulance services, as
allowed under California Health and Safety Codes Sections: 1797.76, 1797.85, 1797.103, 1797.105, 1797.224, and
1797.226. These EOAs are roughly approximate jurisdictions and historical EMS areas based on population density
defined as urban, suburban, rural, and wilderness. Ambulance service providers include private ambulance companies
and fire agencies. These agencies participate in providing mutual aid within the 26 OAs of which 21 are exclusive and 5
non-exclusive. This RFP bundles 11 of the 21 EOAs into one (1) operational Comprehensive Service Area.
SAN BERNARDINO COUNiY

AMBULANCE OPERATING AREAS
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The 2017 approved EMS Plan provides an overview of how the EMS system operates under the direction of ICEMA and
how it meets the 121 EMS standards and recommended guidelines. The EMS Plan includes and defines the ambulance
transportation system, including how EOAs are established and how ambulances respond within each of the EOAs. The
EMS Plan also provides information on dispatch centers, training programs and describes hospital services and specialty
care systems.
B. Ground Ambulance Transport Providers
Currently, ten (10) ground ambulance providers are serving San Bernardino County, responding to approximately
225,000 EMS requests annually. ICEMA charges ambulance providers, who have a contract or Memoranda of
Understanding (MOU) with the agency, a fee for management oversight and system monitoring.
The following ground ambulance providers serve San Bernardino County:
Ambulance Provider BLS ALS IFT CCT

American Medical Response X X X X
Big Bear Fire Department X X
City of Rialto Fire Department X

Desert Ambulance Services X X
Morongo Basin Ambulance X X
Baker EMS dba Needles Ambulance Service X
Running Springs Fire Department X X
San Bernardino County Fire Protection District X X X
Progressive Ambulance dba Liberty Ambulance X
San Manuel Fire Department X
C. Comprehensive Service Area
The Comprehensive Service Area for this procurement includes (EOAs 1, 2, 3, 4, 5b, 6, 7, 8, 9, 11 and 12a). Exhibit 2
provides greater detail on each response zone within the Comprehensive Service Area. The map below illustrates the
Comprehensive Service Area that includes the 11 EOAs.
,.......r--,
\
SAN BERNARDINO COUNTY

AMBULANCE EXCLUSIVE OPERATING AREA AND UPDATED RESPONSE TIME
EOAs OJ to 12a
D. Response Time Requirements
Emergency medical calls are measured at the 90th percentile within each response time zone for Code 3 and Code 2
categories. ICEMA established response times based on patient acuity at time of dispatch determination, and
population density (urban, suburban, rural, wilderness). ICEMA reviews response time compliance of ambulance
providers for all EOAs where a contract or MOU is in place. ICEMA publishes an annual Performance-Based Contracts
Report, listing emergency call data, response times for ambulance providers, and liquidated damages if assessed. These
reports are made available on the ICEMA website: http://www.sbcounty.gov/icema.
E. Interfacility and Critical Care Transports
The RFP requires the provider to respond to ALS, BLS, IFT and CCT requests originating in the Comprehensive Service
Area. For the calendar year 2021, there were 30,228 IFT calls and 3,261 CCT calls.
F. Ambulance Call Volume
Ambulance service call volume as provided by AMR within the Comprehensive Service Area is illustrated in the table
below for calendar years 2018, 2019, 2020 and 2021, Exhibit 3.
Calendar Year 911 Responses 911 Transports IFT Transports CCT Transports
2021 183,455 111,556 30,228 3,261
2020 197,876 117,024 36,010 3,590
2019 184,492 123,692 43,281 3,561
2018 180,397 120,578 41,620 3,044
G. Ambulance Service Payor Mix
Under current contract terms, the County does not pay the provider for ambulance services. Instead, ambulance
services are funded entirely by fee-for-service revenue from third-party payors or clients. Historically, this contractual
arrangement between the County and the private provider had shown mutual benefit, enabling the ambulance provider
to generate adequate revenue from direct client services while also allowing the County to guarantee ambulance
response for residents calling 911.
Payor Mix for Comprehensive Service Area

Calendar Year 2018 2019 2020 2021
Medicare 38% 39% 38% 37%
Medicaid 34% 33% 34% 33%
Commercial 16% 16% 16% 15%
Private Pay 12% 12% 12% 15%
H. Fire Departments
Fire departments in San Bernardino County provide varying degrees of emergency medical services. Many provide ALS
level response, and several provide ALS ambulance transport services. Fire agencies are dispatched when an ambulance
is dispatched, and both crews work together to benefit patient care. The chart below includes information on the level
of medical support participating fire agencies in the County provide. Fire agencies within the Comprehensive Service
Area are bolded.
San Bernardino County Fire Prehospital Providers BLS ALS Ambulance

Apple Valley Fire Protection District X
Arrowbear Lake Fire Department X

Barstow Fire Protection District X
Big Bear Fire Department X X
CALFIRE San Bernardino X
Chino Valley Fire District X
City of Highland Fire Department X
City of Montclair Fire Department X
Colton Fire Department X
Daggett Volunteer Fire Department X
Fontana Fire Protection District X
Fort Irwin Fire Department X
Loma Linda Fire Department X
Marine Corps Air Ground Combat Center Fire Department X
Morongo Valley Community Services District and Fire Department X
Newberry Springs Fire Department X
Ontario Fire Department X
Rancho Cucamonga Fire Protection District X
Redlands Fire Department X
Rialto Fire Department X X
Running Springs Fire Department X X
San Bernardino County Fire Protection District X X X
San Manuel Fire Department X X
Victorville Fire Department X
Yermo-Calico Fire Department X
I. Air Medical Transport
Medical helicopter service is available to transport critical patients when ground ambulance response or transport time
would be excessive, and the patient's condition meets helicopter transport criteria per ICEMA Policies.
These services are provided by two (2) air ambulance companies: Mercy Air Services and REACH Air Medical Services.
Air rescue services are provided by the California Highway Patrol and San Bernardino County Sheriff/Coroner/Public
Administrator Department.
J. Hospitals
The chart details hospitals and specialty care centers in San Bernardino County and neighboring jurisdictions where 911
ambulances will transport patients in accordance with ICEMA Policy 9030. The hospital system of care includes: 20
ambulance Receiving Hospitals, 5 Base Hospitals, 6 ST-Elevation Myocardial Infarction (STEMI) Receiving Centers, 1
Stroke Ready Hospital, 5 Primary Stroke Centers, 1 Thrombectomy Capable Stroke Center, 4 Comprehensive Stroke
Centers, 2 Level I Trauma Centers, 1 Pediatric Level I Trauma Center, and 1 Level II Trauma Center.
San Bernardino County 911 Receiving Hospitals
Receiving Base STEMI Stroke Trauma

Hospitals Hospitals Centers Centers Centers
Arrowhead Regional Medical Center X X CSC LEVEL I
Barstow Community Hospital X
Bear Valley Community Hospital X
Chino Valley Medical Center X X
Colorado River Medical Center X
Community Hospital of San Bernardino X
Desert Valley Hospital X X
Desert Regional Medical Center Riverside County CSC
Hi-Desert Medical Center X X SRH
Kaiser Permanente Fontana Medical Center X PSC
Kaiser Permanente Ontario Vineyard Medical Center X PSC
Loma Linda University Children's Hospital LEVEL I PEDS
Loma Linda University Medical Center X X X CSC LEVEL I
Montclair Hospital Medical Center X
Mountains Community Hospital X
Pomona Valley Hospital Medical Center Los Angeles
County X CSC LEVEL II
Redlands Community Hospital X X TCC

San Antonio Regional Hospital X X PSC
St. Bernardine Medical Center X X PSC
St. Mary Medical Center X X PSC
VA Loma Linda Healthcare System X
Victor Valley Global Medical Center X
Weed Army Community Hospital at Fort Irwin X
Legend:
CSC = Comprehensive Stroke Center
TCC = Thrombectomy Capable Center
PSC = Primary Stroke Center
SRH = Stroke Ready Hospital
K. Dispatch Centers
There are three (3) public safety dispatch centers and one (1) ambulance dispatch center currently responding
emergency resources within the Comprehensive Service Area. ICEMA has identified the following dispatch centers as
Emergency Medical Dispatch (EMD) authorized centers: Consolidated Fire Agencies (CONFIRE), Barstow Police, CAL
FIRE, and City of Ontario Emergency Communication Service (ECS), not all are currently providing EMD services.
CONFIRE is a Joint Powers Authority (JPA) located in San Bernardino County and is a secondary public safety answering
point established to provide communications, dispatch, computer information systems support, and geographic
information systems to CONFIRE members and contract agencies. The City of Ontario operates a primary public safety
answering point dispatching law and fire and is capable to provide backup dispatch services for CONFIRE. CAL FIRE
operates a secondary public safety answering point dispatching fire resources located in the Highland area.
CONFIRE provides Emergency Communication Nurse System (ECNS) dispatch services that operates as a nurse triage
line to provide enhanced caller interrogation and 911 response decisions. Nurse triage systems located within EMS
dispatch centers can reduce 911 ambulance call volume by 8% or greater.
Additionally, there is a separate JPA for the two (2) County regional Computer Aided Dispatch (CAD)-to-CAD projects to
enhance situational awareness and communication.
AMR receives emergency medical requests from the in-county dispatch centers and dispatches their own resources.
AMR additionally receives requests from hospitals for IFT and CCT transports. AMR has a CAD-to-CAD link with CONFIRE.
All other dispatch centers utilize the ring-down method to request an ambulance.
SECTION II - INSTRUCTIONS FOR PROPOSERS

2.1 PROPOSAL PROCESS
The County intends to award a contract to the respondent whose proposal meets all of the Request for Proposals (RFP)
criteria and receives the highest score from the scoring sheet as evaluated by the Proposal Review Committee
(Committee) and best meets the needs of the County.
All proposals become the property of San Bernardino County. The County reserves the right to waive non-material
changes. If Proposers choose to submit a proposal with a subcontractor, or a partnership, all will be held to the
standards within this RFP. The County will not accept any modifications to the RFP after the award.
The County may reject the proposal of any Proposer who previously failed to perform properly, or complete on time
contracts of a similar nature. The County may reject the proposal of any Proposer who is in default of payments of
taxes, or any other monies due to San Bernardino County. This RFP does not commit the County to award a
contract. The County reserves the right to reject any or all Proposals if it is in the best interest of the County to do
so. The County also reserves the right to terminate this RFP process at any time.
Materials submitted as part of the RFP process will not be returned to the Proposer.
2.2 PRE-SUBMITTAL ACTIVITIES
Proposers will be required to submit all questions in writing per the proposed timeline in order for staff to prepare
written responses. Written responses to questions will be shared with all potential bidders through the San Bernardino
County’s Electronic Procurement Network (ePro). Questions should be submitted via ePro:
https://epro.sbcounty.gov/bso/view/login/login.xhtm.
2.3 PROPOSERS’ CONFERENCE
A mandatory Proposers’ Conference will be facilitated in order to review the RFP specifications and process. All written
questions received from potential Proposers, along with County responses, will be posted on ePro for reference.
It is not anticipated that any substantial changes will be made to the RFP after the Proposers’ Conference. If there are
any minor changes or clarifications to the RFP made following the Proposers’ Conference, they will be posted on the
ePro portal. The Proposers’ Conference is mandatory, and only those proposers who attend this public conference will
be able to submit proposals.
A. Request for Changes
(1) If requesting changes to a part of this solicitation, identify the specific words or phrases and the sections and
paragraphs in which they occur. State the reason for each request and provide alternative suggested language.
Substitutions should be submitted by the Proposer no later than during the Proposers’ Conference.
(2) Requests submitted after the deadline will not be accepted. San Bernardino County’s consideration of a
suggestion does not imply acceptance.
B. Request for Substitution of Specified Equipment, Material, or Process
(1) Unless otherwise stated in the solicitation, references to items or processes by trade names, models, or catalog
numbers are to be regarded as establishing a standard of quality and not construed as limiting competition.
(2) If requesting a substitution for a required item, submit requests by the Deadline for Written Questions. Furnish
all necessary information required for San Bernardino County, in its sole judgment, to decide as to the
comparative quality and suitability of any suggested alternatives. San Bernardino County’s decision will be final.
If alternatives are accepted, San Bernardino County will issue an addendum to the solicitation.
2.4 PROPOSAL CONTENT AND ORGANIZATIONAL REQUIREMENTS
A. Proposal Format
Responses to this RFP must be in the form of a proposal package, which must be submitted in the following format:
(1) Presentation – submit all seven (7) hard copies of the proposal on 8 ½ x 11 paper. Each page, including
attachments, must be clearly and consecutively numbered.
(2) Cover Letter – approximately one (1) page in length, signed by an individual authorized to execute legal
documents for the Proposer, identifying the materials submitted.
(3) Authorized Contacts - identify the name, title, phone, and email address of the person to contact regarding the
proposal, as well as all other individuals authorized to represent the organization in contract negotiations.
(4) Table of Contents - all pages of the proposal, including the enclosures, forms, and any supplemental documents
must be clearly and consecutively numbered and correspond to the Table of Contents in Exhibit 1.
(5) Full Proposal – Approach to Scope of Work, (excluding financial information identified in Section 3.1 B).
(6) Supplemental Documents, as requested shall be an attachment to the full proposal.
B. Proposal Contents
(1) Proposals shall comprehensively describe how the Proposer will provide ground ambulance services for the
Comprehensive Service Area in San Bernardino County. Proposals shall demonstrate that the Proposer is to
perform all work in a manner consistent with the level of competency and standard of care normally observed
by an organization successfully providing ground ambulance services. Proposals shall include plans,
documentation, policies, and submissions that demonstrates the Proposer’s ability to comply with:
a. Elements described in this RFP,
b. Applicable federal and state legal requirements for Advanced Life Support (ALS) and Basic Life Support
(BLS) ground ambulance services,
c. The Inland Counties Emergency Medical Agency’s (ICEMA) policies and protocols,
d. Elements of the contract template Exhibit 4.
(2) Explain responses in a manner to be understood by people unfamiliar with industry jargon. Use drawings,
diagrams, schematics, and illustrations as needed, but do not simply refer readers to an exhibit or other section
of the proposal in lieu of a complete response.
(3) Address each requirement outlined in this solicitation in the order presented, describe how the requested
goods and services will be provided. Attention to the details in the Scope of Work shall be considered with the
response.
(4) Include a project schedule with milestones, deliverables, dates, and a project management plan.
(5) Specify any needs for physical space or equipment that the County must provide during the contract.
(6) Explain how work, and knowledge will be transitioned to the County or a new vendor at the end of the contract
period.
C. Price Proposal and Budget Documents
(1) Use the Excel spreadsheet provided in Exhibit 8, for the Price Proposal, use them without modification. Failure
to use the forms or templates provided, or modification of them, may result in rejection of the entire proposal.
(2) Place all cost and pricing data provided in the Exhibit 8, (employee compensation, ambulance transportation
rates and scenarios, operating and start-up budgets) as an attachment to the proposal.
2.5 PROPOSAL SUBMISSION
A. General
All interested and qualified Proposers are invited to submit a proposal for consideration. Submission of a proposal
indicates that the Proposer has read and understands the entire RFP, including all appendices, attachments, exhibits,
schedules, and addenda (as applicable) and that all concerns regarding the RFP have been resolved.
B. Proposal Submission Directions
(1) Proposers must submit their proposal via the Electronic Procurement Network (ePro) portal and provide an
electronic copy on a USB drive along with seven (7) hard copies.
(2) Proposals must be received by the designated date and time. All Proposers must register with the ePro system
prior to the date and time to receive the proposal or they will be disqualified. Late or incomplete proposals
will not be accepted. Electronic response must be submitted through ePro
https://epro.sbcounty.gov/bso/view/login/login.xhtml. Any system-related issues in ePro shall be directed to
the Purchasing Department at (909) 387-2060.
2.6 ERRORS IN PROPOSAL
The County will not be liable for any errors in proposals. Proposals may be rejected as unresponsive if they are
incomplete, are missing pages or information, or cannot be opened for any reason. The County may waive minor
irregularities and request Proposer cure such irregularity, but such waiver will not modify any remaining RFP
requirements. A minor irregularity means that the defect is immaterial or inconsequential as to price, quantity,
quality, or delivery when contrasted with the total costs or scope of the services being procured. This RFP does not
commit the County to award a contract.
A.
(1) Minor irregularities may be waived by the Purchasing Agent when they are any of the following:
a. Do not affect responsiveness,
b. Are merely a matter of form or format,
c. Do not change the relative standing or otherwise prejudice other offers,
d. Do not change the meaning or scope of the RFP,
e. Are trivial, negligible, or immaterial in nature,

f. Do not reflect a material change in the work, or
g. Do not constitute a substantial reservation against a requirement or provision.
In such cases the Proposer will be notified of the deficiency in the Proposal and given an opportunity to correct the
irregularity, defect or variation or the County may elect to waive the deficiency and accept the Proposal. The
decision to provide a waiver shall in no way modify or compromise the overall purpose of the submittal, nor excuse
the Proposer from compliance with all requirements if awarded a Contract.
(2) By submitting a proposal, each Proposer certifies under penalty of perjury that:
a. Its submission is not the result of collusion or any other activity that would tend to influence the selection
process directly or indirectly.
b. The Proposer is able or will be able to comply with all requirements of this solicitation at the time of
contract award.
c. Proposer certifies all statements in the response are true.
d. Neither Proposer, its employees, nor any affiliated firm providing the requested goods and services has
prepared plans, specifications, terms, or requirements for this solicitation, or has any other actual or
potential conflict of interest.
e. The Proposer is aware of the provisions of Section 1090 et seq. and Section 87100 et seq. of the California
Government Code relating to conflict of interest of public officers and employees and is unaware of any
financial or economic interest of any County officer or employee relating to this solicitation.
B. This RFP does not commit the County to award a contract. The County reserves the right to reject any or all
Proposals if it is in the best interest of the County to do so. The County also reserves the right to terminate
this RFP process at any time.
2.7 CONFIDENTIALITY OF PROPOSALS
The content of proposals shall not be released until the County has completed negotiations with the winning Proposer.
At that time, the County may release the content of the proposals for public review.
2.8 CONTACT WITH COUNTY EMPLOYEES
Violation of the following prohibitions may result in a Proposer being found non-responsive, barred from participating
in this or future procurements, and becoming subject to other legal penalties.
A. As of the issuance date of this RFP and continuing until it is canceled, or an award is made, no person, Proposer,
or person acting on behalf of a prospective Proposer may discuss any matter relating to the RFP with any
officer, agent, or employee of San Bernardino County, other than the Authorized Contact Person, or as outlined
in the evaluation or protest procedures.
B. Proposers may not agree to pay any consideration to any company or person to conduct lobbying activities to
influence the award of a contract by the County, nor engage in behavior that may be reasonably construed by
the public as having the effect or intent of influencing the award of a contract. Nothing in this section precludes
a proposer from engaging the services of a company or person to assist in the development of the response to
the RFP.
2.9 WITHDRAWAL OF PROPOSALS
Proposals may be withdrawn, modified, or replaced, and resubmitted as long as submittal is before the due date and
time. If a Proposer chooses to withdraw their proposal after the due date and time, it will be excluded from
consideration.
2.10 NO COMMITMENT
Neither submission of a proposal nor the County’s receipt of proposal materials confer any right to the Proposer nor
any obligation on the County. This RFP does not commit the County to award a contract, nor will the County defray any
costs incurred in preparing proposals or participating in any presentations or negotiation.
2.11 ESTIMATED QUANTITY
The County makes no guarantee, either expressed or implied, as to the actual quantity of goods and services that will
be authorized under the contract. For example, the County cannot guarantee a specific number of ambulance
transports pertaining to this RFP.
2.12 SELECTION
At any time in the evaluation process, the County may request clarifications from Proposers.
A. Determination of Responsiveness:
A proposal must conform to the instructions outlined in this solicitation and any modifications to be considered
responsive. Non-responsive proposals will be rejected. The County, in its sole discretion, may waive non-consequential
deviations if the deviations have not provided an advantage over other Proposers.
B. Proposal Evaluation:
The County will establish a non-biased Proposal Review Committee. Each member of the Committee will evaluate and
score the proposals based on the criteria specified in the solicitation scoring sheet. The scores from all the evaluators
will be calculated to arrive at a final score for each proposal. All Proposals will be evaluated and scored by the
Committee and will be invited to participate in an oral presentation of their proposal. The Committee will recommend
the highest scoring Proposer for final negotiation of contract terms. The Proposer Scoring Sheet is found in Exhibit 5.
2.13 NEGOTIATIONS AND NOTICE OF INTENT TO AWARD
The County may require the potential Proposer(s) selected to participate in negotiations. This may include cost,
technical, or other clarifications needed for contract award.
A. Contract Negotiation
After selection, negotiations may be conducted with the Proposer of the highest-ranked proposal. Negotiations, if held,
shall be within the Scope of Work in the RFP. The contract negotiations will take place in San Bernardino County,
California, the Proposer will be responsible for its travel and other incurred expenses of its personnel.
B. Failure to Negotiate
(1) If the selected Proposer:

a. Fails to provide the information required to begin negotiations in a timely manner; or
b. Fails to negotiate in good faith; or
c. If the Proposer and the County, after a good faith effort, simply cannot come to terms.
Then the County may terminate negotiations with the Proposer initially selected and commence negotiations with the
next highest rated Proposer.
C. Notice of Intent to Award (NOIA) – Proposer Notification of Selection
After the completion of contract negotiations, a written or electronic NOIA and denial letters (or a copy of the NOIA)
will be issued to all Proposers. The issuance date of the NOIA is the date the notice was delivered by email or into the
care of the United States Postal Service (USPS) for delivery to the Proposer.
D. Review of Financial Information
Financial information may be used to evaluate and select the proposal deemed to be in the County’s best value.
Alternatively, at the County’s sole discretion, the financial performance of the intended Contractor may be assessed
prior to contract award. Financial performance deemed unsatisfactory such as but not limited to bankruptcy within
the last 5 years, failed performance on past contracts, inability to pay County charges, may result in non-award or a
recommendation for award to another Proposer.
E. Award
A contract will be awarded based on the highest scoring proposal received. The content of the proposal of the
successful Proposer will become contractual obligations and failure to accept these obligations in a contract may result
in cancellation of the award.
F. Commencement of Performance
After all parties have signed the contract, the County will notify the Proposer and performance may proceed on the
date indicated on the Proposed Timeline or as negotiated. Prior to the County execution of the contract, no County
employee may authorize services under this contract to commence. Any services performed prior to that date will be
uncompensated.
2.14 PROTESTS (APPEAL AND AWARD)
A. In the event a dispute arises concerning the Proposal process prior to the award of the contract, the Proposer
raising the dispute shall submit a request for resolution in writing to the Purchasing Director. The Proposer
may appeal the recommended award or denial of award (Protest), provided the Protest:
(1) Is submitted in writing.

(2) Is submitted within ten (10) calendar days of the issuance date of the NOIA
B. A Protest can only be brought on the following grounds:
(1) Failure of the County to follow the selection procedures and adhere to requirements specified in the RFP or
any addenda or amendments.
(2) Violation of conflict of interest as provided by California Government Code Section 87100 et seq.
(3) Violation of State or Federal law.
Protests will not be accepted for any other reasons than those stated above. All Protests must be sent to:
Pete Mendoza, Interim Purchasing Director

Upon receipt of the formal Protest, the Purchasing Agent, or his/her designee, will attempt to resolve the Protest. A
Protest shall be disallowed when, in the judgment of the Purchasing Agent it has been submitted: (1) as a delay tactic;
(2) for the purpose of posturing the Proposer advantageously for future procurement; (3) in a form that deviates from
the one prescribed; (4) without adequate factual basis or merit; or (5) in an untimely manner.
The Purchasing Agent shall make a decision concerning the appeal, and notify the Proposer submitting the Protest,
within a reasonable timeframe prior to the tentatively scheduled date for awarding the contract. The decision of the
Purchasing Agent shall be deemed final.
Alternatively, at the Purchasing Agent’s discretion, an Appeal Panel consisting of five (5) members appointed by the
Purchasing Agent shall hear the Protest. The Proposer will be provided reasonable notice of the time, date, and location
of the hearing. In the event that a protesting Proposer does not appear at the Protest hearing as scheduled, the Protest
will be disallowed.
The hearing is informal, in that it is not subject to the strict rules of evidence or procedure, and live witnesses, if any,
will not be sworn. All relevant evidence is admissible, including hearsay. It will be up to the Appeal Panel members to
consider the credibility of the evidence and the weight to give it.
The Panel will determine by at least three (3) affirmative votes: 1) whether the Protest was submitted timely; 2) whether
the Protest is based on at least one (1) of the three (3) designated grounds identified above; and 3) whether the grounds
on which the Protest are based have been substantiated.
If any of the grounds are determined to be valid, the Panel will also decide if the valid portion of the Protest has so
tainted the RFP process that it is unfair to the Proposer or whether the valid grounds for the Protest are in the nature
of harmless error and that the RFP process was fair to the Proposer. The Panel will not re-evaluate the Proposals.
The Purchasing Agent shall notify the Proposer making the Protest of the decision, within a reasonable timeframe prior
to the tentatively scheduled date for awarding the contract. The decision of the Appeal Panel shall be deemed final. If
the contract must be approved by the Board, after receiving a decision from the Purchasing Agent or Appeal Panel, the
Proposer may then present its Protest to the Clerk of the Board of Supervisors for the Board’s review and decision. The
Proposer must file its written Protest with the Clerk of the Board or provide a verbal Protest (typically limited to three
minutes) prior to the Board making a decision on the contract. Any decision of the Board shall be deemed final.
A Proposer protesting the results of any of the processes described herein must follow the procedures set forth. By
submitting a “Letter of Intent to Protest”, the Proposer has agreed that the protest procedures herein shall precede
any action in a judicial or quasi-judicial tribunal regarding this Proposal. Protests that do not follow these procedures
shall not be considered. The protest procedures constitute the sole administrative remedy available to the Proposer
under this RFP. Upon exhaustion of this remedy no additional recourse is available.
2.15 PUBLIC RECORDS ACT
All Proposals and other material submitted become the property of the County and are subject to release according to
the California Public Records Act (Government Code Section § 6250). All Proposal information, including Price Proposal,
will be held in confidence during the evaluation and negotiation process. Thereafter, Proposals are subject to becoming
a non-exempt public record.
If a Proposer believes that any portion of its proposal is exempt from public disclosure, it must indicate the specific
portions believed to be confidential and not subject to disclosure on Exhibit 18 - Public Records Act Exemptions. The
Proposer also must include a brief description that sets out the reasons for exemption from disclosure. Each stated
exemption must include a citation to supporting legal authority, including statutory authority or case law, to support
exemption from the Public Records Act. Requested exemptions that do not meet the requirements of this section will
not be considered.
The County will use reasonable means to ensure that such information is safeguarded but will not be held liable for
inadvertent disclosure of the information. Proposals marked “Confidential” in their entirety will not be honored, and
the County might not deny public disclosure of any portion of Proposals so marked.
By submitting a Proposal with portions identified in the Attachment as “Confidential,” Proposer represents that it has
a good faith belief that such portions are exempt from disclosure under the California Public Records Act. Proposer
may be requested to obtain legal protection from disclosure should a Public Records Act request be received. In the
event the County does not disclose the information marked “Confidential,” Proposer agrees to reimburse the County
for, and to indemnify, defend (with counsel approved by County) and hold harmless the County, its officers, employees,
agents, and volunteers from and against any and all claims, damages, losses, liabilities, suits, judgments, fines, penalties,
costs and expenses, including without limitation, attorneys’ fees, expenses and court costs of any nature arising from
or relating to the County’s non-disclosure of any such designated portions of a proposal.
SECTION III - QUALIFICATIONS, EXPERIENCE, AND EVALUATION CRITERIA

3.1 MINIMUM QUALIFICATIONS
The County invites highly qualified and experienced Proposers interested in providing 911 ambulance services. The RFP
allows for various delivery models, including public providers, private providers, Joint Powers Authority (JPA) or a
combination. This RFP additionally allows a Contractor to develop partnerships and/or subcontract for Advanced Life
Support (ALS), Basic Life Support (BLS), Interfacility Transport (IFT) and Critical Care Transport (CCT) ambulance services,
within the Comprehensive Service Area. Contractor will be solely responsible for the performance of its obligations
according to the provisions of this RFP and a partner or subcontractor will not relieve the Contractor of its
responsibilities and obligations. If the Contractor subcontracts for ambulance transport services, the subcontractor shall
be subject to all terms and provisions including the qualifications in this RFP.
Nothing contained in the Request for Proposals (RFP) or otherwise creates any contractual relationship between the
County and a subcontractor. The Contractor agrees to be fully responsible to the County for acts and omissions of its
subcontractor.
A. If the Proposer plans to utilize partners and/or subcontractors, the Proposer shall describe:
(1) How they plan to utilize a partner(s) and/or subcontractor(s) to meet the requirements within the RFP; how
the partnership will work together; and how the Proposer will hold subcontractors to the terms and conditions
of this RFP.
(2) How the Proposer will remain solely responsible and accountable to meet all requirements of the RFP, including
response time and reporting requirements and how the Contractor will be liable to pay any Liquidated
Damages for non-performance by any partner or subcontractor acting on its behalf.
(3) Ancillary services, such as billing; professional, legal, and advisory services; and fleet maintenance services do
not need to meet all the qualifications identified in Section III.
To qualify for evaluation by the Proposal Review Committee (Committee), a Proposer and subcontractor must meet
the following minimum qualifications. Proposers must respond to each of the items below to demonstrate qualifications
and must provide supporting documentation. Each response to the following proposer qualifications will be evaluated
and scored. Proposals not meeting minimum qualifications will be disqualified and not forwarded for evaluation and
scoring by the Committee.
This section evaluates the Proposers ability to meet the minimum organizational experience and capacity, Key
Employee qualifications and experience, and plan for ensuring high quality staffing. Please provide the following
information that supports this evaluation.
B. Organizational Experience
(1) Five (5) years within the last seven (7) years, continuously engaged in providing 911 ALS transport services as
required by a contract in the United States as a primary 911 ambulance services provider at the ALS, IFT and
CCT levels for a large Urban area with a population greater than 1,000,000, including a mix of urban, suburban,
rural and wilderness areas. This requirement can be met through a subcontractor.
(2) If the Proposer is organized as a legally formed partnership or Limited Liability Company (LLC), or governmental
JPA, each partner entity participating in the partnership or LLC must have existed and continuously provided
911 primary ALS transport Emergency Medical Services, for a minimum of five (5) years within the last seven
(7) years, in the United States. If the mix of JPA partners is within San Bernardino County, the collective
experience is sufficient to meet the population and transport requirement in B (1) above, a JPA subcontractor
must meet the requirements detailed in B (1).
(3) Proposers must indicate:
a. The number of years the Proposer has been in business under the present business name.
b. The number of years providing services as a BLS, ALS, IFT and, CCT ambulance transport provider.
c. Whether the Proposer holds a controlling interest in any other company or organization or is owned or
controlled by any other company or organization.
d. Documented proof of ability to measure and achieve compliance with fractile response time performance.
e. Documented proof of ability to measure and achieve compliance with clinical performance requirements.
C. Key Leadership Experience
(1) Each of the key management personnel to be assigned to San Bernardino County listed in this section must
have experience providing or directly overseeing provision of the services identified for each position.
(2) Provide a detailed organizational chart of the management structure, including assigned and responsible team
members for the local operation and provide how the local management team interfaces with the parent
organization or governing body. Identify which positions are located in the County.
(3) Describe the local management including clinical management team, roles and responsibilities including titles
and names of staff members who are responsible for the service. Please include their backgrounds and attach
resumes. The County reserves the right to approve or reject proposed local management based on but not
limited to lack of experience, or prior criminal record.
(4) For field supervisors, billing, Continuous Quality Improvement (CQI), and training positions provide the number
of Full-Time Equivalent (FTE) employees assigned and their expected case load as to how the staffing can meet
the calls for service and employee quantities in the proposed services.
D. References
Proposer shall provide five (5) letters of reference for this RFP. Letters of reference must be signed and dated by the
author and describe the direct or indirect or financial relationship between the author or organization and the Proposer.
Letters of reference may not be supplied by or considered from the Inland Counties Emergency Medical Agency
(ICEMA), County or County staff members. Letters shall describe the extent to which the author/organization is familiar
with the Proposer and the Proposer’s work/performance.
Append five (5) letters of reference specifically related to the organization’s current and existing:
(1) Agreements and contracts
(2) Clinical performance as an ALS contractor
(3) Quality improvement program effectiveness
(4) Response-time performance
(5) Vehicle maintenance and replacement program
(6) Relationships with first responder agencies
(7) Relationships with hospitals and specialty care centers

(8) Relationships with labor organizations
E. Financial Condition
(1) All Proposers shall provide evidence that documents the financial history of the organization including financial
interests in any other related business and demonstrates that it has adequate cash on hand to finance start-
up costs and contract implementation for the first six (6) months of operations as indicated in the Total Expense
line in Exhibit 8.
(2) Provide a statement of the organization’s current estimated net worth and the form of the net worth (liquid
and non-liquid assets).
(3) Proposers must include a statement of the organization’s estimated amount of working capital that will be
committed to start-up cost. Proposers must identify the source of this capital and if any part of it will be
borrowed, as well as verification from a financial institution that the organization is approved or pre-qualified
to borrow sufficient funds. Proposers must provide assurances for such funding from the parent or related
organization in the form of a letter guaranteeing the amount of funding that may be necessary for start- up
and on-going losses if projections are inadequate.
(4) Provide externally audited financial statements for the most recent five (5) years, (public providers must
comply with #5 below). If the Proposer organization is a subsidiary of another corporation or is a dependent
governmental entity, Proposer shall provide externally audited financial statements for the parent entity for
the most recent five (5) years. If financial statements of a parent entity are submitted, the Proposer
organization's financial statements must either be separately shown as a part of those financial statements or
submitted separately in the same format and for the same period. Such a parent entity is required to guarantee
the performance of the Proposer. Failure to submit audited financial statements may cause disqualification
from this RFP process.
(5) Local government Proposers must provide Comprehensive Annual Financial Report (CAFR) statements for each
agency partner for five (5) years and disclose the funding total and sources along with the partnership
agreements for system start-up funding, reserves and holding of billing revenues. The final legal entity for
economic responsibility for fiscal shortfalls must be identified. Should the entity need a public governance vote
or voter approved initiative to backfill ambulance system losses, to the partnerships operating or reserve funds,
these approval points must be disclosed.
(6) Documentation that the Proposer is free of commitments, has no existing obligations that might impact the
ability to provide services under the terms of this contract or any commitment or obligation that would impact
Proposer’s ability to obtain lines of credit, guarantor letters, or otherwise negatively affect the Proposer’s
ability to perform the contract.
(7) Documentation of any legal bankruptcy filings within the last ten (10) years.
(8) The Proposer must be able to obtain and maintain in full force and effect, throughout the term of the contract
a performance guarantee in the form of a performance security bond or an irrevocable Letter of Credit, in the
amount of twenty million dollars ($20,000,000) payable without condition to San Bernardino County, with
surety acceptable to and approved by the Auditor-Controller, which bond or irrevocable Letter of Credit shall
guarantee to the County full and faithful performance of all of the terms and provisions of this contract to be
performed by the Contractor, and as said contract may be amended, supplemented or extended as long as
adjustments are within the scope of this RFP.
F. Legal History
(1) This item may be submitted in an electronic format, such as a USB drive. Proposer shall document its litigation
history for the past five (5) years. A Proposer may be disqualified if a final judgment was issued against
Proposer or any affiliated organization for breach of contract or failure to perform ambulance or other
emergency services competently and adequately. The proposal must include a listing of all resolved or ongoing
litigation involving the Proposer’s organization, including a narrative describing the claim or case and the
resolution or status for the past five (5) years. This listing shall include litigation brought against the Proposer’s
organization or affiliated organizations and any litigation initiated by the Proposer’s organization or affiliated
organizations against any governmental entity or ambulance provider. For purposes of this litigation history,
“affiliated organization” means any organization owned by Proposer, any organization for which Proposer is a
successor entity, any organization that either merged with Proposer or divested from Proposer or any
organization which is a parent or subsidiary of Proposer. The term “litigation” means any civil actions filed in a
court of competent jurisdiction, or any matters filed by an administrative or regulatory body with jurisdiction
over the Proposer agency or affiliated organization, and includes disputes resolved by mediation or arbitration.
“Litigation” also means any bankruptcy petition filed in a court of competent jurisdiction. Proposer shall
document its bankruptcy history for the past ten (10) years, disclose the type of bankruptcy filed and
summarize the bankruptcy proceedings and orders. The Proposer must also provide documentation that they
are legally authorized or eligible to do business in the State of California and/or the ability to obtain such
authorization prior to contract start date.
(2) List applicable licenses and license numbers, including expiration dates relevant to delivery of services; the
names of the holders of those licenses, and the names of the agencies issuing the licenses, excluding field
personnel.
(3) Documentation that Proposer is free of commitments that would impact Proposer’s ability to obtain lines of
credit, guarantor letters, or otherwise negatively affect the company's ability to perform the contract. (No
existing obligations that might impact the ability to provide services under the terms of this contract).
(4) The Proposer must submit a list or table of every ambulance transport contract the Proposer currently serves
and every contract it has served in the last five (5) years as part of the submission of its proposal.
Proposer shall indicate:
a. Type and level of service provided including the population (urban, suburban, rural and wilderness)
compliance categories,
b. The contract periods,
c. Whether the Proposer held exclusive market rights for emergency ambulance service under the contract,
d. Whether the contract was competitively awarded,
e. The name, address, contact person, and telephone number for the contract for reference purposes,
f. Gross revenue of services provided,
g. The name of the contracting agency,
h. The remaining term of the contract and the circumstances under which any contract was terminated, the
cause of the failure or refusal to complete, and any allegations of deficient service, if applicable,
i. Details of any refusals or failure to complete an ambulance contract as a BLS, ALS, IFT or CCT provider.
3.2 EVIDENCE OF INSURANCE OR ABILITY TO OBTAIN INSURANCE
Proposer shall provide Evidence of Insurance/self-insurance, or obtain a letter from an Insurance company/underwriter
of Proposers ability to obtain insurance consistent with the County’s minimum insurance requirements described in
Exhibit 15.
3.3 EVALUATION CRITERIA
Proposals will be evaluated by the Committee following the evaluation criteria outlined in Exhibit 5. Committee
participants will have a broad range of experience in Emergency Medical Services, and county government
administration. Committee members will have an opportunity to adjust scores based upon additional information
provided during oral presentations.
SECTION IV - SCOPE OF WORK AND SCORING CRITERIA

4.1 SUMMARY
The County is committed to providing the highest level of Emergency Medical Services (EMS) through a system design
consisting of fire first response and Advanced Life Support/Basic Life Support (ALS/BLS) ambulance services. The County
intends to award an initial five (5) year contract to a responsive Proposer whose proposal conforms to the Request for
Proposals (RFP) and whose proposal presents the greatest value to the residents and visitors in San Bernardino County.
This section and the exhibits that follow describe elements of the proposal that will be scored. The proposal must
comply with the requirements described in this RFP. Inclusion of this section is intended to help ensure the Proposer
includes critical, scored elements in the proposal. Within the proposal, please organize responses using the
organizational format below. The Proposer should provide sufficient detail in the proposal so that the Proposal Review
Committee (Committee) can effectively evaluate the proposal.
4.2 SYSTEM REQUIREMENTS
A. Commission on Accreditation of Ambulance Services (CAAS)
The County intends to require the Contractor become accredited by the Commission on Accreditation of Ambulance
Services (CAAS) within eighteen (18) months following commencement of the term of the contract. CAAS
accreditation is a process for an ambulance service to increase operational efficiency and decrease risk and liability.
The Contractor shall maintain this accreditation throughout the term of the contract.
B. ICEMA System Monitoring, FirstWatch Surveillance Platform

ICEMA utilizes the FirstWatch surveillance platform provided by the current ambulance provider. The Online
Compliance Utility (OCU) is a real-time web-enabled tool for use by providers and agencies to simplify and manage
response times based on the authorized dispatch centers real-time Computer Aided Dispatch (CAD) data. The web-
based tool provides interactive queues with a consistent look and feel for both the provider and agency allowing real
time review of late calls-based contract requirements.
FirstPass provides the ability to monitor and analyze patient care data, identifying deviations rapidly, consistently, and
automatically. Combined with the County’s electronic Patient Care Reporting (ePCR) program, data is collected and
reviewed quickly without data loss due to entry errors. FirstPass alerts when a patient care report does not match The
Inland Counties Emergency Medical Agency’s (ICEMA’s) protocols.
The Proposer shall be financially responsible to license as needed the FirstWatch products, including FirstWatch On-
line Compliance Utility (OCU), and FirstPass. FirstWatch products must be purchased and licensed to ICEMA by the
Contractor. The Proposer will be expected to pay all costs for data source integration to include initial implementation
costs, ongoing annual support, and maintenance fees as identified in Exhibit 14.
C. Contractor Support of County Compliance Contract Management, Monitoring and Regulatory Activities
This RFP requires the Contractor to reimburse ICEMA for ICEMA’s expenses in monitoring and managing the contract,
and for EMS medical direction and coordination as identified in Exhibit 14. Payments shall be made quarterly with the
first payment due within thirty (30) days of the close of the first quarter with subsequent quarterly payments
throughout the term of this contract. The annual payment shall not exceed the County's actual costs for management
and regulatory activities associated with the contract.
4.3 RESPONSE TIME STANDARDS
This section evaluates the Proposer’s ability to comply with minimum County response time requirements and provides
Proposers the criteria for how the County will measure compliance as identified in Exhibit 6. Proposer’s must consider
the following information in their response and provide requested information that supports this evaluation.
The overall Response Time performance requirement for services under this RFP is intended to ensure the Contractor
responds to and arrives at each incident with an appropriate ambulance resource in accordance with established ICEMA
standards. The standards set forth herein establish the level of Response Time performance required by the Contractor
for calls within the Comprehensive Service Area.
It is the Proposer's sole responsibility to be familiar with the geographic and weather considerations in each Exclusive
Operating Area (EOA) throughout the Comprehensive Service Area, comprising this solicitation. The Contractor will be
held accountable for response time defined as the time the ambulance dispatch center is notified of the request for
service, and the time the ambulance notifies by radio or other reliable method that the ground ambulance has arrived
on-scene (wheels stopped) at the address site or at a designated or assigned staging area. All response times shall be
measured in whole minutes with seconds. In the case of significantly encumbered/restricted access to the patient, the
term “On-Scene” shall be understood to mean the time the ground ambulance arrives at the restricted access point,
e.g., staging area, at the gate of a closed gated area, or rendezvous point to be escorted to the patient by another
individual.
In all incidents where the crew fails to report their arrival on-scene, the Contractor may submit GPS data to confirm on-
scene time, otherwise, the next radio transmission is to be used to confirm on-scene times.
(1) Proposer must supply supporting documentation to demonstrate the Proposer’s ability to meet the response
time criteria. Include documented proof of ability to measure and achieve compliance with fractile response
time performance. Documentation may include reports provided to government oversight entities and letters
confirming compliance with mandated response times. Internal reports with adequate supporting
documentation of the methodology used to create response time performance reports may also be submitted.
(2) There are response time compliance zones for this RFP (Exhibit 2). Proposals must evidence an ability to
maintain response times with at least 90% compliance in each EOA.
a. A measurement period is defined as any complete month, or accumulation of months in which the total
number of calls in a response area equals or exceeds one hundred (100) or a twelve (12) month period,
whichever is first.
b. Measurements will be calculated separately for each EOA for data collection and system improvement.
c. Each EOA is assigned response times based on population (urban, suburban, rural and wilderness)
compliance categories and the Emergency Medical Dispatch (EMD) determinant as approved by the ICEMA
Medical Director.
d. Response times per EOA will be re-evaluated periodically based on population changes identified by the
US Census Bureau.
4.4 CLINICAL PERFORMANCE STANDARDS
This section evaluates the Proposer’s ability to comply with clinical performance standards. The section provides
Proposers the criteria for how the County will measure compliance as identified in Exhibit 7. The following information
must be considered in the response and requested information must be provided which supports this evaluation.
(1) It is well established that quality management efforts improve patient care. Many EMS systems focus on
response time compliance as the lead measurement of quality performance. It is the intent of the County as
part of this RFP to also emphasize clinical performance. Clinical performance measures have been published
and are continuing to evolve in EMS. It is the Proposer's responsibility to be familiar with published clinical
performance standards and EMS quality measures, including those identified for consideration in this RFP
(Exhibit 7).
(2) The Proposer will be held accountable for clinical performance standards as part of a performance-based
contract. These will be developed as part of a new contract and the Proposer should provide detail on how
they will incorporate clinical quality measures into their service contract. Proposals should address the
methods of measurement and quality improvement activities to address adherence to clinical standards.
Including documented proof of ability to measure and achieve compliance with clinical performance standards.
Proposers will not be scored on the performance measures, as these benchmarks will be developed
collaboratively during the first year of the contract. Proposers will be scored on their overall ability to
incorporate quality improvement activities into their patient care practices.
(3) It is the goal of ICEMA to work collaboratively with the Contractor to jointly develop clinical standards and
establish performance benchmarks within the first year of the contract based on the clinical measures
identified in Exhibit 7.
A. Liquidated Damages
There will be liquidated damages for underperformance in both clinical and response time performance. Response time
performance will be measured monthly. Clinical performance will be measured quarterly. Liquidated Damages for
clinical performance will only be assessed after a robust performance improvement process has been conducted to
include root cause analysis and performance improvement mitigations have not been implemented. For an example of
how liquidated damages will be assigned see (Exhibit 6 and 7).
4.5 AMBULANCE DEPLOYMENT AND SYSTEM STATUS PLAN
A. Ambulance Deployment Requirements
This section evaluates the Proposer’s ability to comply with requirements identified below for ambulance deployment
and the system status plan. The following information must be considered in the response and requested information
must be provided which supports this evaluation.
Proposers need to be aware of hospital overcrowding and Ambulance Patient Off-load Delays (APOD) in the
Comprehensive Service Area. ICEMA’s APOD Policy 8100, has a goal of twenty-five (25) minutes to complete patient
transfer of care. In 2021, the average APOD was twenty-eight (28) minutes beyond the 25-minute allowable transfer
period, for a total average of fifty-three (53) minutes. Proposers need to account for APOD in the development of a
system status plan.
Ambulance System Status and Deployment Plans will be approved by ICEMA annually. The plan will describe:
(1) Deployed ALS and BLS Unit Hours by EOA to achieve response times requirements. The plan must show Unit
Hours by time of day and day of week and if there are seasonal variations.
(2) Mechanisms to meet the demand for ambulance response during peak periods or unexpected periods of
unusually high call volume and other surge events, including disasters, large fires, a pandemic or high flu
season.
(3) Include a process that identifies how additional ambulance unit hours will be added by the Contractor if the
on-time response time performance standards are not met.
(4) Include a map identifying proposed ambulance station(s) and/or post locations within the geographic zones
within the response time compliance areas as indicated in this RFP. The Proposer is not required to provide
ambulance stations unless staffing 24-hour shifts.
(5) Workforce necessary to fully staff ambulances identified in the deployment plans.
(6) Any planned use of on-call crews.
(7) Ambulance shifts and criteria to be used in determining shift lengths.
(8) Any mandatory overtime requirements.
(9) Record keeping and statistical analyses used to identify and correct response time performance deficiencies.
(10) Any other strategies to enhance system performance and/or efficiency through improved
deployment/redeployment and mutual aid practices both inside and outside the Comprehensive Service Area.
(11) Provide a sufficient number of ambulances that are fully stocked to meet 133% of peak system demand. For
example, if 100 ambulances are needed to meet peak demand, then 33 additional ambulances are required to
be fully equipped and ready for utilization to meet this standard. The proposer must ensure their surge plan
and response includes equal protection for all EOAs within the Comprehensive Service Area. The requirement
is not to have 133% coverage in each EOA, but rather distribute flexible resources to ensure coverage during
surge periods.
(12) The initial ambulance deployment plan unit hours shall not be decreased for the first twelve months of
operations.
(13) Any modification of the Contractor’s system status plan requires approval from the ICEMA Administrator.
B. Standby and Special Events
This section evaluates the Proposer’s ability to plan for and participate in Special Events. The following information
If an event sponsor desires a dedicated standby ambulance at an event, the provider may enter into a separate contract
with the sponsor for the provision of standby and payment for such services. Standby special events services are not
part of the Comprehensive Service Area. If the Proposer enters into a contract for standby special event services, they
must not utilize a 911 system ambulance to staff contracted standby events.
4.6 VEHICLES
A. Ambulance Requirement
This section evaluates the Proposer’s ability to comply with the ambulance requirements identified below. The
following information must be considered in the response and requested information must be provided which supports
this evaluation.
Ambulances must conform to the following requirements:
(1) Ambulances may be standard Type I, Type II, or Type III.

(2) Ambulance must be configured to meet the safety and ergonomic needs of employees.
(3) Be identically configured.
(4) In certain terrain locations, a four-wheel drive ambulance may be necessary.
(5) It is recommended that ambulances utilize hydraulic gurneys to reduce incidents of spinal load injuries and
increase the margin of safety for patients and EMT/paramedics.
(6) The use of Automatic Vehicle Locators (AVLs), Mobile Data Computers (MDCs), and Global Positioning System
(GPS) mapping technology is required. The AVL system must interface with the Centralized Emergency Medical
Dispatch (EMD) Center CAD system. The Contractor is responsible for all fees associated with the purchase and
monthly operations of the AVL system.
(7) Meet or exceed Federal and State standards at the time of the vehicles’ original manufacture, except where
such standards conflict, in which case the State standards shall prevail.
(8) Meet or exceed the recommendations for ambulances by the Ambulance Manufacturers Division of the
National Truck Equipment Association.
(9) Meet or exceed the equipment standards of the State of California.
(10) Ambulances shall be limited to a maximum mileage of 300,000 and less than ten years of age.
(11) Ambulances not new at the start of this contract must include a list of brand name, model, age, and
maintenance records. No more than 25% of the ambulance fleet shall have over 100,000 miles at the start of
the contract.
(12) Ambulance signage must be approved by ICEMA prior to deployment.
(13) The Proposer will describe how they can provide ambulance transport to accommodate a patient weighing up
to 1,000 lbs. and describe the training personnel shall have for the safe movement and transport of morbidly
obese patients.
(14) Proposer will describe how they will provide NICU transports and describe the training personnel shall receive
for the safe movement of NICU patients.
B. Support Vehicles Requirement
This section evaluates the Proposer’s ability to comply with the support vehicles requirements identified below. The
this evaluation.
(1) Provide specifications for any supervisor vehicle or other support vehicle to be utilized by Proposer for use
under this contract.
(2) Be able to carry all items contained in the ICEMA Standard Drug and Equipment List Policy 7010 R5.
(3) Vehicles must not exceed 250,000 miles.
C. Vehicle Maintenance Program
This section evaluates the Proposer’s ability to comply with vehicles maintenance program requirements identified
below. The following information must be considered in the response and requested information must be provided
which supports this evaluation.
(1) Provide a copy of the vehicle maintenance program. The vehicle maintenance program must be designed and
conducted to achieve the highest standards of reliability appropriate to a modern ambulance service.
(2) Submit a copy of vehicle maintenance records for any vehicles that are not new at the start of the contract.
(3) Submit the qualifications of maintenance personnel to be utilized.
(4) Describe locations of maintenance services.
(5) Describe the proposed automated or manual maintenance program record-keeping system that includes dates
of inspections and repairs. The system should track both scheduled and unscheduled maintenance (by vehicle
and by fleet) and shall track equipment failures during ambulance responses.
(6) Document the vehicle failure rate including units in route, on-scene, or with a patient on board for the past
three (3) years.
D. Vehicle Safety Program
This section evaluates the Proposer’s ability to comply with the vehicle safety program requirements identified below.
The following information must be considered in the response and requested information must be provided which
supports this evaluation.
(1) The Proposer must verify that it will have an emergency vehicle operator’s course (EVOC) for all its field
personnel including on-going driver-training for ambulance personnel to promote safe driving and prevent
vehicular crashes/incidents.
(2) Describe any other mechanism used to promote safe ambulance driving and prevention of crashes/traffic
incidents, such as, a video surveillance system or other methods.
(3) Describe the organization’s methods used to reduce vehicle environmental impact.
(4) Describe how ambulance configurations will be provided, which address workforce ergonomic issues.
4.7 MEDICAL SUPPLIES AND EQUIPMENT
This section evaluates the Proposer’s ability to comply with the medical supplies and equipment requirements
identified below. The following information must be considered in the response and requested information must be
provided which supports this evaluation.
(1) Each ambulance must carry standardized equipment and supplies that meet federal, state, and ICEMA
requirements, policies, and protocols. Such equipment and supplies will be stored in the same location
depending on ambulance types. Durable equipment does not need to be new at the beginning of the contract
but will be required to meet all specifications and periodic maintenance as approved by ICEMA.
(2) Describe how equipment is selected for use and the procedures that ensure such equipment is properly
maintained. Describe how upgrades to equipment will be handled and funded, during the duration of the
contract including items such as biomedical devices or other equipment as deemed appropriate by ICEMA.
(3) All medical equipment shall be in good repair and safe working order. Each ambulance will be fully stocked and
with sufficient medical equipment and expendable supplies to accommodate replacement during repair and
for times of excessive demand in the EMS system.
(4) Provide a detailed list of durable medical equipment, communications equipment, and medical supplies that
will be carried on ambulances, including brand name, age (biomedical equipment only), and specifications of
such equipment.
(5) Provide the supply/equipment inventory tracking and resupply process.
4.8 PERSONNEL
A. Workforce and Diversity
This section evaluates the Proposer’s ability to comply with the workforce and diversity requirements identified below.
(1) The County places a high priority on ensuring a culturally responsive patient care with emphasis on workforce
diversity to ensure equity in serving these populations. Proposers shall define their organizational values,
policies, and structures that will enable staff to work effectively cross-culturally and mirror the diverse nature
of San Bernardino County.
(2) The Proposer shall establish a recruitment, hiring, and retention system consistent with ensuring a quality
workforce of clinically competent employees that are appropriately certified; licensed, and/or accredited. Field
personnel with bilingual skills reflecting the diversity of languages spoken in San Bernardino County are highly
valued. The Proposer is encouraged to describe its organization’s practice ensuring diversity in the workforce
and success addressing alignment with diverse communities served.
(3) All EMS personnel must comply with State of California Live Scan requirements for
certification/accreditation.
B. Ambulance Work Schedules and Conditions
This section evaluates the Proposer’s ability to comply with the ambulance work schedules and condition requirements
provided which supports this evaluation.
Proposers must describe the policies and procedures used to monitor employee fatigue and impairment. Patient care
must not be hampered by impaired motor skills of personnel working extended shifts, part-time jobs, voluntary
overtime, or mandatory overtime without adequate rest. To mitigate fatigue and safety concerns, Contractor’s
paramedics and EMTs working on an ambulance or as field supervisors should work reasonable schedules to ensure
that potential fatigue and the resulting safety issues are reduced.
(1) Provide proposed work schedules and assignments to demonstrate reasonable working conditions for
ambulance personnel.
(2) At least 51% of the employers' proposed schedule shall be Proposer’s full-time employees.
(3) Indicate how ambulance personnel will have sufficient rest periods to ensure that they remain alert and well-
rested during work periods. The conduct and appearance of the Contractor's personnel must always be
professional and courteous.
(4) Provide examples of work schedules, shift assignments, policies including those related to workload protection,
and any audit criteria related to work schedules and working conditions.
(5) Provide methods that will be used to minimize the turnover rate among the Proposer’s personnel.
(6) Provide how workload and fatigue are measured for ambulance crews.
(7) Provide the organization’s personnel recruitment and screening processes.
(8) Provide the organization’s employee retention program.
(9) Provide the organization’s programs, policies, and procedures for occupational health and safety.
(10) Provide the organization’s pre-employment and on-going physical and mental health ability evaluation
processes.
C. Stations and Field Sub-stations
This section evaluates the Proposer’s ability to comply with 24-hour employee stations and field sub-stations
requirements identified below. The following information must be considered in the response and requested
information must be provided which supports this evaluation.
The Contractor is encouraged to provide appropriate accommodations for 24-hour employee stations and “field sub-
stations”. Stations and field sub-stations should be located at strategic posts that are accessible to on-duty field-based
personnel 24/7. At a minimum, these facilities shall:
(3) Be climate controlled (air conditioning and heat),

(4) Have adequate and comfortable seating to accommodate a complete on-duty crew,
(5) Have at least one (1) operable toilet, sink, and microwave as well as a desk and task chair,
(6) Sleeping quarters to accommodate 24-hour personnel
(7) Have capability to enable patient care charting and uploading of documents,
(8) Have adequate accommodations to meet the needs of nursing mothers,
(9) Facilities will be compliant with OSHA/Cal OSHA regulations.
D. Compensation/ Benefits
This section evaluates the Proposer’s ability to provide a fair compensation and fringe benefits program. The following
information must be considered in the response and requested information must be provided which supports this
evaluation.
In order to attract and retain experienced and highly qualified ambulance personnel, the Proposer should provide for
the payment of comparable wages and benefits to all EMS personnel that are generally consistent with those provided
to EMS personnel in the same geographic region (San Bernardino County). The Proposer is encouraged to establish
benefit programs that result in successful recruitment and retention of personnel. The current ambulance provider and
San Bernardino County collective bargaining contracts can be found on the ePro website.
(1) Submit completed copies of the organization’s compensation package for ambulance paramedics, and EMTs
using the Excel spreadsheet found in Exhibit 8.
E. Treatment of the Incumbent Worker
This section evaluates the Proposer’s support of the County’s intent to retain the expertise of the existing workforce
and the requirements identified below. The following information must be considered in the response and requested
There are many dedicated, experienced, and highly proficient paramedics, EMTs, and non-supervisory, ancillary staff
employed by the current ambulance provider. The Proposer will be encouraged to recruit from, and preferentially hire,
the incumbent paramedic, EMT and ancillary workforce. Subject to applicable federal and state laws, it is desirable a
Proposer be willing and able to grant employment to qualified and experienced EMTs and paramedics who are currently
employed in San Bernardino County and who seek employment with the Proposer.
Proposals shall provide specific plans to this effort in their proposal. The Proposer will be encouraged to provide a
mechanism that enables all incumbent paramedic and EMT personnel that are offered employment with the ability to
apply to retain their “seniority” status earned while working for the previous Contractor for such purposes as shift bids.
F. Ambulance Staffing
This section evaluates the Proposer’s ability to comply with the ambulance staffing requirements identified below. The
this evaluation.
(1) ALS ambulances must be staffed with at least one (1) paramedic and the second crew member may be another
paramedic or a California state certified EMT.
(2) BLS ambulances must be staffed with two (2) California state certified EMTs.
(3) Critical Care Transport (CCT) ambulance must be staffed with a minimum of one (1) EMT and a paramedic
trained at the CCT level or a registered nurse or respiratory therapist for patients being transported between
licensed healthcare facilities.
(4) The Proposers shall provide a description of their process for ensuring that ambulance staffing standards are
met, and that staffing levels for ambulance service employees will be equally comparable to or greater than
staffing levels under the County’s previous contracts within the Comprehensive Service Area.
G. Management and Supervision
This section evaluates the Proposer’s ability to comply with the management and supervision requirements identified
below. The following positions are considered Key Employees. ICEMA shall have direct access to key employees
identified in this section at all times. This includes the right to call regular meetings with key employees, as well as
unscheduled visits.
supports this evaluation. This is to illustrate span of control and ensure employees are operating professionally and
competently.
(1) The Proposer must have dedicated in-county management and supervisory personnel to manage all aspects of
ambulance service including administration, operations, EMS training, clinical quality improvement,
community outreach coordinator, record keeping, and field supervision. Field supervision shall be provided
continuously 24 hours a day.
(2) The Proposer must specifically explain their staffing model to show sufficient personnel that will monitor,
evaluate, and improve clinical care provided by the Proposers personnel and ensure that on-duty employees
are operating professionally and competently.

(3) Identify the Key Employees by position for the Comprehensive Service Area ambulance operations. Include
completed Investigative Authorization–Individual and Company forms (Exhibit 9 and 10).
(4) Provide the qualifications, including resumes, and job descriptions for all management, clinical and supervisory
personnel for the ambulance service.
H. Employee Safety and Wellness
This section evaluates the Proposer’s ability to comply with the employee safety and wellness requirements identified
which supports this evaluation
(1) The Proposer shall have an ICEMA approved Communicable Disease Policy that complies with California
Occupational Safety and Health Administration (Cal/OSHA) requirements and other regulations related to
prevention, reporting of exposure, and disposal of medical waste. All EMS personnel shall be trained in
prevention, personal protective equipment, and universal precautions.
(2) Provide the organization’s communicable disease control and safety policies and procedures.
(3) Identify personal protective equipment provided to EMS personnel including uniforms, jackets for inclement
weather and OSHA compliant protective attire.
(4) All EMS personnel shall be trained in prevention, use of personnel protective equipment and universal
precautions.
(5) Proposers shall address the ergonomic needs of employees when selecting ambulances for their response to
this RFP and shall describe the process that includes employee input in major equipment purchases.
(6) Proposers shall identify the process they will use in determining ambulance design to include the ergonomic
comfort and safety of employees.
(7) The Proposer shall have an employee wellness program and health screenings that are designed to help
employees improve their overall physical health.
(8) Proposer shall develop an infection prevention program that emphasizes aggressive hygiene practices and
proactive personal protective equipment donning (e.g., eye protection, gloves, etc.). The Proposer shall
maintain and strictly enforce policies for infection control, cross-contamination, proper cleaning and
disinfection of ambulances and soiled material disposal to decrease the chance of communicable disease
exposure and transmission.
I. Critical Incident Stress Management and Employee Resilience Program
This section evaluates the Proposer’s ability to comply with the Critical Incident Stress Management and Employee
Resilience Program requirements identified below. The following information must be considered in the response and
requested information must be provided which supports this evaluation.
(1) Proposer shall establish a stress management and employee resilience program for its employees to include
an on-going stress reduction program, critical incident debriefs and stress action plan, and reliable access to
trained and experienced professional counselors through an employee assistance program.
(2) Provide the Critical Incident Stress Management Program and Employee Assistance Program which will be used
in San Bernardino County.
J. Training and Continuing Education Program
This section evaluates the Proposer’s ability to comply with the training and continuing education requirements
provided which supports this evaluation
(1) Core Training Requirements:

The Proposer must provide a comprehensive training/education program for all EMS personnel. Joint training
sessions for ambulance and fire service first responders are expected. Such a program shall include, but not be
limited to:
a. Advanced training for EMTs staffing ALS or BLS ambulances,
b. Orientation to the San Bernardino County EMS System,
c. Customer service and cultural sensitivity,
d. Pre-accreditation field evaluation for paramedics,
e. Post-accreditation education, supervision, evaluation,
f. Continuing education that is data driven and aligned with quality improvement activities, including skills,
procedures protocols, issues, and other programs,
g. Other programs and activities to maintain uniform skill proficiency,
h. Provide the organization’s comprehensive training and education program for EMS personnel and how it
will meet all training standards established by ICEMA Policy 1030R1,
i. Provide the organization’s plan on integration of training and education with fire service first responders,
j. Provide the orientation and other training and evaluation that is required for new paramedics,
k. Provide the process to ensure timely, accurate, and accountable communications with EMS personnel
regarding changes in EMS system policies, procedures, protocols, or precautions,
l. Provide the qualifications, job description, and resume for clinical leadership personnel,
m. Provide the database system to be used for maintaining paramedic and EMT records including
employment, certification/licensure, paramedic accreditation, required training programs, and on-going
training.
K. Supplemental Specialty Training
(1) Paramedics must comply with ICEMA policies for accreditation and maintain current valid certifications for:
a. Pediatric Advanced Life Support or Pediatric Emergencies for the Prehospital Provider,
b. Prehospital Trauma Life Support or Basic Trauma Life Support,
c. Advanced Cardiac Life Support.
(2) EMTs must maintain California state certification including:
a. Compliance with ICEMA policies for certification/recertification requirements,
b. Optional Scope, if applicable.
L. Continuing Education Provider
The Contractor must be approved as an ICEMA Continuing Education (CE) Provider within 12 months of Contract start
date. Staff responsible for clinical education and clinical quality improvement must be able to meet the qualifications
for EMS CE clinical direction following the California Code of Regulations, Title 22, Division 9, Chapter 11, and ICEMA
Policy 2100.
M. Training Records
The Contractor must maintain a single electronic database of all clinical personnel training and certification records.
ICEMA shall have electronic access to this database. The Contractors database will be continually updated so that
records are current. The database will include, but not be limited to:
(1) Employment status (e.g., full-time, part-time, currently employed by, previous employment within the County),
(2) Certification/licensure,
(3) Paramedic accreditation,
(4) Any on-going training required by ICEMA and ICEMA’s Medical Director.
4.9 HOSPITAL AND COMMUNITY REQUIREMENTS
A. Hospital and Contractor Relationship and Technology Interface
This section evaluates the Proposer’s ability to comply with the hospital interface requirements identified below. The
following information must be considered in the response and requested information must be provided which
(1) The Proposer will describe a user-friendly and effective system for hospitals to communicate with:
a. Ambulance management and clinical quality improvement staff.
b. Ambulance paramedics and EMTs.
(2) Hospitals require the electronic transmission of 12-lead Electrocardiogram (ECG) for suspected ST-Elevation
Myocardial Infarction (STEMI) to the hospital prior to patient arrival. The 12-lead ECG will be included in the
electronic copy of the patient’s medical record. Describe how 12-lead ECG for suspected STEMI patients will
be made available to the hospital prior to patient arrival.
(3) Ambulance staff are required to provide early notification of incoming patients with all pertinent information
presented in a concise and standardized format and according to ICEMA Policy 9030.
(4) The ePCR will be available to hospital personnel according to ICEMA Policy 5030.
B. Community Involvement
This section evaluates the Proposer’s ability to comply with the community involvement requirements identified below.
supports this evaluation. Contractor shall provide the type, number and frequency of its community involvement and
activities.
(1) The Contractor will be required to plan and implement community education programs, which shall include
presentations to diverse community groups, conducting citizen CPR training events, Stop the Bleed, health and
career fairs, participation in EMS week and other educational activities involving prevention, appropriate use
of 911 and system access.

(2) Describe any provisions to be made to address linguistic access for non-English speakers in public education
and outreach activities.
(3) Provide the organization’s proposed community education and illness/injury program for San Bernardino
County. Include timeline and measures.
(4) The Contractor will report on these activities to ICEMA periodically as determined by ICEMA.
(5) The Contractor will participate in community health initiatives as established through ICEMA.
(6) The Contractor will provide local EMS training programs priority placement for student field observation and
field internships.
4.10 DISASTER PREPAREDNESS/RESOPNSE
A. Multi-Hazard Disaster and Multi-Casualty Plans
This section evaluates the Proposers ability to comply with the Multi-Hazard Disaster and Multi-Casualty Plans
(1) The Contractor shall have an internal multi-hazard disaster plan which includes, but is not limited to, triggers
for activation, notifications, communications, staffing, vehicles, equipment, and EMS surge supplies needed
for at least five (5) days.
(2) The Contractor shall participate with ICEMA in disaster planning activities and participate in the Healthcare
Preparedness Planning Partnership and other disaster committees as requested by ICEMA. This includes
assigning a disaster coordinator having responsibility for multi/mass-casualty and disaster planning and
providing field personnel and transport resources for participation in any ICEMA approved disaster drill in
which the disaster plan/multi-casualty incident plan is exercised.
(3) Provide an example of how the organization has participated in disaster exercises or actual disasters. Include
how the event was evaluated and corrective actions taken to improve future responses.
(4) The Contractor must agree to contract with the Emergency Medical Services Authority (EMSA), house,
maintain, manage, and staff the EMSA state-issued Disaster Medical Support Unit (DMSU). This includes
deploying the DMSU when requested by the ICEMA Administrator, or the Medical Health Operational Area
Coordinator (MHOAC), via the MHOAC/Regional Disaster Medical Health Specialist (RDMHS) mutual assistance
system. This vehicle shall not be used in routine, day-to-day operations, and shall be fully stocked at all times
and kept in good working order. The DMSU shall be available for emergency response to a disaster site or
designated location. This vehicle may be used to carry EMS personnel and equipment to a disaster site.
(5) Contractor shall ensure all EMS personnel, supervisory personnel, and management personnel are trained in
Incident Command System (ICS), Standardized Emergency Management System (SEMS), and National Incident
Management System (NIMS). Current training standards include:
a. Non-supervisory field personnel: Incident Command System (ICS)-100, ICS-200, IS-700, IS-800, and
Standardized Emergency Management System (SEMS),
b. Supervisory field personnel: ICS-100, ICS-200, ICS-300, IS-700, IS-800, and SEMS,
c. Management personnel and personnel who may be assigned to a department or Operational Area
Emergency Operations Center: ICS-100, ICS-200, ICS-300, ICS-400, IS-700, IS-800, and SEMS.
(6) The Contractor will ensure EMS personnel responding to a Mass Casualty Incident (MCI), disaster, or other
large-scale emergencies are fully trained in the EMS system.
(7) Identify staff that will have primary responsibility for disaster preparedness, provide the job description, and
any required specialized training.
(8) The Contractor will participate in the Ambulance Strike Team (AST) program and must ensure that AST
responders and AST Unit leaders have been appropriately trained and approved by ICEMA.
(9) The Contractor may require that field and supervisory personnel be familiar with and trained in, the California
Tactical Casualty Care Training Guidelines to respond as a medical support service provider to law enforcement
incidents and provide field tactical medical care to casualties, as necessary.
B. Disaster Reimbursement
ICEMA will make reasonable efforts to support the Contractor in obtaining reimbursement for disaster response efforts
both within and outside of the County when such funds are available. The Contractor will ensure all documentation
meets FEMA eligibility and/or other federal funding standards, policies, and guidelines.
C. Mutual Assistance
This section evaluates the Proposer’s experience with providing mutual assistance per the requirements identified
To the extent units are available and consistent with its primary responsibility to provide ambulance and emergency
medical services, with ICEMA and/or MHOAC approval, the Contractor will render “automatic aid” and “mutual
assistance” to adjacent jurisdictions. The Proposer will provide their process to render and receive “automatic aid” and
“mutual assistance” to those providers of emergency medical services operating within adjacent areas in and out of
San Bernardino County.
4.11 QUALITY MANAGEMENT
A. Quality Improvement Program and Ongoing Quality Improvement Requirements
This section evaluates the Proposer’s ability to comply with the Quality Improvement (QI) program and ongoing QI
(1) The Proposer will have a comprehensive QI and performance measures program. This program will include all
operations and services and not be limited to clinical care. Data shall be presented to ICEMA as part of the
required online compliance utility program in a format approved by ICEMA.
(2) The QI program must meet the requirements of the California Code of Regulations, Title 22, Chapter 12 (EMS
System Quality Improvement), and ICEMA policies.
(3) The program must be an organized, coordinated, multidisciplinary approach to the assessment of prehospital
emergency medical response and patient care to improve patient care service and outcome.
(4) The program must include methods to measure performance, customer service satisfaction, identify areas
needing improvement, and implementation of improvement plans, and then evaluate the results.
(5) Contractor will be required to submit an update QI Plan annually. The QI Plan shall be reviewed for
appropriateness to the provider’s operations and revised as needed in consultation with ICEMA. The update
shall include, but not be limited to a summary of how the QI program addresses indicators and performance
measures.
(6) Participate in ICEMA’s quality initiatives, including making available relevant records for program monitoring
and evaluation.
(7) Participate in ICEMA clinical trials or pilot projects as approved by the ICEMA Medical Director.
(8) Develop, in cooperation with appropriate personnel/agencies, a performance improvement action plan when
the program identifies a need for improvement. If the area identified as needing improvement includes system
clinical issues, collaboration is required with ICEMA Medical Director or his/her designee.
(9) Submit all required reports to demonstrate how Proposer will be compliant with clinical standards and clinical
benchmarks as determined through the clinical standards-setting process.
(10) Submit data consistent with Health and Safety (H&S) Code 1797.227 to allow ICEMA to participate in the
California EMS System and data required for participation including but not limited to: Quality Core Measures
Project, Cardiac Arrest Registry to Enhance Survival (CARES), National EMS Quality Alliance (NEMSQA), and
Mission: Lifeline.
(11) Additional reports may be required as part of local QI programs for improvement including key performance
indicators for STEMI, stroke, advanced airway, cardiac arrest, trauma, sepsis, choking, childbirth, pain,
customer satisfaction, pediatric skills, medication errors, complaint satisfaction, employee satisfaction, EMT
and paramedic skill retention and safety.
B. Inquiries, Complaints, and Incident Reporting
This section evaluates the Proposer’s ability to comply with the inquiries, complaints and incident reporting
(1) The Contractor will develop a mechanism for internal and external customers to comment on the care provided
by Proposer and will provide access to comments to ICEMA.
(2) The Contractor will provide prompt response and follow-up to inquiries and complaints at a minimum of three
(3) business days, and report findings to ICEMA.
(3) The Contractor will have an accountability system to account for patient belongings.
(4) The Contractor will cooperate with ICEMA and/or EMSA in the investigation of an incident or unusual
occurrence.
(5) The Contractor will complete an incident or unusual occurrence report within 24 hours for personnel involved
in an unusual occurrence. The Contractor will immediately notify ICEMA of potential violations of California
Law.
4.12 ELECTRONIC PATIENT CARE REPORTING REQUIREMENTS
This section evaluates the Proposer’s ability to comply with the ePCR requirements identified below. The following
evaluation.
(1) The Contractor will be required to utilize an electronic Patient Care Report (ePCR), approved by ICEMA,
according to California Health and Safety Code Section 1797.227. The ePCR shall be accurately completed to
include all information as identified in ICEMA policy.

(2) The County has implemented one (1) ePCR software product for all providers in San Bernardino County to
improve efficiency and reduce documentation errors. ICEMA utilizes ImageTrend as the data repository for all
CEMSIS data. Proposer agrees to utilize the ImageTrend Elite ePCR platform used by all first responders and
ambulance transport providers within the EMS system.
(3) The ImageTrend Elite ePCR system has the capability of mobile data entry in the ambulances and at the
patient’s bedside. The ePCR system complies with the National Emergency Medical Services Information
System (NEMSIS) and California Emergency Medical Services Information System (CEMSIS), mapping standards
and data dictionary, as promulgated by the California EMS Authority and ICEMA requirements. The ePCR
system must have the capability to:
a. Link with the CAD to import all data for all calls.
b. Search a patient’s health record for problems, medications, allergies, and end of life decisions to enhance
clinical decision making in the field.
c. Alert the receiving hospital about the patient’s status directly onto a dashboard in the emergency
department to provide decision support.
d. File the ePCR data directly into the patient’s electronic health record for a better longitudinal patient
record.
e. Reconcile the electronic health record information including diagnoses and disposition back into the EMS
patient care report for use in improving the EMS system utilizing the FirstWatch FirstPass product.
(4) The Contractor will be responsible for the full cost of the annual ImageTrend licensing fee including all
associated costs identified in Exhibit 14.
(5) An ePCR must be completed for all patients in a timely manner according to ICEMA policy. The Proposer must
describe a process to demonstrate ePCR accountability through CAD reconciliation for every medical transport.
(6) As health information systems evolve, the Contractor will agree to collaborate with ICEMA and local hospital(s)
to establish and/or participate in a Health Information Exchange (HIE) with each receiving facility, with
automated data sharing for purposes of enhancing EMS system-level treatment, payment, and operations
through continuous quality improvement activities including analysis of outcome data associated with
individual patients.
(7) Provide a description of computers utilized for ePCR including their wireless communication capabilities, that
will be provided to each ambulance unit and staff vehicle.
(8) Describe the process for patient care records to be made available to the receiving hospital.
4.13 CENTRALIZED EMERGENCY MEDICAL DISPATCH (EMD) CENTER
This section evaluates how the Proposer plans to dispatch ambulance services in the Comprehensive Service Area and
comply with the minimum services requirements outlined in Exhibit 11. Proposers must fully describe their dispatch
method, staffing, technology, technology backup system, supervision, and QI processes.
The long-term goal of the County in the first five (5) years of this contract is to have ambulance dispatch and ambulance
system status management physically located together. However, at present, the County Centralized EMD Center does
not have the physical space for the entire ambulance operating needs. Therefore, at contract
start up, the Contractor can operate their own dispatch center and manage their ambulances with a CAD-to-CAD link
with County’s Centralized EMD Center. The Contractor could contract with the Centralized EMD Center for 911
dispatching services in addition to EMD.
The County’s Centralized EMD Dispatch Center will provide Medical Priority Dispatch for resource determination in
accordance with ICEMA’s Medical Director and Dispatch Protocols. The County’s Centralized EMD Center will
determine the Contractor’s priority level to all emergency 911 ALS and BLS calls within the Comprehensive Service Area
following ICEMA approved EMD Policy 4100.
The County requires the Contractor at start-up to enter into a separate agreement with the County’s Centralized EMD
Center and pay for the provision of EMD and CAD-to-CAD coordination services. EMD with Medical Priority Dispatch
Service (MPDS) charges are estimated to be $5.00 per call the first year with annual increases as outlined in, Exhibit 11.
The minimum service requirements are also outlined in Exhibit 11.
4.14 FINANCIAL AND ADMINISTRATIVE REQUIREMENTS
A. Patient Fees
This section evaluates the Proposer’s patient fee schedule to ensure it is consistent with the standards articulated
(1) Current maximum patient fees are included in Exhibit 12. The patient fees must be fixed for at least one (1)
year from the beginning of the contract.
(2) Submit the Proposed Ambulance Rates on the Excel spreadsheet in Exhibit 8.
B. Budget and Fiscal Sustainability
This section evaluates the Proposers submitted budget and other submitted financial documents. The following
evaluation.
(1) Provide all budget information on the Excel spreadsheet in Exhibit 8.

(2) Provide detailed information on the full cost of the proposed service including allocation of indirect costs.
(3) Provide a statement of the method of financing, attach any necessary endorsement documents for all start-up
and operational costs including, but not limited to, the initial ambulance fleet and equipment and facility leases
that are required to begin operations.
(4) Provide a statement of the amount of funding that will be dedicated to Reserve for Contingencies.
(5) Proposer shall submit financial statements for all financial and/or in-kind corporate/parental entity support to
show all sources of funding that will support the provision of ambulance services within the Comprehensive
Service Area.
(6) If the Proposer’s corporate/parental structure is larger than only the provision of ambulance service for San
Bernardino County’s Comprehensive Service Area, this statement shall include disclosing the full cost allocation
of all shared overhead services charged to the San Bernardino County ambulance service for the
Comprehensive Service Area (including rationale). Typical overhead services include but are not limited to risk
management, insurance, purchasing, maintenance, rent, legal and human resources, or other functions if those
functions are not solely dedicated to ambulance service in the Comprehensive Service Area.
(7) Proposers will disclose, if applicable, the interest or use rate at which the parent / corporate entity loans money
or services to the subsidiary corporation providing ambulance services to the San Bernardino County
Comprehensive Service Area.
(8) Using the Excel spreadsheet provided in Exhibit 8, provide the above information for the start-up costs for each
year of the five (5) years of operation. Additionally, provide complete information on projected revenue from
ambulance service billing for each of the five (5) years. If revenue from ambulance service billing does not cover
expected costs of operations, document the projected source of revenue to offset the loss and provide a
projected timeframe to recoup losses. “Full Cost” means all costs attributable to the provision of service.
(9) Proposer will provide a statement indicating the proposer will comply with all of the financial reporting
requirements, payments and service charges, and profit and ambulance rate adjustments as identified in
Exhibit 14.
C. Billing and Collection
This section evaluates the Proposer’s billing system and collection practice. The following information must be
considered in the response and requested information must be provided which supports this evaluation.
(1) The Proposer will be responsible for considerate billing and collection practices. Proposer’s collection practices
shall follow all State and Federal collection laws and regulations. Proposer’s accounts receivable management
system will be capable of timely response to patient and third-party payer inquiries regarding submission of
insurance claims, dates and types of payments made, itemized charges, and other inquiries.
(2) The Proposer will have personnel available at the Proposer’s local headquarters, accessible via a toll-free phone
number to provide an initial response to questions regarding patient bills. The Proposer will provide interpreter
service, relative to billing and collections, to parties having limited English proficiency.
(3) The Proposer will have a billing and collections system that is well-documented, easy to audit, customer-
friendly, assists in obtaining reimbursement from third party sources, and is capable of electronically filing
Medicare and Medi-Cal billing claims.
(4) Direct patient billing statements will be itemized so that all charges are clearly explained. The accounts
receivable management system will automatically generate Medicare and Medi-Cal billing forms electronically
or on paper.
(5) If a patient is initially billed directly, Proposer’s first invoice will request third-party payment information and
ask the patient to contact the billing office. A toll-free number and return envelope will be provided.
(6) If a patient has no third-party coverage, Proposer will have a liberal installment plan policy for payment
arrangements. If the payment arrangements are not adhered to, the account may be assigned for collection.
D. Financial Hardship
This section evaluates the Proposer’s financial hardship policy. The following information must be considered in the
response and requested information must be provided which supports this evaluation. The Proposer shall:
(1) Provide a written policy that addresses patients who do not have medical insurance and who have limited
financial capacity.
(2) Extend discounts to patients based upon such policy and such discounts will consider federal poverty level
standards, ineligibility for Medi-Cal/Medicaid or other third-party coverage, as well as any extenuating
circumstances.
(3) Submit an annual customer satisfaction survey provided by an external agency approved by ICEMA.
(4) Describe their billing and collection system, including Spanish or other language preferences.
(5) Provide a copy of their financial hardship policy.
(6) Provide a copy of a billing late notice.
(7) Describe how the organization evaluates and improves the billing and collection system.
4.15 FUTURE SYSTEM ENHANCEMENTS
This section evaluates the Proposer’s innovative solutions to provide added value to the community.
The County is interested in exploring innovative solutions that could provide added value to the community. Such
programs should be goal-directed; meeting a defined need of a specific patient population in a local community as
articulated by local stakeholders and supported by formal health needs assessments. Proposed programs should also
be team-based integrating multiple providers, both clinical and non-clinical, in meeting the holistic needs of patients
served by the program.
ICEMA anticipates further development and collaborative efforts to enhance the EMS system. ICEMA requires the
Contractor actively participate in county-wide EMS activities, work groups, and studies to determine the efficacy and
financial viability of implementing preventative services and alternative solutions that match individual healthcare
needs with efficacious and fiscally responsible service for aging, at-risk and mental health patient populations.
Preventative services and alternative solutions include but are not limited to communications center nurse triage
systems, clinical computerized decision support systems, community paramedic programs, triage, alternative
destination programs, assess and refer protocols and field telemedicine. All services, solutions and programs shall be
medically guided and, approved by the ICEMA Medical Director. Any new programs shall have a comprehensive
evaluation process to assess patient outcomes to ensure employee and patient safety.
The County is interested in exploring the development of a mental health response and alternate transport using EMS
and or other credentialed personnel in response vehicles to provide assessment, management, transport, and referral
as appropriate to individuals presenting with behavioral/mental health emergencies in the prehospital setting. The
objective is to provide the care and services that will best meet the needs of the individual while reducing the cost
associated with unnecessary ambulance transports contributing to overcrowded emergency departments. The
Proposer shall describe their experience, if any, with the provision of their personnel providing mental health field
alternative response programs.
Although many of these programs have not been finalized for implementation, it is the intent of the County that the
Proposer will agree to meet with the County to determine the scope of the program.
EXHIBIT 1 - REQUIRED TABLE OF CONTENTS

Each proposal must include this Table of Contents and all responses must be in this format and order:
Cover Letter
Authorized Contacts
References
Table of Contents
Section I - Executive Summary and Highlights
Section II - Qualification and Experience
Minimum Qualifications
Organizational Experience
Key Leadership Experience
References
Financial Condition: Brief statement with required supplemental documentation
Legal History: Brief statement with required supplemental documentation
Evidence of Insurance: Brief statement with required supplemental documentation
Section III - Provisions of Services
System Requirements
Response Time Requirements
Clinical Performance Standards
Ambulance Deployment and System Status Plan
Vehicles
Medical Supplies and Equipment
Personnel
Hospital and Community Requirements
Disaster Preparedness/Response
Quality Management
EMS Dispatch
Financial and Administrative Requirements
Future System Enhancements and Optional Enhancements
Section IV - Supplemental Documents
Contractor Qualifications
Organizational Capacity & Experience
Samples, Drawings & Illustrations
Attachments, Certifications & Forms
Financial Documents
Excel Spreadsheet (Budget, Revenues, Expenses, Ambulance Rate Proposal)
EXHIBIT 2 – COMPREHENSIVE SERVICE AREA MAPS OF SAN BERNARDINO

COUNTY
For the purpose of this RFP, San Bernardino County utilized the following definitions as established by the California
EMS Authority.
• Urban - All census places with a population density of 101 to 500 persons per square mile; or census tracts
and enumeration districts without census tracts with a population density of 101 to 500 persons or more per
square mile.
• Suburban - All census places with a population density of 51 to 100 persons per square mile; or census tracts
or enumeration districts without census tracts with a population density of 51 to 100 persons per square
mile.
• Rural - All census places with a population density of 7 to 50 persons per square mile; or census tracts or
enumeration districts without census tracts with a population density of seven to 50 persons per square mile.
• Wilderness - Census tracts or enumeration districts without census tracts have a population of fewer than 7
persons per square mile.
Electronic versions of the maps below are available at https://epro.sbcounty.gov/bso/view/login/login.xhtm.
EOA 01
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@ uNTY AMBULANCE EXCLUSIVE OPERATING AREA AND UPDATED RESPONSE TIM E Suburban: 14:59 ■ Wilderness: 59:59
EOA0 l
EOA 02
Advanced Life Support and Basic Life Support Ground Ambulance Services, Interfacility and Critical Care Transport Services for Exclusive Operating52
Areas in San Bernardino County RFP#:
ICEMA23-ICEMA-4811
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ICEMA23-ICEMA-4811
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ICEMA23-ICEMA-4811
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SAN BERNARDINO COUNTY ■ Urban: 09:59 ■ Rural: 29:59

AMBULA NCE EXCLUSIVE OPERATING AREA AND UPDATED RESPONSE TIME II Suburban: 14 :59 ■Wilderness : 59:59
EOA04
EOA 05b
ICEMA23-ICEMA-4811
55
SAN BERNARDINO COUNTY ■ Urban : 09:59 ■ Rural : 29:59

AMBULANCE EXCLUSIVE OPERATING AREA AND UPDATED RESPONSE TIME IISuburban: 14 : 59 ■Wilderness: 59:59
EOA 05b
EOA 06
ICEMA23-ICEMA-4811
56

AMBULANCE EXCLUSIVE OPERATING AREA AND UPDATED RESPONSE TIME ■ Suburban: 1 4:59 ■ Wilderness: 59:59
EOA06
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ICEMA23-ICEMA-4811
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ICEMA23-ICEMA-4811
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ICEMA23-ICEMA-4811
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AMBULANCE EXCLUSIVE OPERATING AREA AND UPDATED RESPONSE TIME ■ Suburban : 14:59 ■ Wilderness: 59:59
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ICEMA23-ICEMA-4811
60
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AMBULANCE EXCLUSIVE OPERATING AREA AND UPDATED RESPONSE TIME Suburban: 14 :59 ■ Wilderness: 59:59
EOA 11
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ICEMA23-ICEMA-4811
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EOA 12a
COMPREHENSIVE SERVICE AREA
ICEMA23-ICEMA-4811
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Maps are also available as attachments in the County’s electronic Procurement Network (ePro).
ICEMA23-ICEMA-4811
63
EXHIBIT 3 - HISTORICAL CALL DATA

Historical Computer Aided Dispatch (CAD) incident call data will be provided to all Proposers after receipt of a
Letter of Intent.
The chart below illustrates the four-years of call data for the Comprehensive Service Area.
Calendar Year 911 Responses 911 Transports IFT Transports CCT Transports
2021 183,455 111,556 30,228 3,261
2020 197,876 117,024 36,010 3,590
2019 184,492 123,692 43,281 3,561
2018 180,397 120,578 41,620 3,044
Call Volume in each Exclusive Operating Area (EOA) as reported in ICEMA Performance Reports.
Emergency 911 Medical Requests in each EOA throughout the Comprehensive Service Area
Response Volume 2018 2019 2020 2021
EOA 1 – West End Rancho Cucamonga and Upland 20,230 20,147 19,331 18,307
EOA 2 – Montclair and Chino 9,739 9,904 9,729 6,914
EOA 3 – Ontario and Chino Hills 17,882 18,681 18,387 16,757
EOA 4 – Fontana and Lytle Creek 17,275 17,064 17,289 15,854
EOA 5b – Unincorporated Rialto 284 242 275 192
EOA 6 – San Bernardino 41,405 40,783 40,482 33,809
EOA 7 – Grand Terrace 5,134 4,914 5,147 4,719
EOA 8 – Redlands and Yucaipa 14,179 14,203 13,910 12,933
EOA 9 – Loma Linda 2,738 2,619 2,604 2,545
EOA 11 – San Bernardino Area 158 183 147 131
EOA 12a – Victorville Area 35,362 35,852 35,374 31,997
TOTAL Volume 164,386 164,592 162,675 144,158
EXHIBIT 4 - CONTRACT TEMPLATE

THE INFORMATION IN THIS BOX IS NOT A PART OF THE CONTRACT AND IS FOR COUNTY USE ONLY
Contract Number
SAP Number
Inland Counties Emergency Medical Agency (ICEMA)
Department Contract Representative

Telephone Number
Contractor
Contractor Representative
Telephone Number
Contract Term
Original Contract Amount
Amendment Amount
Total Contract Amount
Cost Center
IT IS HEREBY AGREED AS FOLLOWS:
WHEREAS, San Bernardino County (County) desires to contract for ground ambulance services, interfacility
and critical care transport (Services) for an Exclusive Operating Area (Comprehensive Service Area) as
provided for in Section 1797.224 of the California Health and Safety Code; and
WHEREAS, the County conducted a competitive process in accordance with State law and County policy to
find (Contractor) to provide these services, and
WHEREAS, the County finds Contractor qualified to provide ground ambulance services, interfacility and
critical care transport services; and
WHEREAS, Title 22 of the California Code of Regulations, at Section 100168 of Division 9, Chapter 4, Article
7, requires a written agreement for Services; and
WHEREAS, County and Contractor wish to enter into this performance-based Agreement for the Contractor’s
provision of Services; and
WHEREAS, Contractor’s ambulance services shall be provided at the Basic Life Support (BLS) and Advance
Life Support (ALS) level; and
WHEREAS, the County desires that such services be provided by Contractor and Contractor agrees to
perform these services as set forth below;
NOW, THEREFORE, the County and Contractor mutually agree to the following terms and conditions:
DEFINITIONS
A.1 RFP Definitions are stated in Exhibit 17.
CONTRACTOR RESPONSIBILITIES
B.1 The scope of work will be based on this RFP and selected Proposer’s response.
B.2 Specific EOA dispute, grievance, breach and emergency takeover provisions are stated in Attachment
B.
B.3 Reserved.
GENERAL CONTRACT REQUIREMENTS

C.1 Recitals
The recitals set forth above are true and correct and incorporated herein by this reference.
C.2 Contract Amendments

Contractor agrees any alterations, variations, modifications, or waivers of the provisions of the
Contract, shall be valid only when reduced to writing, executed, and attached to the original Contract
and approved by the person(s) authorized to do so on behalf of Contractor and County.
C.3 Contract Assignability

Without the prior written consent of the County, the Contract is not assignable by Contractor either in
whole or in part.
C.4 Contract Exclusivity

This is an exclusive Contract for ground ambulance services within the Comprehensive Service Area.
The County reserves the right to enter into a contract with other contractors for the same or similar
services outside of the Comprehensive Service Area. The County does not guarantee or represent
that the Contractor will be permitted to perform any minimum amount of work or receive compensation
other than on a per order basis, under the terms of this Contract.
C.5 Attorney’s Fees and Costs

If any legal action is instituted to enforce any party’s rights hereunder, each party shall bear its own
costs and attorney fees, regardless of who is the prevailing party. This paragraph shall not apply to
those costs and attorney fees directly arising from a third-party legal action against a party hereto and
payable under Indemnification and Insurance Requirements.
C.6 Background Checks for Contractor Personnel

Contractor shall ensure that its personnel (a) are authorized to work in the jurisdiction in which they
are assigned to perform Services; (d) do not use legal or illegal substances in any manner which will
impact their ability to provide Services to the County; and (c) are not otherwise disqualified from
performing the Services under applicable law. If requested by the County and not in violation of
applicable law, Contractor shall conduct a background check, at Contractor’s sole expense, on all its
personnel providing Services. If requested by the County, Contractor shall provide the results of the
background check of each individual to the County. Such background check shall be in the form
generally used by Contractor in its initial hiring of employees or contracting for contractors or, as
applicable, during the employment-screening process but must, at a minimum, have been performed
within the preceding 12-month period. Contractor personnel who do not meet the County’s hiring
criteria, in County’s sole discretion, shall not be assigned to work on County property or Services, and
County shall have the right, at its sole option, to refuse access to any Contract personnel to any County
facility.
C.7 Change of Address

Contractor shall notify the County in writing, of any change in mailing address within ten (10) business
days of the change.
C.8 Choice of Law

This Contract shall be governed by and construed according to the laws of the State of California.
C. 9 Compliance with County Policy

In performing the Services and while at any County facilities, Contractor personnel (including
subcontractors) shall (a) conduct themselves in a businesslike manner; (b) comply with the policies,
procedures, and rules of the County regarding health and safety, and personal, professional and
ethical conduct; (c) comply with the finance, accounting, banking, Internet, security, and/or other
applicable standards, policies, practices, processes, procedures, and controls of the County; and (d)
abide by all laws applicable to the County facilities and the provision of the Services, and all
amendments and modifications to each of the documents listed in subsections (b), (c), and (d)
(collectively, “County Policies”). County Policies, and additions or modifications thereto, may be
communicated orally or in writing to Contractor or Contractor personnel or may be made available to
Contractor or Contractor personnel by conspicuous posting at a County facility, electronic posting, or
other means generally used by County to disseminate such information to its employees or
contractors. Contractor shall be responsible for the promulgation and distribution of County Policies
to Contractor personnel to the extent necessary and appropriate.
County shall have the right to require Contractor’s employees, agents, representatives, and
subcontractors to exhibit identification credentials issued by County in order to exercise any right of
access under this Contract.
C.10 Confidentiality
Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health
Information Technology for Economic and Clinical Health (HITECH) Act, regulations have been
promulgated governing the privacy of individually identifiable health information. The HIPAA Privacy Rule
and Security Rule specify requirements with respect to contracts between a Covered Entity and its
Business Associates. Contractor shall execute and comply with the attached Business Associate
Agreement (Attachment A). Contractor further agrees to comply with the requirements of other federal
and state law that applies to the information collected and maintained by Contractor for Services
performed pursuant to Contract.
C.11 Primary Point of Contact

Contractor will designate an individual to serve as the primary point of contact for the Contract.
Contractor or designee must respond to County inquiries within two (2) business days. Contractor
shall not change the primary contact without written acknowledgement to the County. Contractor will
also designate a back-up point of contact in the event the primary contact is not available.
C.12 Reserved
C.13 County Representative

The ICEMA EMS Administrator or his/her designee shall represent the County in all matters pertaining
to the services to be rendered under this Contract, including termination and assignment of this
Contract, and shall be the final authority in all matters pertaining to the Services/Scope of Work by
Contractor. If this contract was initially approved by the San Bernardino County Board of Supervisors,
then the Board of Supervisors must approve all amendments to this Contract.
C.14 Damage to County Property

Contractor shall repair, or cause to be repaired, at its own cost, all damages to County vehicles,
facilities, buildings or grounds caused by the willful or negligent acts of Contractor or its employees or
agents. Such repairs shall be made immediately after Contractor becomes aware of such damage,
but in no event later than thirty (30) days after the occurrence.
If the Contractor fails to make timely repairs, the County may make any necessary repairs. The
Contractor, as determined by the County, shall repay all costs incurred by the County for such repairs,
by cash payment upon demand, or County may deduct such costs from any amounts due to the
Contractor from the County, as determined at the County’s sole discretion.
C. 15 Debarment and Suspension

Contractor certifies that neither it nor its principals or subcontracts is presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from participation in this
transaction by any federal department or agency. (See the following United States General Services
Administration’s System for Award Management website https://www.sam.gov). Contractor further
certifies that if it or any of its subcontractors are business entities that must be registered with the
California Secretary of State, they are registered and in good standing with the Secretary of State.
C.16 Drug and Alcohol-Free Workplace

In recognition of individual rights to work in a safe, healthful and productive workplace, as a material
condition of this Contract, the Contractor agrees that the Contractor and the Contractor’s employees,
while performing service for the County, on County property, or while using County equipment:
C.16.1 Shall not be in any way impaired because of being under the influence of alcohol or an
illegal or controlled substance.
C.16.2 Shall not possess an open container of alcohol or consume alcohol or possess or be
under the influence of an illegal or controlled substance.
C.16.3 Shall not sell, offer, or provide alcohol or an illegal or controlled substance to another
person, except where Contractor or Contractor’s employee who, as part of the performance of
normal job duties and responsibilities, prescribes or administers medically prescribed drugs.
The Contractor shall inform all employees that are performing service for the County on County
property, or using County equipment, of the County’s objective of a safe, healthful and
productive workplace and the prohibition of drug or alcohol use or impairment from same while
performing such service for the County.
The County may terminate for default or breach of this Contract and any other Contract the
Contractor has with the County if the Contractor or Contractor’s employees are determined by
the County not to be in compliance with above.
C.17 Duration of Terms

This Contract, and all of its terms and conditions, shall be binding upon and shall inure to the benefit
of the heirs, executors, administrators, successors, and assigns of the respective parties, provided no
such assignment is in violation of the provisions of this Contract.
C.18 Employment Discrimination

During the term of the Contract, Contractor shall not discriminate against any employee or applicant
for employment because of race, religious creed, color, national origin, ancestry, physical disability,
mental disability, medical condition, genetic information, marital status, sex, gender, gender identity,
gender expression, sexual orientation, age, or military and veteran status. Contractor shall comply
with Executive Orders 11246, 11375, 11625, 12138, 12432, 12250, 13672, Title VI and Title VII of the
Civil Rights Act of 1964, the California Fair Employment and Housing Act and other applicable Federal,
State and County laws and regulations and policies relating to equal employment and contracting
opportunities, including laws and regulations hereafter enacted.
C.19 Environmental Requirements

In accordance with County Policy 11-08, the County prefers to acquire and use products with higher
levels of post-consumer recycled content. Environmentally preferable goods and materials must
perform satisfactorily and be available at a reasonable price. The County requires Contractor to use
recycled paper for any printed or photocopied material created as a result of this Contract. Contractor
is also required to use both sides of paper sheets for reports submitted to the County whenever
practicable.
To assist the county in meeting the reporting requirements of the California Integrated Waste
Management Act of 1989 (AB 939), Contractor must be able to annually report the County’s
environmentally preferable purchases. Contractor must also be able to report on environmentally
preferable goods and materials used in the provision of their service to the County, utilizing a County
approved form.
C.20 Improper Influence

Contractor shall make all reasonable efforts to ensure that no County officer or employee, whose
position in the County enables him/her to influence any award of the Contract or any competing offer,
shall have any direct or indirect financial interest resulting from the award of the Contract or shall have
any relationship to the Contractor or officer or employee of the Contractor.
C.21 Improper Consideration

Contractor shall not offer (either directly or through an intermediary) any improper consideration such
as, but not limited to cash, discounts, service, the provision of travel or entertainment, or any items of
value to any officer, employee, or agent of the County in an attempt to secure favorable treatment
regarding this Contract.
The County, by written notice, may immediately terminate this Contract if it determines that any
improper consideration as described in the preceding paragraph was offered to any officer, employee,
or agent of the County with respect to the proposal and award process. This prohibition shall apply to
any amendment, extension, or evaluation process once a contract has been awarded.
Contractor shall immediately report any attempt by a County officer, employee, or agent to solicit
(either directly or through an intermediary) improper consideration from Contractor. The report shall
be made to the supervisor or manager charged with supervision of the employee or the County
Administrative Office. In the event of a termination under this provision, the County is entitled to pursue
any available legal remedies.
C.22 Informal Dispute Resolution

In the event the County determines that service is unsatisfactory, or in the event of any other dispute,
claim, question, or disagreement arising from or relating to this Contract or breach thereof, the parties
hereto shall use their best efforts to settle the dispute, claim, question or disagreement. To this effect,
they shall consult and negotiate with each other in good faith and, recognizing their mutual interests,
attempt to reach a just and equitable solution satisfactory to both parties.
C.23 Legality and Severability

The parties’ actions under the Contract shall comply with all applicable laws, rules, regulations, court
orders and governmental agency orders. The provisions of this Contract are specifically made
severable. If a provision of the Contract is terminated or held to be invalid, illegal, or unenforceable,
the validity, legality and enforceability of the remaining provisions shall remain in full effect.
C.24 Licenses, Permits and/or Certifications

Contractor shall ensure that it has all necessary licenses, permits and/or certifications required by the
laws of Federal, State, County, and municipal laws, ordinances, rules, and regulations. The Contractor
shall maintain these licenses, permits and/or certifications in effect for the duration of this Contract.
Contractor will notify County immediately of loss or suspension of any such licenses, permits and/or
certifications. Failure to maintain a required license, permit and/or certification may result in immediate
termination of this Contract.
C.25 Material Misstatement/Misrepresentation

If during the course of the administration of this Contract, the County determines that Contractor has
made a material misstatement or misrepresentation or that materially inaccurate information has been
provided to the County, this Contract may be immediately terminated. If this Contract is terminated
according to this provision, the County is entitled to pursue any available legal remedies.
C.26 Mutual Covenants

The parties to this Contract mutually covenant to perform all of their obligations hereunder, to exercise
all discretion and rights granted hereunder, and to give all consents in a reasonable manner consistent
with the standards of “good faith” and “fair dealing”.
C.27 Nondisclosure
Contractor shall hold as confidential and use reasonable care to prevent unauthorized access by, storage,
disclosure, publication, dissemination to and/or use by third parties of, confidential information that is
either: (1) provided by the County to Contractor or an agent of Contractor or otherwise made available to
Contractor or Contractor’s agent in connection with this Contract; or, (2) acquired, obtained, or learned by
Contractor or an agent of Contractor in the performance of this Contract. For purposes of this provision,
confidential information means any data, files, software, information, or materials in oral, electronic,
tangible or intangible form and however stored, compiled or memorialize and includes, but is not limited
to, technology infrastructure, architecture, financial data, trade secrets, equipment specifications, user
lists, passwords, research data, and technology data.
C.28 Notice of Delays

Except as otherwise provided herein, when either party has knowledge that any actual or potential
situation is delaying or threatens to delay the timely performance of this contract, that party shall, within
twenty-four (24) hours, give notice thereof, including all relevant information with respect thereto, to
the other party.
C.29 Ownership of Documents

All documents, data, products, graphics, computer programs and reports prepared by Contractor
pursuant to the Contract shall be considered property of the County upon payment for services (and
products, if applicable). All such items shall be delivered to County at the completion of work under
the Contract, subject to the requirements of Section IV–Term of the Contract. Unless otherwise
directed by County, Contractor may retain copies of such items.
C.30 Reserved
C.31 Air, Water Pollution Control, Safety and Health

Contractor shall comply with all air pollution control, water pollution, safety and health ordinances and
statutes, which apply to the work performed pursuant to this Contract.
C.32 Records
Contractor shall maintain all records and books pertaining to the delivery of services under this
Contract and demonstrate accountability for contract performance. All records shall be complete and
current and comply with all Contract requirements. Failure to maintain acceptable records shall be
considered grounds for withholding of payments for invoices submitted and/or termination of the
Contract.
All records relating to the Contractor’s personnel, consultants, subcontractors, Services/Scope of

Work and expenses pertaining to this Contract shall be kept in a generally acceptable accounting
format. Records should include primary source documents. Fiscal records shall be kept in accordance
with Generally Accepted Accounting Principles and must account for all funds, tangible assets,
revenue, and expenditures. Fiscal records must comply with the appropriate Office of Management
and Budget (OMB) Circulars, which state the administrative requirements, cost principles and other
standards for accountancy.
C.33 Relationship of the Parties

Nothing contained in this Contract shall be construed as creating a joint venture, partnership, or
employment arrangement between the Parties hereto, nor shall either Party have the right, power or
authority to create an obligation or duty, expressed or implied, on behalf of the other Party hereto.
C.34 Release of Information

No news releases, advertisements, public announcements, or photographs arising out of the Contract
or Contractor’s relationship with County may be made or used without prior written approval of the
County.
C.35 Representation of the County

In the performance of this Contract, Contractor, its agents and employees, shall act in an independent
capacity and not as officers, employees, or agents of the San Bernardino County.
C.36 Strict Performance

Failure by a party to insist upon the strict performance of any of the provisions of this Contract by the
other party, or the failure by a party to exercise its rights upon the default of the other party, shall not
constitute a waiver of such party’s right to insist and demand strict compliance by the other party with
the terms of this Contract thereafter.
C.37 Subcontracting
Contractor shall obtain County’s written consent, which County may withhold in its sole discretion,
before entering into Contracts with or otherwise engaging any subcontractors who may supply any
part of the Services to County. At County’s request, Contractor shall provide information regarding
the subcontractor’s qualifications and a listing of a subcontractor’s key personnel including, if
requested by the County, resumes of proposed subcontractor personnel. Contractor shall remain
directly responsible to County for its subcontractors and shall indemnify County for the actions or
omissions of its subcontractors under the terms and conditions specified in Section G. All approved
subcontractors shall be subject to the provisions of this Contract applicable to Contractor Personnel.
For any subcontractor, Contractor shall:
C.37.1 Be responsible for subcontractor compliance with the Contract and the subcontract
terms and conditions; and
C.37.2 Ensure that the subcontractor follows County’s reporting formats and procedures as
specified by County.
C.37.3 Include in the subcontractor’s subcontract substantially similar terms as are provided
in Sections B. Contractor Responsibilities and C. General Contract Requirements.
C. 38 Subpoena
In the event that a subpoena or other legal process commenced by a third party in any way concerning
the Goods or Services provided under this Contract is served upon Contractor or County, such party
agrees to notify the other party in the most expeditious fashion possible following receipt of such subpoena
or other legal process. Contractor and County further agree to cooperate with the other party in any lawful
effort by such other party to contest the legal validity of such subpoena or other legal process commenced
by a third party as may be reasonably required and at the expense of the party to whom the legal process
is directed, except as otherwise provided herein in connection with defense obligations by Contractor for
County.
C.39 Reserved
C.40 Time of the Essence

Time is of the essence in performance of this Contract and of each of its provisions.
C.41 Venue
The parties acknowledge and agree that this Contract was entered into and intended to be performed
in San Bernardino County, California. The parties agree that the venue of any action or claim brought
by any party to this Contract will be the Superior Court of California, San Bernardino County, San
Bernardino District. Each party hereby waives any law or rule of the court, which would allow them to
request or demand a change of venue. If any action or claim concerning this Contract is brought by
any third party and filed in another venue, the parties hereto agree to use their best efforts to obtain a
change of venue to the Superior Court of California, San Bernardino County, San Bernardino District.
C.42 Conflict of Interest

Contractor shall make all reasonable efforts to ensure that no conflict of interest exists between its
officers, employees, or subcontractors and the County. Contractor shall make a reasonable effort to
prevent employees, Contractor, or members of governing bodies from using their positions for
purposes that are or give the appearance of being motivated by a desire for private gain for themselves
or others such as those with whom they have family business, or other ties. Officers, employees, and
agents of cities, counties, districts, and other local agencies are subject to applicable conflict of interest
codes and state law. In the event the County determines a conflict of interest situation exists, any
increase in costs, associated with the conflict of interest situation, may be disallowed by the County
and such conflict may constitute grounds for termination of the Contract. This provision shall not be
construed to prohibit employment of persons with whom Contractor’s officers, employees, or agents
have family, business, or other ties so long as the employment of such persons does not result in
increased costs over those associated with the employment of any other equally qualified applicant.
C.43 Former County Administrative Officials

Contractor agrees to provide or has already provided information on former San Bernardino County
administrative officials (as defined below) who are employed by or represent Contractor. The
information provided includes a list of former County administrative officials who terminated County
employment within the last five years and who are now officers, principals, partners, associates or
members of the business. The information also includes the employment with or representation of
Contractor. For purposes of this provision, “County administrative official” is defined as a member of
the Board of Supervisors or such officer’s staff, County Executive Officer or member of such officer’s
staff, County department or group head, assistant department or group head, or any employee in the
Exempt Group, Management Unit or Safety Management Unit.
C.44 Disclosure of Criminal and Civil Procedures

The County reserves the right to request the information described herein from the Contractor. Failure
to provide the information may result in a termination of the Contract. The County also reserves the
right to obtain the requested information by way of a background check performed by an investigative
firm. The Contractor also may be requested to provide information to clarify initial responses.
Negative information discovered may result in Contract termination.
Contractor is required to disclose whether the firm, or any of its partners, principals, members,
associates or key employees (as that term is defined herein), within the last ten years, has been
indicted on or had charges brought against it or them (if still pending) or convicted of any crime or
offense arising directly or indirectly from the conduct of the firm’s business, or whether the firm, or any
of its partners, principals, members, associates or key employees, has within the last ten years, been
indicted on or had charges brought against it or them (if still pending) or convicted of any crime or
offense involving financial misconduct or fraud. If the response is affirmative, the Contractor will be
asked to describe any such indictments or charges (and the status thereof), convictions and the
surrounding circumstances in detail.
In addition, the Contractor is required to disclose whether the firm, or any of its partners, principals,
members, associates or key employees, within the last ten years, has been the subject of legal
proceedings as defined herein arising directly from the provision of services by the firm or those
individuals. “Legal proceedings” means any civil actions filed in a court of competent jurisdiction, or
any matters filed by an administrative or regulatory body with jurisdiction over the firm or the
individuals. If the response is affirmative, the Contractor will be asked to describe any such legal
proceedings (and the status and disposition thereof) and the surrounding circumstances in detail.
For purposes of this provision “key employees” includes any individuals providing direct service to the
County. “Key employees” do not include clerical personnel providing service at the firm’s offices or
locations.
C.45 Copyright (This may need modification based on Proposer)

County shall have a royalty-free, non-exclusive and irrevocable license to publish, disclose, copy,
translate, and otherwise use, copyright or patent, now and hereafter, all reports, studies, information,
data, statistics, forms, designs, plans, procedures, systems, and any other materials or properties
developed under this Contract including those covered by copyright, and reserves the right to authorize
others to use or reproduce such material.
C.46 Reserved
C.47 Reserved
C.48 Reserved
C.49 Reserved
C.50 California Consumer Privacy Act

To the extent applicable, if Contractor is a business that collects the personal information of a
consumer(s) in performing Services pursuant to this Contract, Contractor must comply with the
provisions of the California Consumer Privacy Act (CCPA). (Cal. Civil Code §§1798.100, et seq.). For
purposes of this provision, “business,” “consumer,” and “personal information” shall have the same
meanings as set forth at Civil Code section 1798.140. Contractor must contact the County immediately
upon receipt of any request by a consumer submitted pursuant to the CCPA that requires any action
on the part of the County, including but not limited to, providing a list of disclosures or deleting personal
information. Contractor must not sell, market or otherwise disclose personal information of a consumer
provided by the County unless specifically authorized pursuant to terms of this Contract. Contractor
must immediately provide to the County any notice provided by a consumer to Contractor pursuant to
Civil Code section 1798.150(b) alleging a violation of the CCPA, that involves personal information
received or maintained pursuant to this Contract. Contractor must immediately notify the County if it
receives a notice of violation from the California Attorney General pursuant to Civil Code section
1798.155(b).
D. TERM OF CONTRACT
This Contract is effective as of *date and expires *date but may be terminated earlier in accordance with
provisions of this Contract.
E. COUNTY RESPONSIBILITIES
E.1 Specific duties and responsibilities are those identified in the RFP and as a result of the Proposer’s
response.
E.2 Medical Control Authority over the EMS Area, System and Plan.
E.3 Specific EOA dispute, grievance, breach and emergency takeover provisions are stated in Attachment
B.
FISCAL PROVISIONS
F.1 Compensation – As compensation for the services, equipment and materials furnished under this
Contract, Contractor shall receive the following as full compensation:
1. Market rights as specified herein.
2. Income from fee for service billing and other reimbursement mechanisms as specified.
The consideration to be paid to Contractor, as provided herein, shall be in full payment for all
Contractor’s services and expenses incurred in the performance hereof, including travel and per diem.
F.2 Exclusivity - In consideration for all of the services, equipment, materials, and supplies to be furnished
by Contractor, the ICEMA Governing Board has designated Contractor as an exclusive provider of
ambulance services within the geographical areas defined by this Agreement. The parties further
agree that by such designation and through the other provisions for Contractor compensation
incorporated herein, ICEMA has fulfilled any and all obligations it may have presently or at any time
during the term of this Contract to compensate, reimburse, or otherwise pay Contractor for services
provided to medically indigent patients. Nothing in this section shall affect County’s obligation to pay
for services to medically indigent patients. Nothing in this Contract is intended to create any duty on
the part of ICEMA to pay for ambulance or emergency medical services rendered to any individual.
G. INDEMNIFICATION AND INSURANCE REQUIREMENTS

G.1 Indemnification
The Contractor agrees to indemnify, defend (with counsel reasonably approved by County) and hold
harmless the County and ICEMA and their authorized officers, employees, agents and volunteers from
any and all claims, actions, losses, damages and/or liability arising out of this Contract from any cause
whatsoever, Including the acts, errors or omissions of any person and for any costs or expenses
incurred by the County or ICEMA on account of any claim except where such indemnification is
prohibited by law. This indemnification provision shall apply regardless of the existence or degree of
fault of indemnities. The Contractor indemnification obligation applies to the County’s or ICEMA’s
“active” as well as “passive” negligence but does not apply to the County’s “sole negligence” or “willful
misconduct” within the meaning of Civil Code section 2782.
G.2 Additional Insured

All policies, except for Worker’s Compensation, Errors and Omissions and Professional Liability
policies shall contain additional endorsements naming the County and its officers, employees, agents
and volunteers as additional named insured with respect to liabilities arising out of the performance of
services hereunder. The additional insured endorsements shall not limit the scope of coverage for the
County to vicarious liability but shall allow coverage for the County to the full extent provided by the
policy. Such additional insured coverage shall be at least as broad as Additional Insured (Form B)
endorsement form ISO, CG 2010.11 85.
G.3 Waiver of Subrogation Rights

The Contractor shall require the carriers of required coverages to waive all rights of subrogation
against the County, its officers, employees, agents, volunteers, contractors and subcontractors. All
general or auto liability insurance coverage provided shall not prohibit the Contractor and Contractor’s
employees or agents from waiving the right of subrogation prior to a loss or claim. The Contractor
hereby waives all rights of subrogation against the County.
G.4 Policies Primary and Non-Contributory

All policies required herein are to be primary and non-contributory with any insurance or self-insurance
programs carried or administered by the County.
G.5 Severability of Interests

The Contractor agrees to ensure that coverage provided to meet these requirements is applicable
separately to each insured and there will be no cross liability exclusions that preclude coverage for
suits between the Contractor and the County or between the County and any other insured or
additional insured under the policy.
G.6 Proof of Coverage

The Contractor shall furnish Certificates of Insurance to the County Department administering the
Contract evidencing the insurance coverage at the time the Contract is executed, additional
endorsements, as required shall be provided prior to the commencement of performance of services
hereunder, which certificates shall provide that such insurance shall not be terminated or expire
without thirty (30) days written notice to the Department, and Contractor shall maintain such insurance
from the time Contractor commences performance of services hereunder until the completion of such
services. Within fifteen (15) days of the commencement of this contract, the Contractor shall furnish
a copy of the Declaration page for all applicable policies and will provide complete certified copies of
the policies and endorsements immediately upon request.
G.7 Acceptability of Insurance Carrier

Unless otherwise approved by Risk Management, insurance shall be written by insurers authorized to
do business in the State of California and with a minimum “Best” Insurance Guide rating of “A- VII”.
G.8 Deductibles and Self-Insured Retention

Any and all deductibles or self-insured retentions in excess of $10,000 shall be declared to and
approved by Risk Management.
G.9 Failure to Procure Coverage
In the event that any policy of insurance required under this contract does not comply with the
requirements, is not procured, or is canceled and not replaced, the County has the right but not the
obligation or duty to cancel the contract or obtain insurance if it deems necessary and any premiums
paid by the County will be promptly reimbursed by the Contractor or County payments to the
Contractor will be reduced to pay for County purchased insurance.
G.10 Insurance Review

Insurance requirements are subject to periodic review by the County. The Director of Risk
Management or designee is authorized, but not required, to reduce, waive or suspend any insurance
requirements whenever Risk Management determines that any of the required insurance is not
available, is unreasonably priced, or is not needed to protect the interests of the County. In addition,
if the Department of Risk Management determines that heretofore unreasonably priced or unavailable
types of insurance coverage or coverage limits become reasonably priced or available, the Director of
Risk Management or designee is authorized, but not required, to change the above insurance
requirements to require additional types of insurance coverage or higher coverage limits, provided that
any such change is reasonable in light of past claims against the County, inflation, or any other item
reasonably related to the County’s risk.
Any change requiring additional types of insurance coverage or higher coverage limits must be made
by amendment to this contract. Contractor agrees to execute any such amendment within thirty (30)
days of receipt.
Any failure, actual or alleged, on the part of the County to monitor or enforce compliance with any of
the insurance and indemnification requirements will not be deemed as a waiver of any rights on the
part of the County.
G.11 Insurance Specifications

The Contractor agrees to provide insurance set forth in accordance with the requirements herein. If
the Contractor uses existing coverage to comply with these requirements and that coverage does not
meet the specified requirements, the Contractor agrees to amend, supplement or endorse the existing
coverage to do so.
Without in anyway affecting the indemnity herein provided and in addition thereto, the Contractor shall secure
and maintain throughout the contract term the following types of insurance with limits as shown:
G.11.1 Workers’ Compensation/Employer’s Liability – A program of Workers’ Compensation

insurance or a state-approved, self-insurance program in an amount and form to meet all applicable
requirements of the Labor Code of the State of California, including Employer’s Liability with $250,000
limits covering all persons including volunteers providing services on behalf of the Contractor and all
risks to such persons under this contract.
If Contractor has no employees, it may certify or warrant to the County that it does not currently have
any employees or individuals who are defined as “employees” under the Labor Code and the
requirement for Workers’ Compensation coverage will be waived by the County’s Director of Risk
Management.
With respect to Contractors that are non-profit corporations organized under California or Federal law,
volunteers for such entities are required to be covered by Workers’ Compensation insurance.
G.11.2 Commercial/General Liability Insurance – The Contractor shall carry General Liability
Insurance covering all operations performed by or on behalf of the Contractor providing coverage for
bodily injury and property damage with a combined single limit of not less than five million dollars
($5,000,000), per occurrence. The policy coverage shall include:

Premises operations and mobile equipment.
Products and completed operations.
Broad form property damage (including completed operations).
Explosion, collapse, and underground hazards.
Personal injury.
Contractual liability.
$10,000,000 general aggregate limit.
G.11.3 Automobile Liability Insurance – Primary insurance coverage shall be written on ISO
Business Auto coverage form for all owned, hired, and non-owned automobiles or symbol 1 (any auto).
The policy shall have a combined single limit of not less than five million dollars ($5,000,000) for bodily
injury and property damage, per occurrence.
If the Contractor is transporting one or more non-employee passengers in performance of contract

services, the automobile liability policy shall have a combined single limit of ten million dollars
($10,000,000) for bodily injury and property damage per occurrence.
If the Contractor owns no autos, a non-owned auto endorsement to the General Liability policy
described above is acceptable.
G.11.4 Umbrella Liability Insurance – An umbrella (over primary) or excess policy may be used to
comply with limits or other primary coverage requirements. When used, the umbrella policy shall apply
to bodily injury/property damage, personal injury/advertising injury and shall include a “dropdown”
provision providing primary coverage for any liability not covered by the primary policy. The coverage
shall also apply to automobile liability.
G.11.5 Professional Liability – Professional Liability Insurance with limits of not less than ten million
($10,000,000) per claim
or
Errors and Omissions Liability Insurance – Errors and Omissions Liability Insurance with limits of
not less than ten million ($10,000,000) and twenty million ($20,000,000) aggregate limits.
If insurance coverage is provided on a “claims made” policy, the “retroactive date” shall be shown and
must be before the date of the start of the contract work. The claims made insurance shall be
maintained or “tail” coverage provided for a minimum of five (5) years after contract completion.
G.11.6 Environmental Contracts -

Environmental Liability Insurance with a combined single limit of not less than five million
($5,000,000) per claim or occurrence and a separate aggregate for the contract project. The required
additional insured endorsement shall protect the County without any restrictions.
If insurance coverage is provided on a “claims made” policy, the “retroactive date” shall be shown and
must be before the date of the start of the contract work. The claims made insurance shall be
maintained or “tail” coverage provided for a minimum of five (5) years after contract completion.
G.11.7 Cyber Liability Insurance - Cyber Liability Insurance with limits of no less than $1,000,000
for each occurrence or event with an annual aggregate of $5,000,000 covering privacy violations,
information theft, damage to or destruction of electronic information, intentional and/or unintentional
release of private information, alteration of electronic information, extortion and network security. The
policy shall protect the involved County entities and cover breach response cost as well as regulatory
fines and penalties.
G.11.8 Abuse/Molestation Insurance – Contractor shall have abuse or molestation insurance

providing coverage for all employees for the actual or threatened abuse or molestation by anyone of
any person in the care, custody, or control of any insured, including negligent employment,
investigation, and supervision. The policy shall provide coverage for both defense and indemnity with
liability limits of not less than one million dollars ($1,000,000) with a two million dollars ($2,000,000)
aggregate limit.
H. SUCCESSORS AND ASSIGNS
H.1 This Contract shall be binding upon County and Contractor and their respective successors and
assigns.
H.2 Neither the performance of this Contract, nor any part thereof, nor any monies due or to become due
thereunder may be assigned by Contract without the prior written consent and approval of County.
I. RIGHT TO MONITOR AND AUDIT
I. 1 The County, State and Federal government shall have absolute right to review and audit all records,
books, papers, documents, corporate minutes, and other pertinent items as requested, and shall have
absolute right to monitor the performance of Contractor in the delivery of services provided under this
Contract. Contractor shall give full cooperation, in any auditing or monitoring conducted. Contractor
shall cooperate with the County in the implementation, monitoring, and evaluation of this Contract and
comply with any and all reporting requirements established by the County.
I.2 All records pertaining to services delivered and all fiscal, statistical and management books and
records shall be available for examination and audit by County representatives for a period of three
years after final payment under this Contract or until all pending County, State and Federal audits are
completed, whichever is later.
J. CORRECTION OF PERFORMANCE DEFICIENCIES

J.1 Failure by Contractor to comply with any of the performance standards or requirements as stated in
the RFP, and/or the provisions, covenants, requirements, or conditions of this Contract shall be a
material breach of this Contract. Specific EOA dispute, grievance, breach and emergency takeover
provisions are stated in Attachment B. If there is a conflict between any of the provisions within
Attachment B and Exhibits 6 and 7, the provisions of Exhibits 6 and 7 shall control.
J.2 In the event of a non-cured breach, County may, at its sole discretion and in addition to any other
remedies available at law, in equity, or otherwise specified in this Contract:
Consistent with the provisions in Attachment B, afford Contractor thereafter a time period within which
to cure the breach, which period shall be established at the sole discretion of County; and/or Terminate
this Contract immediately and be relieved of the payment of any consideration to Contractor. In the
event of such termination, the County may proceed with the work in any manner deemed proper by
the County. The cost to the County shall be deducted from any sum due to the Contractor under this
Contract and the balance, if any, shall be paid by the Contractor upon demand.
NOTICES
All written notices provided for in this Contract or which either party desires to give to the other shall be deemed
fully given, when made in writing and either served personally, or by facsimile, or deposited in the United
States mail, postage prepaid, and addressed to the other party as follows:
Inland Counties Emergency Medical Agency Contractor

(ICEMA) Address
1425 S. D St.
Notice shall be deemed communicated two (2) County working days from the time of mailing if mailed as
provided in this paragraph.
ENTIRE AGREEMENT
This Contract, including all Exhibits and other attachments, which are attached hereto and incorporated by
reference, and other documents incorporated herein, represents the final, complete and exclusive agreement
between the parties hereto. Any prior agreement, promises, negotiations or representations relating to the
subject matter of this Contract not expressly set forth herein are of no force or effect. This Contract is executed
without reliance upon any promise, warranty or representation by any party or any representative of any party
other than those expressly contained herein. Each party has carefully read this Contract and signs the same
of its own free will.
M. ELECTRONIC SIGNATURES
This Contract may be executed in any number of counterparts, each of which so executed shall be deemed to
be an original, and such counterparts shall together constitute one and the same Contract. The parties shall be
entitled to sign and transmit an electronic signature of this Contract (whether by facsimile, PDF or other mail
transmission), which signature shall be binding on the party whose name is contained therein. Each party
providing an electronic signature agrees to promptly execute and deliver to the other party an original signed
Contract upon request.
IN WITNESS WHEREOF, the San Bernardino County and the Contractor have each caused this
Contract to be subscribed by its respective duly authorized officers, on its behalf.

(Print or type name of corporation, company, contractor, etc.)
►
By ►
, Chairman, Board of Supervisors (Authorized signature - sign in blue ink)
Dated: Name
SIGNED AND CERTIFIED THAT A COPY OF THIS (Print or type name of person signing contract)
DOCUMENT HAS BEEN DELIVERED TO THE
CHAIRMAN OF THE BOARD Title
Lynna Monell (Print or Type)
Clerk of the Board of Supervisors
of the San Bernardino County
By Dated:
Deputy
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FOR COUNTY USE ONLY
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County Counsel
Date Date Date
ATTACHMENT A
BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement (Agreement) supplements and is made a part of the contract (Contract)
by and between the San Bernardino County [DEPARTMENT] (hereinafter Covered Entity) and [INSERT
CONSULTANT NAME HERE] (hereinafter Business Associate). This Agreement is effective as of the effective
date of the Contract.
RECITALS
WHEREAS, Covered Entity (CE) wishes to disclose certain information to Business Associate (BA) pursuant
to the terms of the Contract, which may include Protected Health Information (PHI); and
WHEREAS, CE and BA intend to protect the privacy and provide for the security of the PHI disclosed to BA
pursuant to the Contract in compliance with the Health Insurance Portability and Accountability Act of 1996,
Public Law 104-191 (HIPAA), the Health Information Technology for Economic and Clinical Health Act, Public
Law 111-005 (HITECH Act), their implementing regulations, and other applicable laws; and
WHEREAS, The Privacy Rule and the Security Rule require CE to enter into a contract containing specific
requirements with BA prior to the disclosure of PHI, as set forth in, but not limited to, Title 45, sections 164.314,
subdivision (a), 164.502, subdivision (e), and 164.504, subdivision (e) of the Code of Federal Regulations
(C.F.R.) and contained in this Agreement; and
WHEREAS, Pursuant to HIPAA and the HITECH Act, BA shall fulfill the responsibilities of this Agreement by
being in compliance with the applicable provisions of the HIPAA Standards for Privacy of PHI set forth at 45
C.F.R. sections 164.308 (Administrative Safeguards), 164.310 (Physical Safeguards), 164.312 (Technical
Safeguards), 164.316 (Policies and Procedures and Documentation Requirements), and, 164.400, et seq.
and 42 United States Code (U.S.C.) section 17932 (Breach Notification Rule), in the same manner as they
apply to a CE under HIPAA;
NOW THEREFORE, in consideration of the mutual promises below and the exchange of information pursuant
to this Agreement, the parties agree as follows:
A. Definitions
Unless otherwise specified herein, capitalized terms used in this Agreement shall have the same meanings
as given in the Privacy Rule, the Security Rule, the Breach Notification Rule, and HITECH Act, as and when
amended from time to time.
1. Breach shall have the same meaning given to such term under the HIPAA Regulations [45 C.F.R.
§164.402] and the HITECH Act [42 U.S.C. §§17921 et seq.], and as further described in California
Civil Code section 1798.82.
2. Business Associate (BA) shall have the same meaning given to such term under the Privacy Rule,
the Security Rule, and the HITECH Act, including but not limited to 42 U.S.C. section 17921 and
45 C.F.R. section 160.103.
3. Covered Entity (CE) shall have the same meaning given to such term as under the Privacy Rule
and Security Rule, including, but not limited to 45 C.F.R. section 160.103.
4. Designated Record Set shall have the same meaning given to such term under 45 C.F.R. section
164.501.
5. Electronic Protected Health Information (ePHI) means PHI that is maintained in or transmitted by
electronic media as defined in the Security Rule, 45 C.F.R. section 164.103.
6. Individual shall have the same meaning given to such term under 45 C.F.R. section 160.103.
7. Privacy Rule means the regulations promulgated under HIPAA by the United States Department of
Health and Human Services (HHS) to protect the privacy of Protected Health Information, including,
but not limited to, 45 C.F.R. Parts 160 and 164, subparts A and E.
8. Protected Health Information (PHI) shall have the same meaning given to such term under 45
C.F.R. section 160.103, limited to the information received from, or created or received by Business
Associate from or on behalf of, CE.
9. Security Rule means the regulations promulgated under HIPAA by HHS to protect the security of
ePHI, including, but not limited to, 45 C.F.R. Part 160 and 45 C.F.R. Part 164, subparts A and C.
10. Unsecured PHI shall have the same meaning given to such term under the HITECH Act and any
guidance issued pursuant to such Act, including, but not limited to 42 U.S.C. section 17932,
subdivision (h).
B. Obligations and Activities of BA
1. Permitted Uses and Disclosures
BA may disclose PHI: (i) for the proper management and administration of BA; (ii) to carry out the
legal responsibilities of BA; (iii) for purposes of Treatment, Payment and Operations (TPO); (iv) as
required by law; or (v) for Data Aggregation purposes for the Health Care Operations of CE. Prior
to making any other disclosures, BA must obtain a written authorization from the Individual.
If BA discloses PHI to a third party, BA must obtain, prior to making any such disclosure, (i)
reasonable written assurances from such third party that such PHI will be held confidential as
provided pursuant to this Agreement and only disclosed as required by law or for the purposes for
which it was disclosed to such third party, and (ii) a written agreement from such third party to
immediately notify BA of any breaches of confidentiality of the PHI, to the extent it has obtained
knowledge of such breach. [42 U.S.C. section 17932; 45 C.F.R. sections 164.504(e)(2)(i),
164.504(e)(2)(i)(B), 164.504(e)(2)(ii)(A) and 164.504(e)(4)(ii)]
2. Prohibited Uses and Disclosures
i. BA shall not use, access or further disclose PHI other than as permitted or required by this
Agreement and as specified in the attached Contract or as required by law. Further, BA shall
not use PHI in any manner that would constitute a violation of the Privacy Rule or the HITECH
Act. BA shall disclose to its employees, subcontractors, agents, or other third parties, and
request from CE, only the minimum PHI necessary to perform or fulfill a specific function
required or permitted hereunder.
ii. BA shall not use or disclose PHI for fundraising or marketing purposes.
iii. BA shall not disclose PHI to a health plan for payment or health care operations purposes if the
patient has requested this special restriction, and has paid out of pocket in full for the health
care item or service to which the PHI solely relates. (42 U.S.C. section 17935(a) and 45 C.F.R.
section 164.522(a)(1)(i)(A).)
iv. BA shall not directly or indirectly receive remuneration in exchange for PHI, except with the
prior written consent of CE and as permitted by the HITECH Act (42 U.S.C. section 17935(d)(2);
and 45 C.F.R. section 164.508); however, this prohibition shall not affect payment by CE to BA
for services provided pursuant to this Agreement.
3. Appropriate Safeguards
i. BA shall implement appropriate safeguards to prevent the unauthorized use or disclosure of

PHI, including, but not limited to, administrative, physical and technical safeguards that
reasonably protect the confidentiality, integrity and availability of the PHI BA creates, receives,
maintains, or transmits on behalf of the CE, in accordance with 45 C.F.R. sections 164.308,
164.310, 164.312 and 164.316. [45 C.F.R. sections 164.504(e)(2)(ii)(b) and 164.308(b).]
ii. In accordance with 45 C.F.R. section 164.316, BA shall maintain reasonable and appropriate
written policies and procedures for its privacy and security program in order to comply with the
standards, implementation specifications, or any other requirements of the Privacy Rule and
applicable provisions of the Security Rule.
iii. BA shall provide appropriate training for its workforce on the requirements of the Privacy Rule
and Security Rule as those regulations affect the proper handling, use confidentiality and
disclosure of the CE’s PHI.
Such training will include specific guidance relating to sanctions against workforce members
who fail to comply with privacy and security policies and procedures and the obligations of the
BA under this Agreement.
4. Subcontractors
BA shall enter into written agreements with agents and subcontractors to whom BA provides CE’s
PHI that impose the same restrictions and conditions on such agents and subcontractors that
apply to BA with respect to such PHI, and that require compliance with all appropriate safeguards
as found in this Agreement.
5. Reporting of Improper Access, Use or Disclosure or Breach
Every suspected and actual Breach shall be reported immediately, but no later than one (1)
business day upon discovery, to CE’s Office of Compliance, consistent with the regulations under
HITECH Act. Upon discovery of a Breach or suspected Breach, BA shall complete the following
actions:
i. Provide CE’s Office of Compliance with the following information to include but not limited to:
a) Date the Breach or suspected Breach occurred;
b) Date the Breach or suspected Breach was discovered;
c) Number of staff, employees, subcontractors, agents or other third parties and the names
and titles of each person allegedly involved;
d) Number of potentially affected Individual(s) with contact information; and
e) Description of how the Breach or suspected Breach allegedly occurred.
ii. Conduct and document a risk assessment by investigating without unreasonable delay and in
no case later than five (5) calendar days of discovery of the Breach or suspected Breach to
determine the following:
a) The nature and extent of the PHI involved, including the types of identifiers and likelihood
of re-identification;
b) The unauthorized person who had access to the PHI;
c) Whether the PHI was actually acquired or viewed; and
d) The extent to which the risk to PHI has been mitigated.
iii. Provide a completed risk assessment and investigation documentation to CE’s Office of
Compliance within ten (10) calendar days of discovery of the Breach or suspected Breach with
a determination as to whether a Breach has occurred. At the discretion of CE, additional

information may be requested.
a) If BA and CE agree that a Breach has not occurred, notification to Individual(s) is not
required.
b) If a Breach has occurred, notification to the Individual(s) is required and BA must provide
CE with affected Individual(s) name and contact information so that CE can provide
notification.
iv. Make available to CE and governing State and Federal agencies in a time and manner
designated by CE or governing State and Federal agencies, any policies, procedures, internal
practices and records relating to a Breach or suspected Breach for the purposes of audit or
should the CE reserve the right to conduct its own investigation and analysis.
6. Access to PHI
To the extent BA maintains a Designated Record Set on behalf of CE, BA shall make PHI maintained
by BA or its agents or subcontractors in Designated Record Sets available to CE for inspection and
copying within ten (10) days of a request by CE to enable CE to fulfill its obligations under the Privacy
Rule. If BA maintains ePHI, BA shall provide such information in electronic format to enable CE to
fulfill its obligations under the HITECH Act. If BA receives a request from an Individual for access
to PHI, BA shall immediately forward such request to CE.
7. Amendment of PHI
If BA maintains a Designated Record Set on behalf of the CE, BA shall make any amendment(s) to
PHI in a Designated Record Set that the CE directs or agrees to, pursuant to 45 C.F.R. section
164.526, or take other measures as necessary to satisfy CE’s obligations under 45 C.F.R. section
164.526, in the time and manner designated by the CE.
8. Access to Records
BA shall make internal practices, books, and records, including policies and procedures, relating to
the use, access and disclosure of PHI received from, or created or received by BA on behalf of, CE
available to the Secretary of HHS, in a time and manner designated by the Secretary, for purposes
of the Secretary determining CE’s compliance with the Privacy Rule and Security Rule and patient
confidentiality regulations. Any documentation provided to the Secretary shall also be provided to
the CE upon request.
9. Accounting for Disclosures
BA, its agents and subcontractors shall document disclosures of PHI and information related to such
disclosures as required by HIPAA. This requirement does not apply to disclosures made for
purposes of TPO. BA shall provide an accounting of disclosures to CE or an Individual, in the time
and manner designated by the CE. BA agrees to implement a process that allows for an accounting
to be collected and maintained by BA and its agents or subcontractors for at least six (6) years prior
to the request. At a minimum, the information collected and maintained shall include: (i) the date of
disclosure; (ii) the name of the entity or person who received PHI and, if known, the address of the
entity or person; (iii) a brief description of PHI disclosed; and (iv) a brief statement of purpose of the
disclosure that reasonably informs the individual of the basis for the disclosure, or a copy of the
Individual’s authorization, or a copy of the written request for disclosure.
10. Termination
CE may immediately terminate this agreement, and any related agreements, if CE determines that
BA has breached a material term of this agreement. CE may, at its sole discretion, provide BA an
opportunity to cure the breach or end the violation within the time specified by the CE.
11. Return of PHI

Upon termination of this Agreement, BA shall return all PHI required to be retained by the BA or its
subcontractors, employees or agents on behalf of the CE. In the event the BA determines that
returning the PHI is not feasible, the BA shall provide the CE with written notification of the conditions
that make return not feasible. Additionally, the BA must follow established policies and procedures
to ensure PHI is safeguarded and disposed of adequately in accordance with 45 C.F.R. section
164.310 and must submit to the CE a certification of destruction of PHI. For destruction of ePHI, the
National Institute of Standards and Technology (NIST) guidelines must be followed. BA further
agrees to extend any and all protections, limitations, and restrictions contained in this Agreement,
to any PHI retained by BA or its subcontractors, employees or agents after the termination of this
Agreement, and to limit any further use, access or disclosures.
12. Breach by the CE
Pursuant to 42 U.S.C. section 17934, subdivision (b), if the BA is aware of any activity or practice
by the CE that constitutes a material Breach or violation of the CE’s obligations under this
Agreement, the BA must take reasonable steps to address the Breach and/or end eliminate the
continued violation, if the BA has the capability of mitigating said violation. If the BA is unsuccessful
in eliminating the violation and the CE continues with non-compliant activity, the BA must terminate
the Agreement (if feasible) and report the violation to the Secretary of HHS.
13. Mitigation
BA shall have procedures in place to mitigate, to the extent practicable, any harmful effect that is
known to BA of a use, access or disclosure of PHI by BA, its agents or subcontractors in violation of
the requirements of this Agreement.
14. Costs Associated to Breach
BA shall be responsible for reasonable costs associated with a Breach. Costs shall be based upon
the required notification type as deemed appropriate and necessary by the CE and shall not be
reimbursable under the Agreement at any time. CE shall determine the method to invoice the BA
for said costs. Costs shall incur at the current rates and may include, but are not limited to the
following:
• Postage
• Alternative means of notice
• Media notification
• Credit monitoring services
15. Direct Liability
BA may be held directly liable under HIPAA for impermissible uses and disclosures of PHI; failure
to provide breach notification to CE; failure to provide access to a copy of ePHI to CE or individual;
failure to disclose PHI to the Secretary of HHS when investigating BA’s compliance with HIPAA;
failure to provide an accounting of disclosures; and, failure to enter into a business associate
agreement with subcontractors.
16. Indemnification
BA agrees to indemnify, defend and hold harmless CE and its authorized officers, employees,
agents and volunteers from any and all claims, actions, losses, damages, penalties, injuries, costs
and expenses (including costs for reasonable attorney fees) that are caused by or result from the
acts or omissions of BA, its officers, employees, agents and subcontractors, with respect to the use,
access, maintenance or disclosure of CE’s PHI, including without limitation, any Breach of PHI or
any expenses incurred by CE in providing required Breach notifications.
17. Judicial or Administrative Proceedings
CE may terminate the Contract, effective immediately, if (i) BA is named as a defendant in a criminal
proceeding for a violation of HIPAA, the HITECH Act, the Privacy Rule, Security Rule or other
security or privacy laws or (ii) a finding or stipulation is made in any administrative or civil proceeding
in which the BA has been joined that the BA has violated any standard or requirement of HIPAA, the
HITECH Act, the Privacy Rule, Security Rule or other security or privacy laws.
18. Insurance
In addition to any general and/or professional liability insurance coverage required of BA under the
Contract for services, BA shall provide appropriate liability insurance coverage during the term of
this Agreement to cover any and all claims, causes of action, and demands whatsoever made for
loss, damage, or injury to any person arising from the breach of the security, privacy, or
confidentiality obligations of BA, its agents or employees, under this Agreement and under HIPAA
45 C.F.R. Parts 160 and 164, Subparts A and E.
19. Assistance in Litigation or Administrative Proceedings
BA shall make itself, and any subcontractors, employees, or agents assisting BA in the performance
of its obligations under the Agreement, available to CE, at no cost to CE, to testify as witnesses, or
otherwise, in the event of litigation or administrative proceedings being commenced against CE, its
directors, officers, or employees based upon a claimed violation of HIPAA, the HITECH Act, the
Privacy Rule, the Security Rule, or other laws relating to security and privacy, except where BA or
its subcontractor, employee or agent is a named adverse party.
C. Obligations of CE
1. CE shall notify BA of any of the following, to the extent that such may affect BA’s use, access,
maintenance or disclosure of PHI:
i. Any limitation(s) in CE’s notice of privacy practices in accordance with 45 C.F.R. section 164.520.
ii. Any changes in, or revocation of, permission by an individual to use, access or disclose PHI.
iii. Any restriction to the use, access or disclosure of PHI that CE has agreed to in accordance with
45 C.F.R. section 164.522.
D. General Provisions
1. Remedies
BA agrees that CE shall be entitled to seek immediate injunctive relief as well as to exercise all other
rights and remedies which CE may have at law or in equity in the event of an unauthorized use,
access or disclosure of PHI by BA or any agent or subcontractor of BA that received PHI from BA.
2. Ownership
The PHI shall be and remain the property of the CE. BA agrees that it acquires no title or rights to
the PHI.
3. Regulatory References
A reference in this Agreement to a section in the Privacy Rule and Security Rule and patient
confidentiality regulations means the section as in effect or as amended.
4. No Third-Party Beneficiaries
Nothing express or implied in the Contract or this Agreement is intended to confer, nor shall anything
herein confer, upon any person other than CE, BA and their respective successors or assigns, any
rights, remedies, obligations or liabilities whatsoever.
5. Amendment
The parties acknowledge that state and federal laws related to privacy and security of PHI are rapidly
evolving and that amendment of the Contract or this Agreement may be required to ensure
compliance with such developments. The parties shall negotiate in good faith to amend this
Agreement when and as necessary to comply with applicable laws. If either party does not agree to
so amend this Agreement within 30 days after receiving a request for amendment from the other,
either party may terminate the Agreement upon written notice. To the extent an amendment to this
Agreement is required by law and this Agreement has not been so amended to comply with the
applicable law in a timely manner, the amendment required by law shall be deemed to be
incorporated into this Agreement automatically and without further action required by either of the
parties. Subject to the foregoing, this Agreement may not be modified, nor shall any provision hereof
be waived or amended, except in a writing duly signed and agreed to by BA and CE.
6. Interpretation
Any ambiguity in this Agreement shall be resolved to permit CE to comply with the Privacy and
Security Rules, the HITECH Act, and all applicable patient confidentiality regulations.
7. Compliance with State Law
In addition to HIPAA and all applicable HIPAA Regulations, BA acknowledges that BA and CE may
have confidentiality and privacy obligations under State law, including, but not limited to, the
California Confidentiality of Medical Information Act (Cal. Civil Code §56, et seq. (“CMIA”)). If any
provisions of this Agreement or HIPAA Regulations or the HITECH Act conflict with CMIA or any
other California State law regarding the degree of protection provided for PHI and patient medical
records, then BA shall comply with the more restrictive requirements.
8. Survival
The respective rights and obligations and rights of CE and BA relating to protecting the confidentiality
or a patient’s PHI shall survive the termination of the Contract or this Agreement.
ATTACHMENT B
I. DISPUTE AND GRIEVANCE
A) Dispute Resolution - ICEMA's duties shall include monitoring the operation of this Contract and ensuring
that PROVIDER fulfills its obligations hereunder. In fulfilling this responsibility, ICEMA shall employ a staff
member knowledgeable in issues concerning emergency medical · services, emergency ambulance
services and the terms of this Contract.
B) Performance Reports - ICEMA shall review monthly and quarterly reports regarding PROVIDER's
performance under the terms and conditions of this Contract and shall assess liquidated damages to be
paid by PROVIDER, if any, as specified in this Contract and according to the terms hereof. Such reports
shall include, but are not limited to, a summary report of all response time exemptions requested by
PROVIDER. The reports shall provide a detailed explanation of all response time exception requests,
which PROVIDER chooses to submit for consideration.
C) Disputes and Grievances - ICEMA shall attempt to resolve disputes or grievances concerning Contract
performance matters between PROVIDER and any city, fire district, public agency, consumer of service,
and any other interested person or party. ICEMA shall not consider a dispute and grievance unless it
concludes that the person or party filing said dispute and grievance has exhausted all other remedies,
which are reasonably available.
D) Strike Notification - PROVIDER shall notify ICEMA, local hospitals, and area EMS providers upon
reasonable knowledge of a strike by PROVIDER's personnel. This notification shall occur as soon as the
information becomes verifiable prior to the effective strike date. An action plan will be provided to ICEMA
as soon as possible, but not more than twenty-four (24) hours following ICEMA notification. The action
plan must be acceptable to ICEMA.
E) Strike Mitigation - PROVIDER shall take every reasonable action necessary to prevent the strike from
adversely affecting the provision of emergency medical services. In the event of a strike, ICEMA may
exercise the “emergency take over" provision contained within the Contract until the PROVIDER can
resume normal operations where (1) no action plan is provided and/or initiated by the PROVIDER; or (2)
PROVIDER's action plan is unable to meet standards under this Contract. ICEMA will not unreasonably
withhold acceptance of PROVIDER's action plan.
F) Minor Breach of Contract - ICEMA shall also have the power to assess liquidated damages for
PROVIDER's "minor breaches" of this Contract. "Minor breaches" shall mean failure to fulfill any of the
terms and conditions of this Contract that do not amount to a major breach of the Contract, as delineated
within Attachment B, Section II. A.: “Major Breach Definitions”.
G) Appeal to ICEMA - ICEMA's decisions in the matters referred to above may be appealed by PROVIDER
to the ICEMA Governing Board, in writing within fifteen (15) calendar days of receipt of notice relative to
decision. If no appeal is taken, ICEMA 's decision is final. When such matters are appealed to the ICEMA
Governing Board, the Chairperson shall conduct a hearing, consider such evidence, testimony, and
argument as may be reasonably presented, and shall, within thirty (30) calendar days following the
hearing, render written findings and decision to uphold, modify, or overturn the initial decision. The ICEMA
Governing Board's decision shall be final. Notwithstanding this provision, PROVIDER may utilize the
Dispute Resolution provisions as set forth in Attachment B, Section I. C.: "Disputes and Grievances” of
this Contract for final resolution of such disputes.
II. MAJOR BREACH AND EMERGENCY TAKEOVER PROVISIONS
A. Major Breach Definitions – Conditions and circumstances which, shall constitute a major breach of
contract by the PROVIDER shall include the following:
1. Failure of the PROVIDER to operate its services in a manner which enables ICEMA and the
PROVIDER to remain in compliance with the requirements of this Contract, or of the applicable
federal, state and local laws, rules and regulations. Minor infractions of such requirements
shall not constitute a major breach of this Contract. Once a takeover has been completed,
ICEMA shall, as soon as reasonably· possible, select a new ambulance provider, utilizing a
competitive bid process.
2. If the PROVIDER is not successful in curing underperformance regarding Response Time as

outlined below, it may be considered a Major Breach.
i. If the PROVIDER falls below 90th percentile in any EOA, a Liquidated Damage
assessment of $10,000 will be applied. The Contractor will be required to add
additional ambulance unit hours until compliance has been achieved.
ii. If the PROVIDER fails to meet minimum response times in the same zone for a second
consecutive month without adding the additional unit hours approved, a $50,000
Liquidated Damage assessment will be applied. The PROVIDER will be required to
add additional ambulance unit hours until compliance is achieved.
iii. If the PROVIDER is out of compliance in multiple zones more than three times in a
year, a $75,000 Liquidated Damage assessment will be applied, in addition to
Liquidated Damages noted in item number one (1). The PROVIDER will be required
to add additional ambulance unit hours as a cure.
3. Falsification or intentional omission of data or information supplied to ICEMA, which affects or

has the effect of enhancing PROVIDER's performance under this Contract.
4. Failure to report and comply when penalty provisions apply.
5. Failure to maintain in force throughout the term of this Contract, including any extensions
thereof, the insurance coverage required herein.
6. Multiple or unmediated failures to correct any minor breach within a reasonable period of time
after written notice from ICEMA.
7. Any act or omission of PROVIDER, which, in the reasonable opinion of the ICEMA Medical
Director, poses a serious risk to public health and safety.
8. PROVIDER terminates its contract with the County for provision of indigent transport services.
B. Notice to PROVIDER - If it appears that any of the conditions or circumstances set forth above exists
or has occurred, then the ICEMA Executive Director, in consultation with the ICEMA Medical Director,
shall notify PROVIDER of such existence or occurrence. PROVIDER shall have a period of time, which
shall be reasonable under the circumstances, to take appropriate remedial action to correct the
deficiencies. PROVIDER and ICEMA staff shall attempt in good faith and with all reasonable effort to
resolve the allegations between and among themselves without recourse to the other remedies
available herein.
C. Unresolved Allegation - If an allegation of major breach has not been resolved under the above
provisions, the ICEMA Executive Director, in consultation with the ICEMA Medical Director, shall notify
PROVIDER in writing and ICEMA shall immediately undertake an emergency takeover of
PROVIDER's operations pursuant to the provisions herein.
D. ICEMA Discretion - If ICEMA finds that only a minor breach has occurred, or that a major breach has
occurred but the public health and safety would not be endangered by allowing PROVIDER to continue
its operations, then ICEMA may require other actions, short of termination and takeover, as it deems
appropriate under the circumstances.
E. ICEMA Governing Board Hearing

1. After PROVIDER is given reasonable notice of Minor Breach, and PROVIDER has not taken
appropriate remedial action to correct the deficiency, the ICEMA Governing Board shall hold
a hearing upon the ICEMA Executive Director's or EMS Administrator’s recommendations.
The ICEMA Governing Board shall receive and consider any additional information and
evidence on the matter which PROVIDER or others may wish to present, and determine
whether a major breach of this Contract has occurred and whether said breach is such that
the public health and safety would be endangered by allowing PROVIDER to continue its
operations under this Contract. If the ICEMA Governing Board finds that a major breach has
occurred and PROVIDER has failed to cure the deficiency, it shall declare this Contract
termination and commence action to affect an immediate takeover by lCEMA of PROVIDER's
operations.
2. If the Governing Board finds that only a minor breach has occurred, or that a major breach has
occurred but that allowing PROVIDER to continue its operations would not endanger the public
health and safety, the ICEMA Governing Board may take such other actions, short of
termination and takeover, as it deems appropriate under the circumstances.
F. Expedited Hearing Process - If, in the judgment of the ICEMA Executive Director or EMS
Administrator, it appears a condition or circumstance of major breach exists or has occurred and that
such condition or circumstance presents an immediate danger to the public health and safety, the
ICEMA Executive Director, after giving notice to PROVIDER, may take the matter directly and
immediately to the Governing Board for its determination under the above provisions.
G. Notice of Default - Pursuant to the above provisions, ICEMA shall have the right to terminate, cancel,
or takeover services provided under this Contract or to pursue any appropriate legal remedy in the
event of a major breach. In such Instance, ICEMA shall provide written notice to PROVIDER specifying
the date and time of intended termination or takeover.
H. Emergency Takeover - Without limiting ICEMA's rights as set forth herein, in the event ICEMA
determines that a major breach, actual or threatened, has or will occur, or that another event has or
will occur that prevents performance, and if the nature of the breach or inability to perform is, in the
reasonable opinion of the ICEMA Executive Director, such that public health and safety are
endangered, and after PROVIDER has been given notice and an opportunity deemed· reasonable by
the ICEMA Executive Director to correct the deficiency (which notice may be less than 30 days,
depending on the circumstances and gravity of the breach), the matter may be presented to the
Governing Board. If the Governing Board concurs that (1) a breach has occurred, (2) the PROVIDER
has failed to cure the breach, ·and (3) that the health and safety would be endangered by allowing
PROVIDER to continue its operations, PROVIDER shall cooperate fully with ICEMA to affect an
immediate takeover by ICEMA of PROVIDER's EOA. Such takeover may be affected at any time after
action by the Governing Board or within such time period as the Governing Board deems to be
appropriate. In the event of an emergency takeover, the County, at its sole option, will have complete
ability to replace the contractor’s management team with County selected leadership and assume
management and control over Contractor’s personnel, equipment and facilities to continue ambulance
operations. This does not apply upon expiration or earlier termination of the contract pursuant to the
terms of the contract. County’s full use of the personnel, equipment and facilities will continue until a
replacement provider for the Comprehensive Service Area is selected through the applicable
procurement process.
I. Takeover Cooperation
1. If PROVIDER disputes any such finding of major breach through litigation, such litigation shall not
have the effect of delaying, in any way, the immediate takeover of operations by the ICEMA.
2. These provisions are specifically stipulated and agreed to by both parties as being reasonable and
necessary to the protection of public health and safety, and any legal dispute concerning the
finding that a major breach has occurred shall be initiated and shall take place only after the
emergency takeover has been completed, and shall not under any circumstances, delay the
process of the emergency takeover by ICEMA.
3. PROVIDER's cooperation with and full support of such emergency takeover shall not be construed
as acceptance by the PROVIDER of the finding of major breach, and shall not in any way
jeopardize PROVIDER's right to recovery should a court later find that declaration of major breach
was made in error. However, failure on the part of the PROVIDER to cooperate fully with ICEMA
to effect a safe and smooth takeover of operations shall itself constitute a major breach of this
Contract, even if it was later determined that the original declaration of major breach was made in
error.
4. The ICEMA Governing Board shall be the final authority for ICEMA.
EXHIBIT 5 - PROPOSER SCORING SHEET

Proposer Minimum Qualification Sheet
To qualify for evaluation by the Proposal Review Committee (Committee), a Proposer must meet the following
minimum qualifications with a YES score in all categories.
Proposal Meets Minimum Qualifications YES/NO
Category YES NO
Organizational Experience
Key Leadership Experience
Reference Letters
Financial Condition
Legal History
Evidence of Insurance
Evidence of Ability to Provide Performance Bond or

Irrevocable Letter of Credit
Proposal Review Committee Instructions

A Proposal review committee chosen by the County, shall review, rate, and rank all proposals based on criteria identified
in this Request for Proposals (RFP).
In selecting an exclusive provider, the Committee shall review the following considerations:
(1) The quality of the service to be provided,
(2) The level of service to be provided,
(3) The rates charged to the public for services provided,
(4) Documented evidence of ability to work effectively with local agencies,
(5) Evidence of expertise, capability, and capacity to provide for or arrange for ambulance services as described in the
RFP,
(6) The financial stability of service to be provided,
(7) The effect Proposer’s wages, benefits, shift schedules and expected productivity will have on the Proposer’s ability
to attract and retain experienced personnel, especially the existing employed Paramedics and Emergency Medical
Technicians (EMTs) in San Bernardino County.
Committee participants will receive a copy of all submitted proposals, along with a Proposer Scoring Sheet to rate each
proposal based on the information provided, to evaluate the response against the RFP criteria.
The Evaluator Rating Descriptions provide direction for scoring each of the Scope of Work items and Special Provisions
within the RFP. The Committee participants should mark the column that best represents the rating for each section.
Individual Committee members will remain confidential. It is likely the scores will be aggregated and shared in the final
process.
Evaluation Guide
(1) Does the Proposer provide complete responses in accordance with the RFP specifications?
(2) Does the Proposer demonstrate relevant experience to conduct the scope of work outlined in this RFP?
(3) Does the Proposer demonstrate knowledge of state and local standards required for this procurement?
(4) Does the Proposer adequately address all portions of the scope of work described in this RFP?
(5) Does the proposal clearly explain the roles each person assigned to the project will have in connection with the
RFP?
(6) Do the individuals assigned to the project possess relevant education, training, and experience to perform their
roles in the scope of work?
(7) Does the proposal sufficiently describe the Proposer’s plan for meeting the reporting requirements described in
this RFP?
(8) Does the proposed ambulance rate accurately reflect the Proposer’s effort to meet requirements and objectives?
(9) Does the proposed Operating and Start-up Budget demonstrate an understanding of and adhere to the
requirements described within this RFP?
Proposer Name: _____________________________________________________________________
Evaluator Number: _________________________________________Date: _____________________
Points
Rating Description
Awarded
The proposal successfully addresses all relevant aspects of the element being evaluated
and provides clear examples of how they will accomplish this requirement. Exceeds
Excellent expectations, very innovative, clearly superior to that which is average or expected as 100%
the norm. Excellent probability of success and in achieving all objectives and meeting
RFP specification.
The proposal addresses the element well; although there may be some inconsistency in
Very Good the examples provided, all requirements are addressed. Good probability of success, 80%
better than that which is average or expected as the norm. Achieves all objectives per
RFP requirements and expectations.
Minimally The proposal addresses the element adequately; although limited examples are
provided, and certain requirements are not completely addressed. Average probability 60%
Satisfactory
of success, however some objectives may be met in a minimally sufficient manner.
The proposal broadly addresses the element; however, details are missing and there are
Fair significant weaknesses that would need additional clarification or justification 40%
concerning meeting the overall criterion. Has a reasonable probability of success,
however, some objectives may not be met.
The proposal has inherent weaknesses concerning the element being evaluated and
Poor does not materially support the criterion and falls short of expectations, is substandard 20%
to that which is the average or expected norm, has a low probability of success in
achieving objectives per the RFP
No Response The Proposer did not provide information related to this scoring element. 0%
Evaluator Rating
SECTION IV – SCOPE OF WORK AND

SCORING CRITERIA Total Points
Very Minimally No Total Points
Scope of Work and Special Provisions Excellent Fair Poor Possible per
Good Satisfactory Response per Item
are outlined in the RFP. The sections Category
are provided as a guide.
4.2 System Requirements 5
System Requirements:
A. Commission of Accreditation of
Ambulance Services (CAAS)
B. System Monitoring FirstWatch 5
Surveillance Platform
C. Contractor Support of County
Compliance Contract Management
4.3 Response Time Standards 30
A. Response Time Standards 30
4.4 Clinical Performance Standards 40
A. Clinical Performance Standards 40
4.5 Ambulance Deployment and System

50
Status Plan
B. Ambulance Deployment
45
Requirements
C. Standby and Special Events 5
4.6 Vehicles 15
A. Ambulance Requirements
5
B. Support Vehicle Requirements
C. Vehicle Maintenance Program

10
D. Vehicle Safety Program
4.7 Medical Supplies and Equipment 10

A. Medical Supplies and
10
Equipment
4.8 Personnel 95
A. Workforce and Diversity 5
B. Ambulance Work Schedules and

5
Conditions
C. Stations and Field Sub-Stations 5
D. Compensation/Benefits
15
E. Treatment of Incumbent Worker
F. Ambulance Staffing 5
G. Management and Supervision 40
H. Employee Safety and Wellness 5
I. Critical Incident Stress

5
Resilience Program
J-M. Training and Continuing

10
Education and Training Records
4.9 Hospital and Community

15
Requirements
A. Hospital and Technology Interface 5
B. Community Involvement 10
4.10 Disaster Preparedness/Response 20
A. Multi-Hazard Disaster and Multi-

10
Casualty Plans
B. Disaster Reimbursement 5
C. Mutual Assistance 5
4.11 Quality Management 50
A. Quality Improvement Program

40
Requirements
B. Inquiries, Complaints, and Incident

10
Report
4.12 Electronic Patient Care Report 15
A. Electronic Patient Care Report

15
(ePCR)
4.13 Centralized Emergency Medical
25
Dispatch (EMD) Center
A. Emergency Medical Services (EMS)
25
Dispatch
4.14 Financial and Administrative
50
Requirements
A. Patient Fees 25
B. Budget and Fiscal Sustainability 15
C. Billing and Collections System 5
D. Financial Hardship 5
4.15 Future System Enhancements 10
A. Collaboration with system partners to

5
Enhance the EMS System
B. Innovation Solutions to Mental

Health Response and Alternate 5
Transport Services
Total Score 430
EXHIBIT 6 - RESPONSE TIMES AND LIQUIDATED DAMAGES

The goal of the Inland Counties Emergency Medical Agency (ICEMA) is to ensure a high-performance Emergency
Medical Services (EMS) system. This Request for Proposals (RFP) represents a system that expects the Contractor to
perform. The Contractor must commit to employing whatever effort is necessary to achieve the Response Time
requirements for ambulance service requests within the Comprehensive Service Area.
Ambulance Response Time standards are designed to provide the appropriate pre-hospital clinical care in a time frame
that is appropriate to the patient situation. There are eleven (11) Exclusive Operating Areas (EOAs) in the
Comprehensive Service Area, and Response Times are based on population density and historical call volume. The
Contractor will be required to meet all response times at the 90th percentile in each of the eleven (11) EOAs. ICEMA
will require the Contractor to implement a performance improvement plan that includes a root cause analysis for any
EOA falling below 90%. ICEMA believes all attempts to comply with Response Time requirements, including system
status plan adjustments or increased ambulance unit hours, need to be part of a corrective action plan.
Response Time compliance will be measured monthly.
A. 911 Response Time Standards

(1) Response Times are based on call prioritization as determined by the ICEMA Medical Director.
Code 3 Responses - Immediate dispatch of an Advanced Life Support (ALS) ambulance with lights and
siren.
Code 2 Responses - Immediate dispatch of a Basic Life Support (BLS) ambulance, with no lights and siren.
(2) The Contractor must meet response times for ALS and BLS requests at the 90th percentile in each of the eleven
(11) EOAs, and for response areas as illustrated in the chart below.
Urban Suburban Wilderness

Response Type Rural Response
Response Response Response
Code 3 ALS 9:59 14:59 29:59 59:59
Code 2 BLS 15:59 22:59 44:59 99:59
(3) Extended Response Time: Response Time over ten (10) minutes shall be considered an Extended Response.
ICEMA will require the Contractor to audit all Extended Responses to identify the root cause and review the
patient's ePCR to determine if any negative outcome may be attributed to the Extended Response. Extended
Responses shall be reported to ICEMA along with any planned corrective action.
B. Interfacility Transport (IFT) and Critical Care Transport (CCT)

(1) Interfacility and Critical Care Transports are measured separately at the 90th percentile standard.
Response Term Compliance Standard
Emergency ALS IFT 09:59 minutes
Non- Emergency Pre-Scheduled IFT > 2 hours +/- 15 minutes of scheduled time
CCT 59:59 minutes
C. Response Time Management
(1) The FirstWatch On-line Compliance Utility (OCU) is the program ICEMA currently utilizes to monitor its EOA
providers. OCU will calculate all Contractor Response Times. Response Times will be measured in minutes and
integer (whole) seconds, and compliance will be calculated on a fractile basis.
(2) ICEMA will calculate response time compliance for each EOA and each response area (urban, suburban, rural
and wilderness) and each response level (Code 3 and Code 2). ICEMA will publish a compliance report within
ten (10) business days following the end of each month.
(3) Each incident is a separate response.
(4) The Response Time of the Contractor's first arriving ambulance will be used to compute the Contractor's
Response Time for that incident. This includes an ambulance response from an entity requested to provide
Mutual Aid for the Contractor.
(5) Compliance will not be calculated until an EOA achieves at least 100 calls at the end of the month. If there are
less than 100 calls in an EOA, calls are added to the next month or months until the 100 calls have been reached
or exceeded.
(6) Emergency ALS IFTs shall be treated as a 911 ALS emergency call. This emergency IFT is for patients requiring
rapid transport to a higher lever specialty care center (Trauma Center, Stroke and STEMI hospital). Emergency
ALS IFTs are calculated as part of the total 911 Response Time compliance category.
(7) Non-emergency IFT is for non-emergency patients transported between facilities. Non-emergency IFTs have a
response time of no greater than fifteen (15) minutes after the scheduled time for transport if the transport is
scheduled at least two hours prior. IFT responses will be totaled monthly and calculated to the 90% standard.
(8) CCT is for patients requiring a higher level of care between licensed healthcare facilities. This transport category
shall have a Response Time of fifty-nine minutes and fifty-nine seconds (59:59) from the request time. If a CCT
is pre-scheduled as a non-emergency transport, the non-emergency IFT Response Time requirement will be
applied. CCT responses will be totaled monthly and calculated to the 90% standard.
D. Calculation of Response Time
(1) Response Time shall begin at the time the following information, at a minimum, is transmitted to the assigned
ambulance crew:
i. Call priority
ii. Exact address or descriptive location such as building or landmark
iii. If no ambulance is available when the dispatcher is ready to dispatch an ambulance, the ambulance
Response Time shall begin at the time that the dispatcher notes in the automated dispatch system
record that no ambulance is available.
(2) Response Time shall stop when:

i. The assigned ambulance notifies dispatch that it is "on-scene," which is defined as fully stopped
(wheels not in motion) at the location where it shall be parked during the incident; or
ii. In the instance of a response to an apartment complex or mobile home park when the unit enters the
complex; or
iii. In the event, "staging" is necessary for personnel safety, at the time the assigned ambulance arrives
at the staging area; or
iv. The time that dispatch notifies the assigned ambulance to cancel its response.
(3) In incidents when the assigned ambulance crew fails to report their arrival on-scene, the time of the
subsequent radio communication from the crew or other personnel that indicate that the ambulance arrived
on-scene shall be used as the on-scene time. The Contractor may also validate on-scene time by MDC
timestamp as documented in CAD or AVL playback.
E. Calculating Response Times - Changes in Call Priority
Response Time calculations to determine compliance with Contract standards and penalties for non-
compliance shall be as follows:
i. Downgrades – If a call is downgraded to a lower priority before the ambulance arrives at the scene,
the Contractor's compliance will be calculated based on whether the higher priority Response Time
standard was exceeded at the time of the downgrade.
ii. Upgrades – If a call is upgraded or there is more than one priority change associated with a given
incident before the ambulance arrives at the scene, the Contractor shall be deemed compliant,
provided the upgrade, or change in priority does not occur after the passage of the lower priority
Response Time threshold.
iii. Reassignment Enroute – If an ambulance is reassigned enroute or turned around before arriving at the
scene (e.g., to respond to a higher priority request), compliance and penalties will be calculated based
on the Response Time standard applicable to the assigned priority of the initial response. The
Response Time clock will not stop until the arrival of an ambulance at the scene from which the
ambulance was diverted.
iv. Canceled Calls – If an assignment is canceled before the ambulance arrives at the scene, compliance
will be calculated based on the elapsed time from dispatch to when the call was canceled.
F. Response Time Correction Exception
(1) When the assigned ambulance crew fails to report their arrival at the scene, the time of the subsequent radio
communication from the crew or other personnel on-scene indicates to dispatch the ambulance has arrived
on-scene shall be used as the arrival time. Alternatively, at scene time may be validated by the Computer Aided
Dispatch (CAD) timestamp or Global Positioning System (GPS) based on the Automatic Vehicle Location (AVL)
playback.
(2) In some cases, specific responses will be excepted by ICEMA and deemed as compliant responses for Response
Time compliance. These Exceptions will be for good cause only, as reasonably determined by ICEMA. The
burden of proof that there is good cause for the Exception shall rest with the Contractor.
(3) The Contractor shall file a request for each desired Response Time correction or Exception via OCU following
ICEMA policy. Such requests list the date, time, and specific circumstances causing the delayed response.
ICEMA will respond to time correction requests utilizing OCU. Examples of Exceptions include but are not
limited to:
i. Automatic Appeals (to be granted by ICEMA):

a. The call was downgraded at the scene by responders or by the dispatcher following protocol
and is Response Time compliant.
b. The call was upgraded and is Response Time compliant.
c. Response canceled before the unit arrived at the scene; must provide evidence that call was
canceled within required Response Time.
ii. Case-by-Case Appeals (to be considered by ICEMA):

a. Off-road or off-paved road locations. The on-time performance will be measured from the
time of dispatch to when the ambulance arrived at the unpaved road.
G. Response Time Exemptions
(1) The Contractor shall maintain the ambulance unit hours as identified in their submitted and approved system
status plan. The plan may include deploying additional unit hours for holidays, special events, and weather-
related emergencies.
(2) Exemptions will only be considered when the Contractor deploys the minimum number of ambulance unit
hours specified in the approved system status plan.
(3) In the monthly calculation of Response Time compliance, every request for ambulance service within the
Comprehensive Service Area shall be included except in some cases, late and specified other responses will be
excluded from Response Time compliance calculations. These Exemptions will be for good cause only, as
reasonably determined by ICEMA in its sole discretion. The burden of proof that there is good cause for the
Exemption shall rest with the Contractor.
(4) The Contractor may request that a response be excluded from the calculation of Response Time if that call
meets the criteria defined below. The Contractor shall file a request for each desired Response Time Exemption
utilizing the OCU program. ICEMA shall grant or deny exemptions to performance standards and advise the
Contractor. ICEMA will respond to Exemption requests using OCU.
Examples of Exemptions include, but are not limited to:
i. Automatic Appeals (to be granted by ICEMA):
a. Additional ambulances responding to the same incident; the first unit must meet Response
Time standard; and
b. The responding ambulance is involved in a traffic collision, and the Contractor is determined
to be not at fault by law enforcement.
ii. Case-by-Case Appeals (to be considered by ICEMA):
a. Extreme weather conditions that impair visibility or create other unsafe driving conditions
b. Incorrect address provided by the requesting party
c. An unavoidable delay caused by road construction
d. Restricted roadway access
e. Ambulance Patient Offload Delay (APOD) delays greater than sixty (60) minutes in transferring
care to a hospital emergency department and ≥ 5% deployed ambulances on APOD impacting
System Status Plan in accordance with ICEMA Policy 8100. It will be the Provider's
responsibility to adequately document the facts surrounding the occurrence to include at
minimum the facility, date, and all clock times (dispatch of the call through time unit
available).
f. Activation of Multi-Casualty Incident (MCI) Management Plan and ≥ 5% of the current
deployment is requested to the incident.
g. All other exemption requests shall be for good cause only, as determined by ICEMA.
Exemptions shall be considered on a case-by-case basis. The burden of proof that there is a
good cause for an exemption shall rest with the Contractor, and the Contractor must have
acted in good faith. The alleged good cause must have been a substantial factor in producing
excessive response times.
H. Response Time Reporting Requirements
(1) Response Time performance reporting requirements and documentation of incident time shall include, but is
not limited to:
i. Time call received by Contractor,
ii. Time location verified,
iii. Time ambulance crew assigned,
iv. Time enroute to the scene,
v. Arrival on-scene time,
vi. Arrival at patient's side,
vii. Total at scene time,
viii. Time enroute to transport destination
ix. Total time to transport to the destination,
x. Arrival time at the destination,
xi. Time of patient transfer to receiving hospital personnel (transfer of care); and,
xii. Time available (Time unit is back in services and available for response).
(2) These reporting requirements may change. ICEMA agrees to meet and confer with the Contractor over such
changes. If reporting requirements are modified and the Contractor demonstrates an associated financial
impact, ICEMA agrees to meet and confer with the Contractor over that impact and cost or revenue mitigation.
(3) The Contractor must synchronize all its clocks with Coordinated Universal Time (UTC).
I. Liquidated Damages
ICEMA may assess Liquidated Damages if a Response Time percentage falls below the 90% performance requirement
in any EOA. In addition, the Contractor will be required to conduct a comprehensive performance improvement process
any time performance is below 90%. The Contractor will be required to submit the performance improvement report
to ICEMA within fifteen (15) days following the identification of underperformance. ICEMA will review and provide
further recommendations as necessary. The Contractor will be required to add additional ambulance unit hours until
compliance has been achieved.
(1) If the Contractor falls below 90th percentile in any EOA, a Liquidated Damage assessment of $10,000 will be
applied. The Contractor will be required to add additional ambulance unit hours until compliance has been
achieved.
(2) If the Contractor fails to meet minimum response times in the same zone for a second consecutive month
without adding the additional unit hours approved, a $50,000 Liquidated Damage assessment will be applied.
The Contractor will be required to add additional ambulance unit hours until compliance is achieved.
(3) If the Contractor is out of compliance in multiple zones more than three times in a year, a $75,000 Liquidated
Damage assessment will be applied, in addition to Liquidated Damages noted in item number one (1). The
Contractor will be required to add additional ambulance unit hours as a cure.
(4) If the Contractor is not successful in curing underperformance following these measures, the Contractor may
be considered in Breach of Contract.
(5) The Contractor may be assessed Liquidated Damages if there is a single Extended Response greater than ten
minutes (10:00) beyond the maximum response time requirement. The chart below illustrates Liquidated
Damages that ICEMA may assess.
Extended Response Times

Priority Liquidated
Urban Suburban Rural Wilderness
Level Damages
Code 3 >19:59 > 24:59 > 39:59 >69:59 $500
Code 2 > 25:59 > 32:59 > 54:59 >109:59 $500
(6) Example of Extended Response: An Urban response requirement of 9:59 has an on-scene time greater than
19:59 (minutes and seconds). The provider will be assessed and pay liquidated damages of $500.00 for being
over ten (10) minutes late on that one (1) response. ICEMA will require the Contractor to audit all Extended
Responses for root cause and conduct a quality improvement review to determine if any negative outcome
may be attributed to the extended response. Audit requirements include, but are not limited to:
i. Conduct and participate in a process review study to identify causes and opportunities to reduce the
number of Extended Responses.
ii. Conduct 100% review (Clinical and Operations) on Extended Response calls.
J. Additional Liquidated Damages
Additional Penalty Assessment (per incident)

A preventable mechanical failure with a patient on board an ambulance (If the vehicle is out of
compliance with county-approved maintenance schedule, exceeds mileage or age limits, or empty $500
fuel tank, etc.)
Failure of the crew to report response times on-scene and the on-scene time is not verifiable by
$250
other pre-agreed reliable means such as GPS.
K. Payments and Use of Liquidated Damage Funds

(1) ICEMA will make the final Liquidated Damage determination based on this section and inform the Contractor
of the monthly incidents and penalties. The Contractor shall pay ICEMA all Liquidated Damages within thirty
(30) days of receipt of the notification. A five percent (5%) late payment charge will be assessed monthly on
any payment made after the due date. The Contractor will pay all penalty assessments to ICEMA.
(2) Liquidated Damages collected will be utilized for EMS system enhancements and community outreach.
L. Phase-In Period
For the first three (3) months of the contract, Response Time requirements shall be calculated; however, Liquidated
Damages will not be assessed. The phase-in-period allows for adjustments in the system status management plan. Plan
modifications must be submitted for approval by ICEMA.
EXHIBIT 7 - CLINICAL PERFORMANCE STANDARDS, EXEMPTION AND

LIQUIDATED DAMAGES
Clinical Performance Measures:

Participation in State and National Benchmarking
ICEMA will require the submission of data consistent with Health and Safety (H&S) Code 1797.227 that would allow the
County to participate in programs such as California EMS System Core Quality Core Measures Project, Cardiac Arrest
Registry for Enhanced Survival (CARES), National Emergency Medical Services Quality Alliance (NEMSQA: formerly
Emergency Medical Services [EMS] Compass), and Mission: Lifeline.
Inland Counties Emergency Medical Agency (ICEMA) EMS Clinical Performance Measures
ICEMA requires the Proposer to describe how they will conform to jointly developed Clinical Performance Standards
based on the measures listed below. The proposal may contain additional Clinical Performance Standards. The agreed
upon Clinical Performance Standards will become part of the contract. It is understood, due to the nature of Clinical
Performance Standards, a phase-in period may be necessary, and measures may not be completely defined at the
beginning of the contract, but will be based on the ICEMA Policy and Protocol Manual, state regulations and current
best practice. These may include assessment, treatment, communication, transport, and documentation such as:
Assessment
● Blood Glucose measurement for patients with altered neurological function,
● 12-lead ECG obtained in patients with chest pain of suspected cardiac etiology,
● Injured patients assessed for pain,
● Estimate weight for pediatric patients.
Treatment
● Aspirin administered for chest pain of suspected cardiac etiology,
● Glucose or glucagon administered for hypoglycemia,
● Benzodiazepine administered for status epilepticus,
● Nitroglycerin administered for acute pulmonary edema,
● Albuterol administered for symptomatic asthma or Chronic Obstructive Pulmonary Disease (COPD),
● Pain management (pharmacologic or non-pharmacologic) if pain scale >2,
● End-tidal CO2 measured on every successful endotracheal intubation.
Communication and Transport:

● Prearrival hospital notification for stroke, ST-Elevation Myocardial Infarction (STEMI), or major trauma,
● Direct transport of a patient with a suspected stroke, STEMI, or meeting trauma triage criteria to appropriate
designated specialty care center.
Documentation:
● For refusal of care or transport, documentation that patient has decisional capacity,
● Documentation of stroke scale assessment and time last known well for patients with stroke.
Summary of ICEMA EMS Clinical Performance Standards
The chart below summarizes the background and derivation of the Clinical Performance Standards.
CA Core
NEMSQA2 Mission: Lifeline3 GAMUT4 Meyers et al5 TQIP6
Measures1
Assessment
Blood Glucose measured

X X X X
for Altered Mental Status
12-lead
Electrocardiogram (ECG) X
for chest pain
Injured patients assessed

X
for pain
Pediatric weight
X
estimation
Treatment
Aspirin for chest pain X X X
Nitroglycerin Sublingual
Tablets (NTG) for chest X
pain or pulmonary edema
Glucose given for

X X
hypoglycemia
Benzodiazepine for status

X X
epilepticus
Albuterol for asthma or

X X
COPD
Treatment of pain if
X
>2/10
End-tidal CO2 for

Endotracheal Intubation
(ETI)
Communication
Pre-arrival hospital
notification for stroke, X X
STEMI, or major trauma
Transport
Stroke, STEMI, or major

trauma to specialty care X X X X X
center
I I
Additional Suggested Measures (for consideration by Proposer)
● Medication Errors - Total annual or rate
● Ambulance accidents – Response or transport
● Mechanical issues delaying ambulance response or transport
● Near misses (clinical error that does not result in an adverse patient outcome)
● Patient complaints
● Patient satisfaction surveys
● EMS stakeholder and customer satisfaction surveys
Measurement of Clinical Performance
Clinical Performance Standards are a performance-based approach rather than an undefined level of effort. The
Contractor shall commit to employing the level of effort is necessary to achieve the agreed-upon Clinical Performance
Standards. As identified in the RFP, there are specific timelines for these to be developed in collaboration with ICEMA.
It is understood that adequate time is being provided to determine a baseline measurement for each of the ongoing
performance standards. The Contractor shall ensure EMS personnel are trained to current ICEMA standards in a
manner consistent with this goal. Below are examples of Clinical Performance Measures used to indicate performance
throughout EMS systems.
Example of
911
Clinical Emergency Medical Basic Life Advanced Life
Receiving Specialty Care
Performance Dispatch (EMD) Support (BLS) Support (ALS)
Hospital
Standards
Cardiac Arrest 1. Identification 1.Confirm 1. Cardiac 1. ECG if Return of

of cardiac pulselessness Monitor Spontaneous
arrest Circulation (ROSC)
2. Cardiopulmonary 2. Vascular
2. High Priority Resuscitation (CPR) access 2. Primary
Dispatch Percutaneous
3. Automated 3. Medications
Coronary
3. Instructions External
4. ECG if ROSC Intervention (PCI)
for chest Defibrillator (AED)
for STEMI
compressions
3. Targeted
Temperature
Management
Chest Pain - 1. Determine call 1. Assess Vital 1. Cardiac 1. 12-lead 1. 12-lead ECG within
Non traumatic acuity level Signs monitor ECG 10 minutes of
within arrival
2. Administer O2, 2. 12-Lead ECG
10
titrate SpO2 to
3. Acetylsalicylic minutes
> 94%
Acid (ASA) of arrival
Shortness of 1. Identify high 1. O2 1. Assess O2

Breath priority
2. Assess 2. Albuterol for
asthma/COPD
3. NTG for
Pulmonary
Edema
Altered 1. Identify high 1. Assess vital 1. Evaluate for 1. If stroke

Neurological priority signs stroke suspected,
Function Computed
2. SpO2 2. Blood Glucose
Tomography /
3. Blood glucose 3. Vascular Computed
Access Tomography
4. Treatment for Angiography
low BG 4. Treatment for (CT/CTA)
low BG
5. Naloxone for
suspected
opioid
overdose
Clinical Performance Standard Liquidated Damages
It is the goal of ICEMA to ensure the delivery of quality clinical care that adequately addresses the medical condition of
all patients. To adequately implement these measures, a period of twelve (12) months that begins with the
commencement of the contract will be necessary to allow time to identify, test, implement a process to measure
specific clinical performance and evaluate performance improvement strategies.
The Contractor shall work with ICEMA to identify baseline compliance rates and set an anticipated increased growth
toward higher compliance rates after the initial 12 month period. If the Contractor underperforms, based on baseline
compliance rates, the Contractor shall conduct a comprehensive performance improvement process that includes
identification of the root causes. The Contractor will be required to implement a corrective action plan. ICEMA’s Medical
Director will work in consultation with the Contractor to make recommendations and ICEMA’s Medical Director will
have final approval of any corrective actions prior to implementation. If the Contractor fails to identify, evaluate, and
then implement a corrective action plan, Liquidated Damages shall be assessed.
The Contractor understands and agrees that the failure to comply with Clinical Performance Standards or other
requirements in this contract will result in damage to ICEMA and the County. It will be impracticable to determine the
actual amount of damage whether in the event of underperformance or nonperformance, failure to meet standards,
or any other deviation. Therefore, the Contractor and ICEMA agree to the process to establish Liquidated Damages
specified in this contract. It is expressly understood and agreed that the Liquidated Damage amounts are not to be
considered a penalty, but shall be deemed, taken, and treated as a reasonable estimate of the damages to the County.
If all corrective actions identified are implemented, no Liquidated Damages will be assessed.
The Contractor shall pay Liquidated Damages to ICEMA every quarter following the initial 12 month period that the
Contractor fails to attain Clinical Performance Standards and understands that the Clinical Performance Standards will
be periodically updated to reflect current medical standards. Liquidated Damages paid by the Contractor for each
Clinical Performance Standard in which the Contractor fails to maintain the requisite compliance after a comprehensive
Performance Improvement Plan, shall be established and assessed. The chart below is only an example. Baseline metrics
will be set for each Clinical Performance Standard established for compliance as part of the contract. It is understood
that these standards and baseline metrics will be established through a collaborative process and the standards and
metrics will change and/or be modified over the terms of the contract. Contractor will be expected to meet the baseline
metric for each clinical performance standard established.
The table below provides examples of proposed Clinical Performance Standards (actual performance standards will
be established):
Clinical Baseline Under- Damage Under- Damages Under- Considered

Performance Metric performance Assessed performance Assessed performance Breach of
Standard Contract
Examples
Blood Glucose 95% 85-94% $1,500 75-84% $3,000 Anything below Notify of
measurement for 65% in a Contract
patients with quarter Breach
altered
neurological
function
Albuterol 80% 75-79% $1,500 65-74% $3,000 Anything below Notify of

administered for 65% in a Contract
symptomatic quarter Breach
asthma or COPD
The Contractor shall pay liquidated damages to ICEMA for the under-performance of Clinical Performance Standards
as measured quarterly unless exempted by ICEMA. Exemptions include, but are not limited, to the following:
(1) Verified equipment failure with appropriate documentation of reporting and resolution
(2) Verified technical failure to upload 12-lead ECG
(3) Communication failure for advance notice of trauma and stroke
(4) Patient declines treatment and it is properly documented
(5) Specialty Care Center unable to accept stroke, STEMI, or trauma patient.
(6) Higher priority concerns take precedence (e.g., scene safety).
Clinical References
(1) California EMS System Core Quality Measures Project – 2019 manual (rev. 8/20): https://emsa.ca.gov/wp-
content/uploads/sites/71/2020/08/2019_CM_Manual.pdf
(2) National EMS Quality Alliance (NEMSQA) National EMS Quality Measure Set - 2019 Revised Measures:
https://www.nemsqa.org/completed-quality-measures/
(3) Mission: Lifeline - 2021 Criteria: https: http://www.heart.org/-/media/files/professional/quality-
improvement/mission-lifeline/ml-ems-recognition-criteria82620.pdf?la=en
(4) Ground Air Medical Quality Transport Quality Improvement Collaborative (GAMUT) Metrics:
http://gamutqi.org/metrics.html
(5) Myers JB, Slovis CM, Eckstein M, et al: Evidence-based performance measures for emergency medical
services systems: a model for expanded EMS benchmarking. Prehospital Emergency Care. Apr-Jun
2008;12(2):141-51
(6) American College of Surgeons Trauma Quality Improvement Plan (TQIP): https://www.facs.org/quality-
programs/trauma/tqip/best-practice
EXHIBIT 8 - FINANCIAL REPORTING EXCEL SPREADSHEET
Instructions for Revenue and Expense Assumptions MS-Excel File
Instructions
The Proposer is to complete the Revenue Assumptions, Expense Assumptions and Output tabs to their best ability
using information listed in the Request for Proposals (RFP) and Computer Aided Dispatch (CAD) data provided by the
Inland Counties Emergency Medical Agency (ICEMA).
The active spreadsheet can be found in the San Bernardino County Electronic Procurement Network (ePro)
https://epro.sbcounty.gov/bso/view/login/login.xhtml
Revenue Assumptions
Description Year 1 Year 2 Year 3 Year 4 Year 5 Comment I Explanation
Patient Revenue As.wmpttons;
A.LS Rate schedule 100.0% 11.>0.0% 100.0% 100.0% 100.0%

Base charec per trip s s s s
Mi lNgecharge per mile s s s s
0KVR('fl charRC pc.y USC s s s s
Other {describe)
8l5 R.JtC! SChC!dulc 0.1)% 0.0% 0.0% 0.0% 0 .0%

S..s.ech arReP('f' lrip s s s
Mi l~chargl" Jlf!f mi lr s s s
O.ygen cha, ge per use $ $ s
Othet (de.crib~)
T1...a1,IN0Tr4n'iport ,(l,d µerc:er,1<1Keof 101.tl 1, ips 00" 0.0% 0()% 0.0% 0-°"
lre.,t/No hanwar t c;hargepw tr ip s s s
lnte.-f..cilily ham,,J)Of l o.m. 00% 00'1< 00% 00ll
~ sechMgeper trip $ $ $ $ $
Mileagech.u geper mi lf> s s s s s
Oxygen Chill'SC per use s s s s s
Olhcr (dC5Gribc)
C,itic.-1 Ct,.. 1r,.,:.ft()f l 0 _0% ()_°" lUJ1i; n_o-. 00,£

nas.. ch.-8'"~ h ip s s s
Mi l~ch.airg,,permile s s s
Oxygmch.Hger)er u* s s s
Olhcr (d~ribcl
Trip Volume .and P,ver MlxA"4.lmPUon•:

Number o f total trips [lnclud lng Treat/No Transport)
Number o f AlS completed trips

Number ol Bl.5 completed Lrips
Nurnbef or rreat/No fr4nsport completed t ripi
Numbtir of lntemcilitycomple1ed trips
Number of Critic~ Ctrf'cOmpleted trip:.
P"'Ver Milt (perCWll.f8HOh rips):

MediC.UC!': IJ.0% O.O"J6 0.0% n.m£ 01~
Medicaid 0.0ll 0.0':4 o.°" 0.0% 0.0%
Commcrci~l lnsu~Ka 0.0!< 0.0% 0.Oll o.°" o.°"
Priv.aiteP,iV& Olh~ O.Oll 0.Oll 0.0% 0Oll 0Oll
Other Revenue AS$Umptlons:

QUAF Reve nue
Vohuue
Gt°" Re venue s s s
Net Colloctions s s s
PPIGT Reve nue
volume
Gross RNmu~ s s s s s
Net CoU«tions s s s s s
All Other Revenue
Volume
GrossRevt!flue s s s
Net Collections s $ s
Additional Calculations Year 1 Year2 Year 3 Year4 Year 5 Comment/ £xplanation
_Addi_,,_;ona
_ l_C_al_cul_a_t_ion
_s_ _ _ __ _ _ _ _ _ __ __ __ Ye_a_r_1_ _ _ _Y_ea_,_2_ _ _ _Y_e_ar_3_ _ _ _Y
_e_a_r 4_ _ _ __Ye_a_r_s Comment/Explanation
Expense Assumptions
Operating Expense AMUmptiom

SalaryRange(Year l)
He adcount (FTEs) ,~ High FTEsbyyear
Paramedics
EMT,
Position
Position
Position
Position
Position
Position
Position
Position
Position
Position
Subt otal - Headcount (FTEs)
SalariesandWages
Employee Regular 0.0%
Employee OVertime 0.0%
Contract labor 0.0%
Subtotal-Salaries and Wages 0.0%
Payrol/Tue s& Employee Benefits

All PiJVroll Taxes/Worke~Comp 0.1)%
Employee Benefits
Pension {Employer Match) 0 .0%
Medical/ Health care 0.1)%
Dental 0.()%
Vision 0 .0%
Uniforms 0.0%
0.0%
Subtotal - PiJVrotl Taxes & Employee Benefits 0.0%
PurchasedServites
Partnef'Ship/Subcootracting 0 .0%
EMS Agency Oversight and Monitoring Services 0 .0%
Centralized EMD Dispatch Center 0 .0%
Firstwatch Initial Olarge 0.0%
First:watch Annual Charge 0 .0%
lmageTrend Annual Olarge 0.0%
Other Purchased Services 0 .0%
Subt ot al -Purchased Services 0.0%
Estimated Response Time Penalties 0.0% S
_o,
_ .,
_ n~·•-• _on_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _v_ ,_,._1_ _ _ _Ye
_w_ 2_ _ _ _v_,.,
_ 3____
Ye_w_4_ _ _ _v_, .,
_ s_ C.omment /Elcpl.-.ation
General & Administrative

Professional services/ consulting fees 0.0%
Rent/leases 0.0%
Utilities and telephone 0.0%
Office supplies/ equipment 0.1)%
Billini and coflection expense 0 .0%
Geneul and Auto Liability Insurance 0 .0%
Performance Security expense 0 .0%
Other Oll'erhead expense 0 .0%
Corporate/ Reiional allocations 0 .0%
Depreciation 0.0%
Othe< 0 .0%
Subt ot al -General & Administrative 0.0%
Vehides
Vd'liclelease 0 .0%
Gas,oil, tires 0.0%
Repairsandmaintenance 0.()%
Depreciation 0.0%
0th« 0 .0%
Subtot al -Vehicles 0 .0%
Medical Supplie s/ Equipment

Equipment lease 0 .0%
Medic.ii Supplies 0 .0%
Repairs and maintenance 0.0%
Depreciation 0.0%
0th« 0.0%
Subt otal - Medical Supplies/Equipment 0 .0%
Other Operatini Expen5es

Information Technology expenses 0 .0%
Trainin&;/QI expenses 0 .0 %
Communit y Educat ion expen!ieS 0 .0%
Other dispatch/communicat ion expense 0.1)%
Depreciation 0 .0%
Othe< 0 .0%
Subt ot al -Other Operating Expenses 0.0%
Interest Expense 0.0% S
Total Operating Expenses 0.0% S
Output
Dlllml!'.!!!!!
loftr11N
Y••1
Gr,-a.,....,,...,. ,..,c,;,11~
, .._ ,_,
"-""'--
,..,eo,...,. •ottrt""
...... _
'l'HrS
NetCollKt5- hh,.. _
............ Net Coli.cue-
.._
, 'l'•• S
Gn>......_ ...,e.ohrt:t-.
-·
--·
i1in , ..:1..,, CMrc-•
tomffltt'(l.. lftW~
IRUI
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JOU!
1"0 1
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Pt1vtteP!,:&Olhet
""'' ""'' '""' ..u,
..,,
""" "'" "'"' ""''
Subtot.. •AII Patlantctwp_.
""' ''"' '""' "''" ""' ""'
--
OtM,a.w. .u
,...,,.......,
AIIOt·R~
Sulltotall•OtMtlMw-•
...,, _,
Tot.i,-1it."'""'
""'' '"'" ""''
C)paradrisr.-•..
s.,.,lt<JNW4f;tS
P'ilYfoU bxeslf, [m~krN,flt,
P\.irtMW!d St,,,'lu,s
P111Mt>Np/wbcorlt•~IJIIC
Centr•ll«d IMOOl-i?«thCMUI
Othnf'\<rd\Me,d~ti
~bfcc•• Pw<~MMUt
hl~1e11~nnwPen.i116
~.. lf,Mfflll'IIM.r•tw
_,..
Mdt..rWl!Ples/(qulPf!Md
OCMC)p«•ine~
IMitt"t;;l ~ M
TotllOper11i.~-
~-"""~"'°"" ''"' • t fl
..,,,
-· _,
EXHIBIT 9 - INVESTIGATIVE AUTHORIZATION - COMPANY

The undersigned organization, a prospective Proposer, to provide ground ambulance service for San Bernardino County,
recognizes that public health and safety requires assurance of safe, reliable, and cost-efficient ambulance service. That
assurance will require an inquiry into aspects of company operations deemed relevant by Inland Counties Emergency
Medical Agency (ICEMA) or its agents. The company specifically agrees that ICEMA or its agents may conduct an investigation
into, but not limited to the following matters:
(1) The financial stability of the company, including its owners and officers, any information regarding a potential
conflict of interests, past problems in dealing with other clients or cities where the company has rendered service,
or any other aspect of the company operations or its structure, ownership, or key personnel which might reasonably
be expected to influence the County’s selection decision,
(2) The company’s current business practices, including employee compensation and benefits arrangements, pricing
practices, billing and collections practices, equipment replacement and maintenance practices, in-service training
programs, means of competing with other companies, employee discipline practices, public relations efforts, current
and potential obligations to other buyers, and general internal personnel relations,
(3) The attitude of current and previous customers of the company toward the company’s services and general business
practices, including patients or families of patients served by the company, physicians, or other health care
professionals knowledgeable of the company’s past work, as well as other units of local government with which the
company has dealt in the past,
(4) Other businesses in which company owners and/or other key personnel in the company currently have a business
interest,
(5) The accuracy and truthfulness of any information submitted by the company in connection with such evaluation.
This authorization shall expire one year from the date of the signature.
AUTHORIZATION FOR SUCH INVESTIGATION IS HEREBY EXPRESSLY GIVEN BY THE COMPANY:
Date
Organization
By: Signature (authorized representatives)
Name(s) (typed)
Title
State of
County of
On this ___________ day of ___________________ 2022 before me, the undersigned, a Notary Public in and for the said
County and State, personally appears _____________________ to me known to be the person described herein and who
executed the foregoing Affirmation Statement and acknowledged that s/he executed the same has her/his free act and deed.
Witness my hand and Notary Seal subscribed and affixed in said County and State, the day and year above written.
Notary Public
(Seal)
My Commission Expires
EXHIBIT 10 - INVESTIGATIVE AUTHORIZATION - INDIVIDUAL

The undersigned, being (title) for _____(Company), which is a Proposer to provide
Advanced Life Support (ALS), Basic Life Support (BLS), Interfacility Transport (IFT) and Critical Care Transport (CCT)
ambulance service to San Bernardino County, recognizes that public health and safety requires assurance of safe,
reliable, and cost-efficient ambulance service. In order to judge this bid, it is necessary to require an inquiry into matters
which are deemed relevant by San Bernardino County, Inland Counties Emergency Medical Agency (ICEMA), or its
agents, such as, but not limited to, the character, reputation, and competence of the company’s owners and key
employees.
The undersigned specifically acknowledges that such inquiry may involve an investigation of his or her personal work
experience, educational qualifications, moral character, and general background, and specifically agrees that San
Bernardino County, ICEMA, or its agents, may undertake a personal investigation of the undersigned for the purpose
stated. This authorization shall expire twelve (12) months from the signature date.
AUTHORIZATION FOR SUCH INVESTIGATION IS HEREBY EXPRESSLY GIVEN:
Date
Signature
Individual Name (typed)
State of
County of
On this ___________ day of ___________________ 2022 before me, the undersigned, a Notary Public in and for the
said County and State, personally appears _____________________ to me known to be the person described herein
and who executed the foregoing Affirmation Statement and acknowledged that s/he executed the same has her/his
free act and deed.
Witness my hand and Notary Seal subscribed and affixed in said County and State, the day and year above written.
Notary Public
(Seal)
My Commission Expires
EXHIBIT 11 - EMS DISPATCH CENTER & COMMUNICATION EQUIPMENT

REQUIREMENTS
The County requires the Contractor at start-up to enter into a separate agreement with the County’s Centralized
Emergency Medical Dispatch (EMD) Center and pay for the provision of EMD and Computer Aided Dispatch (CAD)-to-
CAD coordination services.
The County’s Centralized EMD Center will provide Medical Priority Dispatch for resource determination and will
determine the Contractor’s priority level to all 911 ALS and BLS calls within the Comprehensive Service Area following
Inland Counties Emergency Medical Agency (ICEMA) Medical Director approved EMD policies and protocols. The
County’s Centralized EMD services with Medical Priority Dispatch System (MPDS) charges are estimated at $5.00 per
call the first year with annual increases.
Centralized EMD Center Services
1. Shall provide a system for Emergency Medical Services (EMS) dispatch meeting the International Academies of
Emergency Dispatch EMD standards and ICEMA policies.
2. Receive and process calls for emergency medical assistance from primary and/or secondary public safety
answering points,
3. Utilize EMD for systemized caller interrogation as approved by ICEMA’s Medical Director,
a. Prioritize the urgency of the response,
b. Dispatch appropriate EMS resources,
c. Give post-dispatch and pre-arrival instructions to callers,
4. Coordinate with the Contractor to establish a CAD-to-CAD link at the Contractor’s expense.
5. Coordinate with public safety and the Contractor’s personnel as needed,
6. Develop dispatch procedures cooperatively with ICEMA and the Contractor including dispatch performance
standards and compliance,
7. Centralized EMD Center will utilize the Quality Improvement (QI) programs ProQA and AQUA to ensure
dispatcher compliance to MPDS protocols, and provide monthly reports to ICEMA,
8. Develop dispatch procedures cooperatively with ICEMA and the Contractor including dispatch performance
standards and compliance with the goal of achieving Accredited Center of Excellence (ACE) Accreditation within
eighteen (18) months,
9. Provide timely electronic reports that are designed jointly by the Centralized EMD Center, Contractor and
ICEMA following agreed-upon timelines,
10. Implement priority dispatch protocols, to include dispatching of Basic Life Support (BLS) and Advanced Life
Support (ALS) ambulances according to ICEMA policies, provision of Emergency Communication Nurse System
(ECNS), and telemedicine in the future when established by ICEMA.
11. Provide uninterrupted EMD/ MPDS services 24/7/365.
12. Enable CAD view capability to ICEMA.
Contractor Requirements
1. Shall operate and utilize a CAD system that has the capability to manage deployment of all ambulance services,
2. Shall have a full-time dispatch center manager, employ experienced dispatch system status Controllers
24/7/365 with the full authority to control the re-positioning of ambulances between posts, Exclusive
Operating Areas (EOAs), and to manage crew breaks and shift changes,
3. Establish a CAD-to-CAD link with the Centralized EMD Center,
4. Schedule ALS, BLS, IFT and CCT transports,
5. Obtain, install, and maintain in the Contractor’s ambulances all such communications equipment as
determined by ICEMA to be necessary for the effective and efficient dispatch of ambulances. For ambulances
responding to 911 calls, Global Positioning System (GPS) Location Systems are required,
6. Be financially responsible for installation, purchase, rental, and maintenance of communication equipment in
all ambulances and staffed vehicles provided in this proposal,
7. Establish policies that ensure upon receipt of a private request for ambulance services, pertinent information
including callback number, location, time of notification, time of dispatch, and nature of the incident is
ascertained,
8. Ensure that a record of calls, as defined in Title 13 of the California Code of Regulations, Chapter 5, Article 1,
Section 1100.7 is maintained,
9. Deploy ambulances most optimally and efficiently including but not limited to:
a. Describe the process for making changes to the ambulance deployment plan, or the third-party software
and the turnaround time for such changes,
b. Describe the required information needs to ensure ambulance performance to the ambulance deployment
plan, or the third-party software and the turnaround time for such changes,
c. Describe the type of reports and timelines associated with these reports,
d. Describe the anticipated dispatching performance standards and measurements.
Communication Equipment Requirement
1. The Contractor will be responsible to install and maintain all telecommunications equipment on the
appropriate frequencies necessary to complete the scope of work as identified in this RFP.
2. The current system uses the 800 frequencies as the primary ambulance dispatch frequency and uses
alphanumeric pagers or SMS messaging to mobile communication devices, Mobile Data Computers (MDCs),
and Location Station Alerting Systems through the Centralized EMD Dispatch Center CAD system.
3. Fire service agencies operate on Very High Frequency (VHF) radio frequencies. Contractor’s supervisor units
and ambulances can access this system via a separate fire channel.
4. The Contractor must have Automatic Vehicle Locators (AVL)/GPS/ Mobile Data Computers (MDC) in place in
ambulances, and field supervisor vehicles. This equipment must be integrated with the County’s Centralized
EMD Center CAD.
5. The Contractor must equip each ambulance with appropriate emergency communications and alerting devices
capable of being used to notify ambulance personnel of response needs. Every ambulance and crew member
must be able to communicate at all times, in all locations, with the Centralized EMD Center, other ambulances,
supervisor’s vehicles, receiving hospitals, and fire agencies.
6. Each ambulance must have a mobile radio in the front cab with the capability for hospital communication in
the rear patient compartment.

7. Each ambulance must have two (2) portable radios, one (1) for each crew member and capable of
interoperability with fire responders.
8. Each ambulance shall have a mobile computer with MDC capability, CAD access, mapping software, and the
ability to send electronic patient care records to the receiving hospital and a centralized server via wireless
technology. Each ambulance will be equipped with AVL, and GPS fully interfaced to the CAD system for unit
recommendation and System Status deployment purposes.
9. Identify all communications equipment (type, brand, number) that will be carried on ambulances and
supervisors’ vehicles including, but not limited to:
a. Radios
b. AVL/GPS/MDCs
c. Telephones
d. Alerting devices
e. Laptop computers for ePCR.
EXHIBIT 12 - CURRENT SAN BERNARDINO COUNTY AMBULANCE RATES
Inland Counties En1ergency Medical Agency

J4HSQ';';~[) S.~t. Su B~ ~ CA 9'H U-OO~ • {909) ns-,sl3 · f:a. (909) 3SS·)Sl$ •1r.l'"ll',i«illl.U1:IIC
S ,,wogSan<&mani"", Inyo, on,f?.t""" Counti.u

([)aa j,f!/,f = , Intaim'Vtt,S,/1,fmmut,alur
~t"ra 4'aaaz:in: !A{'D,. 9.1dicaf©i1Utor
D.-UE: Jtme03, 2022

TO: EMS Groond Transport Provider; . San Bernardino Cotmty
FROM: Daniel Munoz

lnierim EMS Administrator
SUBJECT: FY 20ll-23 AMBIJ"l.A.'ICE RU E ADJUSTh.lENT

EFITCTI\'EJULY 1, 2022-JU!<'E 30, 2023
Ju coufortnance with theJCEMA Reference #3060 - ICEMA Gr0tmd Based Ambulance. Rate Setting Policy -
San Bernarcino County approved by the ICEMA Governing Board on ~ y 8, 2012, the fullowing reyresents
amb,tlauce rate adju,-tDlalts effective July I, 2022. The ~ttached "Grotmd Ambulance Sen,ce Rate
Definitions"will be utilized in the.application of the rates.
Base Rate lncrease CPI + Final Rate

FY 2021-2022 Rate Cou......., Conv--.,rison FY 2022-2023 Rate
Ambulance Rate
Components Rural/ Rural/ Rural/
Urban Wilderness Urban Wifdemes.s Urban Wildemes.s
Operatirg Operating Operatrg Operating Operatirg Operating
Areas Areas. Areas Areas Areas Areas
Advanced Lf e Support (AlS)
Base Rate (AJl l'lctusive) $1,732.92 $1,906.21 $137.69 $151.46 S1,870.61 $2,057.67
E
rt<BlS1Rate $1,248.36 $1 373.20 $99.19 $109.11 S1 347.55 $1.482.31
Fee $305.35 $335.89 $8.56 $9.42 $313.91 $345.31
$189.39 $208.33 $5.31 $5.84 $194.70 $214.17
e $218.62 $240.52 $6.13 $6.74 $224.75 $247.26
Critical Care Transoort S2 051.56 $2 256.70 $57.55 $63.31 S2 109.11 $2 320.01
Mileage (per mile or fraction
thereof\ $32.11 $32.11 $0.90 $0.90 $33.01 $33.01
Wait Time $57.35 $57.35 $1.60 $1.60 $58.95 $58.95
EKG $130.36 $130.36 $3.65 $3.65 $134.01 $134.01
If vou have any questions re!!.llfding ihe. policy and associated rate. calculations, please coutact Geay
Gardner, Supen,ismg EMS Specialist, al (909) 38S-5816 or via e-mail at w-ald.=dner'ii:,:ao.sbcountv.gov.
DM/ggg
Att1chmeut
c: File Copy
BOARDOFDIRECTORS ~
Da-enRowe OJrtHaQman _
COL PaulCool!Ret.• J.:n!CeRlltnMOra Vb!Chalr Chairman ..meoaca, .f£.
fSs OU;111Ct Secorn:I Oltitn::t Tnl!U OlStnet Fourth 01&.trtt f1l'll'I Olsttr:t
EXHIBIT 13 - ASSURANCE OF COMPLIANCE WITH SECTION 504 OF THE

REHABILITATION ACT OF 1973
The undersigned (hereinafter called "Contractor(s)") hereby agrees that it will comply with Section 504 of the
Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable United States Department of Health
and Human Services (DHHS) regulation, and all guidelines and interpretations issued pursuant thereto.
The Contractor(s) gives/give this assurance in consideration for the purpose of obtaining contracts after the date of this
assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the
representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors,
transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this
assurance on behalf of the Contractor(s).
The Contractor(s): (Check a or b)
☐ a. Employs fewer than 15 persons.
☐ b. Employs 15 or more persons and, pursuant to section 84.7 (a) of the regulation (45 C.F.R. § 84.7 (a), has designated
the following person(s) to coordinate its efforts to comply with the DHHS regulation.
Name of 504 Person:
Name of Contractor(s):
Street Address or P.O. Box:
City, State, Zip Code:
I certify that the above information is complete and correct to the best of my knowledge
Signature:
Title of Authorized Official:
Date:
*Exception: DHHS regulations state that: "If a recipient with fewer than 15 employees find that, after consultation with
a disabled person seeking its services, there is no method of complying with (the facility accessibility regulations) other
than making a significant alteration in its existing facilities, the recipient may, as an alternative, refer the handicapped
person to other providers of those services that are accessible."
EXHIBIT 14 - FINANCIAL REQUIREMENTS

Financial Reporting
1. The Contractor shall make available quarterly system reports to include revenue and system expenses as compared
to budget in a manner approved by the Inland Counties Emergency Medical Agency (ICEMA).
2. The Contractor shall make available a Year-end Financial Report to ICEMA Administrator for review. This report
shall include annual financial statements reviewed by an independent certified public accountant in accordance
with generally accepted accounting procedures. Statements shall be available to ICEMA on an annual basis within
one hundred twenty (120) calendar days of the close of the Contractor’s fiscal year. If the Proposer’s financial
statements are prepared on a consolidated basis, then separate balance sheets and income statements for the San
Bernardino County operation shall be required and shall be subject to the independent auditor’s review.
3. The Proposer shall provide a statement agreeing to provide ICEMA all financial reports identified above including
an annual audited financial statement according to Generally Accepted Accounting Principles (GAAP).
Payment and Charges
The Contractor shall also be required to pay a fee in accordance with the cost of contract compliance monitoring as set
by ICEMA and the Board of Supervisors. This fee is intended to offset ICEMA’s cost of oversight of Contractor’s
operations, in accordance with 2 CFR Part 200 Uniform Guidance. The contract compliance monitoring fee is estimated
to be $1,800,000 for the first year of the contract and will receive an annually Consumers Price Index (CPI) adjustment.
The Contractor will pay the following service charges as estimated below annually:
Estimated Annual Services

Emergency Medical Services (EMS) Agency Oversight & Monitoring services $1,800,000
ImageTrend, Annual estimate $180,000
FirstWatch, On-line Compliance Utility (OCU), FirstPass Initial $100,850
FirstWatch, OCU, FirstPass Annual $17,356
Centralize Emergency Medical Dispatch (EMD) Center* $917,275
*Based on 2021 911 call volume at $5.00 per call
Ambulance Transport Rate Adjustments
1. Ambulance rates may be adjusted annually to compensate for inflation which shall be based on the percentage
increase in the average CPI of the following Consumer Price Index factors for All Urban General Consumers (CPI-U)
and the Medical Care Services of the Commodities and Services Group of the CPI for All Urban Users, Los Angeles,
Orange and Riverside counties index, as compiled and reported by the Bureau of Labor Statistic for the previous
12-month period last for which published figures are then available:
a. 50% of the CPI – Medical Care Index
b. 50% of the CPI – All Urban General Consumers (CPI-U)
2. Any rate adjustment made under the CPI provision shall not exceed 5% and must be approved in writing by the
ICEMA Administrator. In the event that CPI-based rate adjustments do not compensate for the increased cost of
operating ambulance services in the Comprehensive Service Area. The Contractor may request an additional rate
increase, which shall be subject to approval by the ICEMA Administrator in order to ensure a fair and appropriate
cost to residents and visitors in the Comprehensive Service Area. The ICEMA Administrator's decision will be
informed by documentation submitted by the Contractor to substantiate the need for a rate increase. Such
documentation may include but is not limited to system statements, audited financial report, collection rate and
payer mix.
3. The Contractor may propose rate changes to ICEMA no more frequently than annually, unless the Contractor can
demonstrate to the satisfaction of ICEMA that, due to extraordinary changes in reimbursement or the cost structure
of operations (beyond the control of the Contractor), an undue financial hardship would exist in the absence of an
immediate rate consideration. No rate increase will be considered for the first year of the contract.
4. Any increase of greater than 5% must be approved by the San Bernardino County Board of Supervisors. ICEMA
reserves the right, in its sole discretion, to conduct a local program audit in the event that the Contractor requests
a fee increase in excess of 5%. ICEMA will require a program audit to conclude whether the Contractor is complying
with the financial and operational terms and conditions of the contract. ICEMA will hire the auditor and the cost of
the audit will be paid by the Contractor. The auditor will identify key agreement terms and conditions, and review
the related documentation (e.g., invoices, agreement amendments, regulatory requirements, accounting records,
financial reports, correspondence). The audit report will provide findings, conclusions and recommendations
related to the Contractor's compliance. Failure of the Contractor to comply fully with the audit shall result in denial
of the requested increase. The Board of Supervisors must approve any rate adjustment beyond those specified
above to adjust for inflation.
EXHIBIT 15 - INSURANCE
The Contractor shall provide proof of insurance or a letter from their insurance company/underwriter of their ability to
obtain and maintain the minimum insurance coverage in full force and effect throughout the term of this contract, and
thereafter as to matters occurring during the term of this contract. If the Proposer is self-insured, the Proposer shall
document its capability to provide similar coverage or assurance of coverage consistent with the insurance
requirements.
Provide evidence of proof of ability to obtain insurance as identified below:
The Contractor shall carry General Liability Insurance covering all operations
performed by or on behalf of the Contractor providing coverage for bodily injury and
property damage with a combined single limit of not less than five million dollars
($5,000,000), per occurrence. The policy coverage shall include:
a. Premises operations and mobile equipment.

General Liability (Including
b. Products and completed operations.
operations, products, and
□
completed operations, as c. Broad form property damage (including completed operations).
applicable.)
d. Explosion, collapse, and underground hazards.
e. Personal injury.
f. Contractual liability.
g. $10,000,000 general aggregate limit.
Primary insurance coverage shall be written on an International Organization for

Standardization (ISO) Business Auto coverage form for all owned, hired, and non-
owned automobiles or symbol 1 (any auto). The policy shall have a combined single
limit of not less than five million dollars ($5,000,000) for bodily injury and property
□ Automobile Liability damage, per occurrence.
If the Contractor is transporting one or more non-employee passengers in

performance of contract services, the automobile liability policy shall have a
combined single limit of ten million dollars ($10,000,000) for bodily injury and
property damage per occurrence.
A program of Workers’ Compensation insurance or a state-approved, self-insurance

program in an amount and form to meet all applicable requirements of the Labor
Code of the State of California, including Employer’s Liability with $250,000 limits
covering all persons including volunteers providing services on behalf of the
□ Workers’ Compensation Contractor and all risks to such persons under this contract.
If Contractor has no employees, it may certify or warrant to the County that it does
not currently have any employees or individuals who are defined as “employees”
under the Labor Code and the requirement for Workers’ Compensation coverage will
be waived by the County’s Director of Risk Management.
With respect to Contractors that are non-profit corporations organized under

California or Federal law, volunteers for such entities are required to be covered by
Workers’ Compensation insurance.
An umbrella (over primary) or excess policy may be used to comply with limits or
other primary coverage requirements. When used, the umbrella policy shall apply
Umbrella Liability Insurance to bodily injury/property damage, personal injury/advertising injury and shall include
a “dropdown” provision providing primary coverage for any liability not covered by
the primary policy. The coverage shall also apply to automobile liability.
$1,000,000 - each accident, $1,000,000 policy limit bodily injury by disease,

□ Employers’ Liability
$1,000,000 each employee bodily injury by disease.
Professional Liability – Professional Liability Insurance with limits of not less than ten
million ($10,000,000) per claim and twenty million ($20,000,000) aggregate limits.
or
Errors and Omissions Liability Insurance – Errors and Omissions Liability Insurance
with limits of not less than ten million ($10,000,000) and twenty million
Professional Liability (Errors
□ ($20,000,000) aggregate limits
and Omissions)
or
If insurance coverage is provided on a “claims made” policy, the “retroactive date”

shall be shown and must be before the date of the start of the contract work. The
claims made insurance shall be maintained or “tail” coverage provided for a
minimum of five (5) years after contract completion.
Contractor shall have abuse or molestation insurance providing coverage for all
employees for the actual or threatened abuse or molestation by anyone of any
person in the care, custody, or control of any insured, including negligent
□ Abuse/Molestation Insurance
employment, investigation, and supervision. The policy shall provide coverage for
both defense and indemnity with liability limits of not less than one million dollars
($1,000,000) with a two million dollars ($2,000,000) aggregate limit.
In addition to the Basic Requirements/Specifications for all Contracts, any contract

that involves the use, handling, transportation, storage, abatement, containment or
testing of any substance that is potentially toxic or hazardous to the environment,
including but not limited to, those listed as hazardous by the United States
Department of Transportation or the CAL OSHA “Director’s list of Hazardous
□ Environmental Liability Substances” or listed as radioactive by the Nuclear Regulatory Commission, shall
have the following additional requirements:
a. Environmental Liability Insurance with a combined single limit of not less than
five million ($5,000,000) per claim or occurrence and a separate aggregate for
the contract project. The required additional insured endorsement shall protect
the County without any restrictions.
b. If insurance coverage is provided on a “claims made” policy, the “retroactive

date” shall be shown and must be before the date of the start of the contract
work. The claims made insurance shall be maintained or “tail” coverage
provided for a minimum of five (5) years after contract completion.
Cyber Liability Insurance with limits of no less than $1,000,000 for each occurrence
or event with an annual aggregate of $5,000,000 covering privacy violations,
information theft, damage to or destruction of electronic information, intentional
□ Cyber Liability and/or unintentional release of private information, alteration of electronic
information, extortion, and network security. The policy shall protect the involved
County entities and cover breach response cost as well as regulatory fines and
penalties.
The Proposer must be able to obtain and maintain in full force and effect,
throughout the term of the contract a performance guarantee in the form of a
performance security bond or an irrevocable Letter of Credit, in the amount of
twenty million dollars ($20,000,000) payable without condition to San Bernardino
County, with surety acceptable to and approved by the Auditor-Controller, which
bond or irrevocable letter of credit shall guarantee to the County full and faithful
performance of all of the terms and provisions of this contract to be performed by
□ Performance Security the Contractor, and as said contract may be amended, supplemented or extended.
If using a performance bond, it must be issued by a bonding company, which is an

Admitted Surety Insurer under the provisions of Title 14, Chapter 2, Article 6 of the
Code of Civil Procedure, commencing with Section 995.610 et seq., and licensed to
conduct the business of insurance in the State of California. Such performance bond,
including the bonding company issuing the bond, shall be acceptable in form and
content to the County.
EXHIBIT 16 - ATTESTATION
The Proposer acknowledges and agrees that by submitting a proposal the Proposer attests that the Proposer has
read the entire RFP and all Exhibits, and understands all of the requirements contained within, prior to submitting their
proposal.
The Proposer also acknowledges and agrees that by submitting a proposal the Proposer is expressing that they will
accept all of the following statements as true if their proposal is selected:
(1) Proposer will comply with all elements of their proposal.

(2) Proposer will comply with County Contract Standard Terms and Conditions.
(3) Proposer will comply with all ICEMA policies and protocols.
(4) Proposer will pay Liquidated Damages as part of the contract for under performance, and the Proposer
understands that Exhibits 6 and 7 list the exemption considerations.
(5) Proposer understands the County’s Centralized Emergency Medical Dispatch (EMD) Center will provide EMD
and Medical Priority Dispatch System (MPDS) services in accordance with the Inland Counties Emergency
Management Agency (ICEMA) Medical Director’s dispatch process and protocols, and will comply with all
communication requirements in Exhibit 11.
(6) Proposer understands they will be required to establish a Computer Aided Dispatch (CAD)-to-CAD link with the
County’s Centralized Dispatch Center.
(7) Proposer understands they will be required to operate an ambulance dispatch center or contract with the
County’s Centralized Dispatch Center for 911 ambulance dispatch services,
(8) Proposer will purchase for licensure under ICEMA the Emergency Medical Services (EMS) System Monitoring,
FirstWatch (FirstWatch On-line Compliance Utility [OCU] & First Pass) Surveillance Platform, pay for all
connections, programming charges and agree to pay the ongoing maintenance charges.
(9) Proposer will comply with all the financial reporting requirements as identified in Exhibit 14.
(10) Proposer will pay ICEMA support charges for County compliance management and regulatory activities as
identified in Exhibit 14.
EXHIBIT 17 - DEFINITIONS
Accredited Center of Excellence (ACE) - Accreditation awarded by International Academies of Emergency
Dispatch to dispatch centers that show clear evidence of compliance and consistent performance to standards.
Advanced Life Support (ALS) – As defined in Health and Safety Code Section 1797.52.
Agreement – The Contract between the Inland Counties Emergency Medical Agency (ICEMA), San Bernardino County,
and the Contractor awarded according to this solicitation.
ALS Unit – An ambulance specially equipped to provide advanced life support services, staffed by at least one
Emergency Medical Technician (EMT) and one paramedic.
Ambulance – Any vehicle specially constructed, modified, or equipped, and licensed by the California Highway Patrol if
required, and used for transporting sick, injured, infirmed, or otherwise incapacitated person, and capable of supporting
Basic Life Support (BLS) or a higher level of care.
Ambulance Ordinance - The San Bernardino County EMS Ordinance can be found by going to CHAPTER 8: AMBULANCES
(amlegal.com).
Ambulance Unit – An ambulance staffed with qualified personnel and equipped with appropriate medical equipment
and supplies.
Automated External Defibrillation (AED) – A procedure to deliver electrical shock and convert specific heart rhythms
back to normal; used by the public, public safety, and BLS providers.
Authorized EMS Dispatch Center - The Authorized Emergency Medical Services (EMS) Dispatch Center, within San
Bernardino County, authorized for the dispatch of ambulance services by ICEMA.
AVL – Automatic Vehicle Locator.
Bariatric Ambulance - A bariatric ambulance is an ambulance vehicle modified to carry the severely obese. They have
extra-wide interiors, carry bariatric stretchers, and specialized lifting gear capable of carrying very large patients.
Basic Life Support (BLS) – As defined in Health and Safety Code Section 1797.60.
BLS Unit – As defined in Health and Safety Code Section 1797.60. Emergency first aid and cardiopulmonary resuscitation
procedures which, as a minimum, include recognizing respiratory and cardiac arrest and starting the proper application
of cardiopulmonary resuscitation to maintain life without invasive techniques until the patient may be transported or
until advanced life support is available.
Business Day - Monday through Friday except for holidays as observed per the California Government Code 6700 et
seq.
California Division of Occupational Safety and Health Agency (CAL/OSHA) – State agency that protects and improves
the health and safety of working men and women in California.
Call Prioritization – A process in which service requests are prioritized based on predefined criteria approved by the
ICEMA Medical Director.
Cardio-Pulmonary Resuscitation (CPR) – An emergency procedure that combines chest compressions often with
artificial ventilation in an effort to manually preserve intact brain function.
Cardiac Arrest Registry to Enhance Survival (CARES) – Data registry initiated in 2004 as an agreement between the
Center for Disease Control and Prevention (CDC) and the Department of Emergency Medicine at Emory University to
help communities determine standard outcome measures for out-of-hospital cardiac arrest locally allowing for quality
improvement efforts and benchmarking capability to improve care and increase survival.
Clinical Performance Measures – The method or instrument to estimate or monitor the extent to which the actions of
a healthcare practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality.
Commission on Accreditation of Ambulance Services (CAAS) - An independent Commission established to set a
comprehensive series of standards for the ambulance service industry designed to help increase operational
efficiency and decrease risk and liability across the entire spectrum of the organization.
Comprehensive Annual Financial Report (CAFR) - The official annual report of a governmental unit containing the basic
financial statements, management discussion and analysis (MD&A) and other required supplementary information and
statistical data prepared in accordance with standards established by the Governmental Accounting Board.
Comprehensive Service Area – Emergency Operating Areas bundled (1, 2, 3, 4, 5b, 6, 7, 8, 9, 11, and 12a) to establish
a Comprehensive Service Area.
Computer-Aided Dispatch (CAD) – A system consisting of but not limited to associated hardware and software to
facilitate call taking, system status management, unit selection, ambulance coordination, resource dispatch and
deployment, event time stamping, creation, and real-time maintenance of incident database, and providing
management information.
Continuous Quality Improvement (CQI) – The approach to quality management that builds upon traditional quality
assurance methods by emphasizing the organization and systems.
Contract Materials - Finished or unfinished documents, data, studies, maps, photographs, reports, specifications, lists,
manuals, software, and other written or recorded materials produced or acquired by the Contractor pursuant to the
contract for or on behalf of the County, whether or not copyrighted.
Contract - The agreement between ICEMA, San Bernardino County, and the Contractor awarded according to this
solicitation.
Contractor - The person or other entity awarded a contract in conformance with the terms of this solicitation and any
subsequently agreed-upon terms.
County Data - All information, data, and other content, including confidential information and other information
whether or not made available by ICEMA, San Bernardino County or San Bernardino County’s agents, representatives,
or users, to a Contractor or potential Contractor or their employees, agents, or representatives, and any information,
data and content directly derived from the foregoing, including data reflecting user access or use.
County Systems - The information technology infrastructure of San Bernardino County or any of its designees, including
computers, software, databases, networks, and related electronic systems.
County – San Bernardino County
Critical Care Transport (CCT) – Ambulances staffed with a paramedic or registered nurse, trained at the critical care
transport level to provide a higher level of care to patients being transported between licensed healthcare facilities.
ICEMA Policy 8020 also allows for a Respiratory Therapist as part of a CCT team.
Critical Incident Stress Management (CISM) – Adaptive, short-term psychological helping-process that focuses solely
on an immediate and identifiable problem.
Deployment – The procedures by which ambulances are distributed throughout the service area. The deployment
includes the locations at which the ambulances are placed (or posted) and the number of ambulances placed in service
for the particular time period.
Dispatch Time – Common unit of measurement from receipt of a call until a unit has been selected and notified it has
an assignment.
Electronic Patient Care Report (ePCR) – A document that records patient information, assessment, care, treatment,
and disposition by prehospital personnel.

Emergency – Any real or self-perceived event which threatens life, limb, or well-being of an individual in such a manner
that a need for immediate medical care is created.
Emergency Air Ambulance – An aircraft with emergency medical transport capabilities.
Emergency Ambulance – Any vehicle meeting California regulatory standards that are equipped or staffed to provide
EMS levels at BLS or higher for emergency transportation.
Emergency Call – A real or self-perceived event where the EMS system is accessed by the 911 emergency access number
or an interfacility transfer where the patient’s health or well-being could be compromised if the patient is held at the
originating facility.
Emergency Department (ED) – An approved receiving department within a licensed hospital.
Emergency Medical Dispatch (EMD) – Personnel trained to state and national standards on emergency medical
dispatch techniques including call screening, call and resource priority, and pre-arrival instruction.
EMS Agency – Inland Counties Emergency Medical Agency (ICEMA)
Emergency Medical Services (EMS) – This refers to the full spectrum of pre-hospital care and transportation (including
interfacility transports), encompassing bystander action (e.g., CPR), priority dispatch and pre-arrival instructions, first
response and rescue service, ambulance services, and on-line medical control.
EMS Aircraft - Includes air ambulances and all categories of rescue aircraft as defined in the California Code of
Regulations, Title 22, Division 9, Chapter 8.
EMS Medical Director – shall mean the ICEMA Medical Director, contracted to oversee the medical control and quality
assurance programs of the EMS System.
EMS System – The EMS System consists of those organizations, resources, and individuals from whom some action is
required to ensure a timely and medically appropriate response to medical emergencies.
Emergency Medical Technician (EMT) – An individual trained in all facets of BLS according to standards prescribed by
the California Code of Regulations and who has a valid certificate issued according to that code.
Emergency Medical Technician-Paramedic (EMT-P) – Individuals whose scope of practice to provide advanced life
support is according to the California Code of Regulations and who has a valid license issued according to the California
Health and Safety Code.
Enroute Time – The elapsed time from unit alert to unit enroute.
Exclusive Operating Area (EOA) – An EMS area or subarea defined by the emergency medical services plan for which a
local EMS Agency, upon the recommendation of a county, restricts operations to one or more ambulance services or
providers of limited advanced life support or advanced life support as defined in California Health and Safety Code
Section 1797.85.
Fire Responder – Fire based emergency medical responder in San Bernardino County.
First Responder – An agency with equipment and staff (e.g., fire department, police, or non-transporting ambulance
unit) with personnel capable of providing appropriate first responder pre-hospital care.
Force Majeure - An event or circumstance not caused by or under the control of a party, and beyond the reasonable
anticipation of the affected party, which prevents the party from complying with any of its obligations under the
contract, including acts of God, fires, floods, explosions, riots, wars, hurricane, sabotage, terrorism, vandalism, accident,
governmental acts, and other events.
Fractile Response – A method of measuring ambulance response times in which all-applicable response times are
stacked in ascending length. Then, the total number of calls generating response within nine minutes fifty-nine seconds
(9:59 for example) is calculated as a percent of the total number of calls. A 90th percentile, or 90%, the standard is most
commonly used. When a 90th percentile response time standard is employed, 90 percent of the applicable calls are
arrived at in less than 9:59 minutes, while only 10%take longer than 9:59 minutes.
Geographical Information Systems (GIS) – A framework for gathering, managing, and analyzing data.
Global Positioning System (GPS) – A system that utilizes satellite data to determine location.
Health Insurance Portability and Accountability Act (HIPAA) – legislation that provides data privacy and security
provisions for safeguarding medical information.
ICEMA Policies and Protocol Manual – The polices and protocols directing the medical operations of emergency
medical services for ICEMA participants. http://www.sbcounty.gov/icema/main/policies_and_protocols.aspx
Incident Command System (ICS) – Standardized approach to the command, control, and coordination of emergency
response providing a common hierarchy within which responders from multiple agencies can be effective.
Inland Counties Emergency Medical Agency (ICEMA) – The regional Emergency Medical Services agency representing
San Bernardino, Inyo, and Mono counties.
Inter-Facility Transports (IFT) – Ambulance transports between healthcare facilities.
Key Employee - Employees of the Proposer possessing unique skill and experience assigned to carry-out all aspects of
the contract resulting from this RFP.
LEMSA – Local EMS Agency
LIFENET - The LIFENET® System is a comprehensive cloud-based platform that helps teams work more efficiently. Share
critical patient data to help care teams reduce time-to-treatment for ST-Elevation Myocardial Infarction (STEMI)
patients. Request remote cardiology consult through the dedicated LIFENET Consult application. Rapidly distribute post-
event review data to crews immediately after a code. Manage LIFEPAK device software and configuration fleet-wide
from a single website. The LIFENET System provides innovative tools to help teams work as efficiently as possible.
Medical Priority Dispatch System (MPDS) – A set of established protocols utilized by dispatchers to determine the level
of response necessary.
MDC – Mobile data computer (also known as MDT- Mobile Data Terminal)
Multi-Casualty Incident (MCI) – An emergency situation where the number of patients overwhelms the available
resources.
Medical Base Hospital – The source of direct medical communications and supervision of the immediate field
emergency care performance by EMTs or Paramedics.
Medical Protocol – Written standards for patient medical assessment and management.
Mutual Aid/Mutual Assistance – Shall refer to 1) responses into the San Bernardino County Comprehensive Service
Area from a ground transport provider outside the Comprehensive Service Area for the purpose of assisting the
Contractor with ambulance requests for service; 2) responses by the Contractor to service areas outside the San
Bernardino County Comprehensive Service Area for the purpose of assisting the ground transport provider in an
adjacent service area.
National Incident Management System (NIMS) – A systematic, proactive approach to guide departments and agencies
at all levels of government, non-governmental organizations, and the private sector to work together seamlessly.
Occupational Safety and Health Agency (OSHA) – Federal agency that protects and improves the health and safety of
working men and women.
Online Compliance Utility (OCU) – Software that interprets real-time CAD and ePCR data to produce reports and online
tools to track EMS system effectiveness and compliance.
On-Scene – The time when a unit communicates to dispatch that it has arrived at the address of the call. Normally, this
is when the vehicle stops at the address of the call. If staging is required for crew safety, at scene is determined when
the unit reaches a safe distance from the call and waits for law enforcement to determine it is safe to enter. If off-road
location, such as a park or private road with gated access, at scene is determined by reaching the end of a paved
roadway or closed gate.
Paramedic – An individual trained and licensed to perform ALS procedures under the direction of a physician. Also,
known as an EMT-P.
Peak-Load Staffing – The design of shift schedules and staffing plans so that coverage by crews matches the System
Status Plan’s requirements.
Post – A designated location for ambulance placement within the System Status Plan (SSP). Depending upon its
frequency and type of use, a “post” maybe a facility with sleeping quarters or day rooms for crews, or simply a street-
corner or parking lot location to which units are sometimes deployed.
Priority Dispatching and EMD Determinant – A structured method of prioritizing requests for an ambulance and first
responder services, based upon highly structured telephone protocols and dispatch algorithms. Its primary purpose is
to safely allocate available resources among competing demands for service.
ALPHA = No lights or siren response typically for a BLS ambulance
BRAVO = Lights and siren response typically for a BLS ambulance
CHARLIE = BLS or ALS ambulance response, no lights, and siren (depending)
DELTA = ALS ambulance response, serious injury / medical
ECHO = ALS ambulance response for life status questionable (cardiac arrest, traumatic arrest)
Productivity – The measures of work used in the ambulance industry that compare the used resources (unit- hours)
with the production of the work product (patient transports). Productivity is expressed and calculated by determining
the number of transports per unit-hours.
Proposal Review Committee (Committee) – A committee consisting of professional subject matter experts with
experience in healthcare delivery models and government procurement procedures, to evaluate responsive proposals
based on the criteria specified in the solicitation. Committee members shall be bound by the terms of a conflict-of-
interest statement and confidentiality agreement.
PST - Pacific Standard Time, including Pacific Daylight Time when in effect
Public Access Defibrillation (PAD) – A program that places automatic external defibrillators throughout communities.
Public Safety Answering Point (PSAP) – A government-operated facility that receives emergency calls for assistance
through the 911 system or over private telephone lines.
ReddiNet - A web-based program designed to address resource management needs providing users the ability to
understand the operational status of a hospital or emergency department in order to make critical operational
decisions.
Release at Scene – Patients refusing treatment and/or transport when the paramedic agrees there is no need for care.
Response Time – The actual elapsed time between receipt by the Contractor of a call that an ambulance is needed and
the arrival of the ambulance at the requested location.
ST-Elevation Myocardial Infarction (STEMI) – A heart attack caused by the complete blockage of a heart artery.
Standardized Emergency Management System (SEMS) – A structure for coordination between the government and
local emergency response organizations.
System Standard of Care – The combined compilation of all priority-dispatching protocols, pre-arrival instruction
protocols, medical protocols, protocols for selecting destination hospitals, standards for certification of pre-hospital
personnel, as well as standards governing requirements for on- board medical equipment and supplies, and licensing
of ambulance services and first responder agencies. The System Standard of Care simultaneously serves as both a
regulatory and contractual standard.
System Status Management - A management tool to define the "unit hours" of production time, their positioning and
allocation, by hour and day of week to best meet demand patterns.
System Status Plan (SSP) – A planned protocol or algorithm governing the deployment and event-driven redeployment
of system resources, both geographically and by time of day/day of week. Every system has a system status plan. The
plan may or may not be written, elaborate or simple, efficient, or wasteful, effective, or dangerous.
Transport Volume – The actual number of requests for service that result in patient transport.
Unit Activation Time – The time interval on an ambulance call measured from the time the ambulance crew is first
notified to respond until it is enroute to the scene.
Unit Hour – One hour of service by fully equipped and staffed ambulance assigned to a call or available for dispatch.
Unit Hour Utilization (UHU) Ratio – A measurement of how hard and how effectively the system is working. It is
calculated by dividing the number of responses initiated during a given period of time, by the number of unit hours
(hours of service) produced during the same period of time. Special event coverage and certain other classes of activity
are excluded from these calculations.
Utilization – A measure of work that compares the available resources (unit-hours) with the actual time that those unit-
hours are being consumed by productive activity. The measure is calculated to determine the percentage of unit-hours
actually consumed in productivity with the total available unit-hours.
EXHIBIT 18 – PUBLIC RECORDS ACT EXCEPTION FORM
PUBLIC RECORDS ACT EXEMPTIONS
PROPOSER NAME
ADDRESS
TELEPHONE# ( ) FAX # ( )
Proposer requests that specific portions of the contents of this Proposal be held confidential and not subject to public
disclosure pursuant to the Public Records Act. The specific portions are detailed below: (Please identify and list any
exemptions by indicating the Section or Paragraph number, and Page number, of the Proposal where the content is
contained.) Each stated exemption must include a citation to supporting legal authority, including statutory authority
or case law, to support exemption from the Public Records Act. Requested exemptions that does not meet the
requirements of this section will not be considered.
EXHIBIT 2
4.14 – Financial and Administrative Requirements

4.14 A. – Patient Fees
This section evaluates the Proposer’s patient fee schedule to ensure it is consistent with the standards articulated below.
The following information must be considered in the response and requested information must be provided which supports
this evaluation.
(1) Current maximum patient fees are included in Exhibit 12. The patient fees must be fixed for at least one (1) year
from the beginning of the contract.
(2) Submit the Proposed Ambulance Rates on the Excel spreadsheet in Exhibit 8.
 CONFIRE EMS Agrees/Complies.
CONFIRE EMS has developed a five-year patient fee schedule that is based on system costs
and reimbursement levels for each payor type (Medicare, Medi-Cal, Private Insurance, etc.)
Proposed fees will be fixed for at least one (1) year from the beginning of the contract.
Please refer to our Proposed Ambulance Rates contained in the Excel

spreadsheet submitted as Attachment 26 in the included flash drive with
paper submission and as a stand-alone attachment with electronic
submission.
4.14 B. – Budget and Fiscal Sustainability

This section evaluates the Proposers submitted budget and other submitted financial documents. The following information
Budget Information
(1) Provide all budget information on the Excel spreadsheet in Exhibit 8.
CONFIRE EMS has submitted the completed Exhibit 8 Excel spreadsheet as Attachment 26
on the included USB drive with its paper submission and as a stand-alone attachment with its
electronic submission. This file contains detailed information on the full budget, including
allocation of direct and indirect costs.
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The Exhibit 8 spreadsheet provided includes information for the start-up costs for each of the
five (5) years of operation, as well as complete information on projected revenue from
ambulance service billing for each year.
Full Cost of Proposed Service, Including Allocation of Indirect Costs

(2) Provide detailed information on the full cost of the proposed service including allocation of indirect costs.
The proposed cost of the system includes the following categories:
Salaries and Wages for new and existing CONFIRE administrative personnel that will be
responsible for the oversight of the EMS system.
Payroll Taxes & Employee Benefits related to the employees described above.
Subcontracting to Priority Ambulance that will provide staffed ambulance hours to meet the
deployment requirements described herein. These costs will be reimbursed on a per-unit-
hour basis and cover the following costs: direct payroll costs for field crews and related
payroll taxes and benefits indirect payroll costs for management and support services and
related payroll taxes and benefits, ongoing vehicle maintenance, fuel, medical supplies,
vehicle registration and licensing fees, radio supplies and equipment, medical equipment,
real estate leases for operating stations, utilities, telecommunications expenses, office
equipment and supplies, building maintenance, personal property taxes, casualty insurance
premiums, workers’ compensation insurance premiums, uniform expenses, drug screening,
continuing education and training, business licenses, professional services, including legal
services, depreciation on capital equipment including ambulances, interest expenses on
outstanding debt and allocation of corporate management expenses as described below.
CONFIRE EMS member fire agencies that have agreed to provide surge coverage and 9-1-1
patient transports as needed will also be reimbursed on a per-unit-hour basis.
EMS Agency Oversight and Monitoring Services fee to ICEMA for oversight of the EMS
system as required in the RFP.
Centralized EMD Dispatch Center fee of $5 per call as required in the RFP.
FirstWatch Initial Charge for system setup as required in the RFP.
FirstWatch Annual Charge for ongoing use of the software.
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ImageTrend Annual Charge for ongoing use of the software.
Other Purchased Services for subscription to MARVLIS software for automatic vehicle
location (AVL) tracking and system status management.
Estimated Response Time Penalties. CONFIRE EMS fully intends to run the system in
compliance with all performance metrics, including, without limitation, response time
requirements. However, CONFIRE EMS realizes that unforeseen circumstances might arise
from time to time during the course of the contract that could lead to response time
liquidated damages. Accordingly, out of an abundance of caution, CONFIRE has built a
contingency for such expenses into its business model for the system of $250,000.
General & Administrative includes real estate lease expenses for CONFIRE EMS stations,
utilities, telecommunications expenses, office equipment and supplies, third-party billing
contractor fees at 3.25% of revenue, casualty insurance premiums and the assessment for
the non-federal share to fund the Medi-Cal IGT/GEMT program of approximately $15.1
million.
Interest Expense for debt service on outstanding CONFIRE EMS debt required to meet
working capital requirements at the outset of the contract.
Method of Financing
(3) Provide a statement of the method of financing, attach any necessary endorsement documents for all start-up and
operational costs including, but not limited to, the initial ambulance fleet and equipment and facility leases that are required
to begin operations.
CONFIRE JPA will fund $6 million of net working capital to support CONFIRE expense
obligations (CONFIRE payroll, operating expenses, subcontractor obligations, etc.) before
payor collections and state grant collections are received (estimated to be 90-120 days from
the start-up date.)
Priority Ambulance will fund initial capital of approximately $41 million to acquire the
ambulance fleet, equipment and facility lease deposits. Priority Ambulance will also fund
approximately $16 million to support the first 60 days of net working capital prior to
CONFIRE JPA’s first subcontractor payment due to Priority Ambulance.
274
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MOBILE HEALTH
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275
@ NF/RE
MOBILE HEALTH
Reserve for Contingencies

(4) Provide a statement of the amount of funding that will be dedicated to Reserve for Contingencies.
CONFIRE JPA will accommodate for all liabilities of the EMS division, along with a reserve
for contingencies between 5% to 10% of the yearly budget approved by the governing
committees and CONFIRE’s board of directors. Priority Ambulance has in place a $25
million line of credit.
Financial Statements & Source of Funding

(5) Proposer shall submit financial statements for all financial and/or in-kind corporate/parental entity support to show all
sources of funding that will support the provision of ambulance services within the Comprehensive Service Area.
We have submitted five (5) years of historical financial statements for CONFIRE JPA and
Priority Ambulance, LLC, which represent the two legal entities that will support funding for
the provision of ambulance services within the San Bernardino County Comprehensive
Service Area. Please see table below for total sources and uses of funding for the San
Bernardino County EMS system:
Sources Uses
Priority Cash, Debt & Equity - Consonance Capital Partners $ 57,000,000 Priority Capital Expenditures $ 41,000,000
CONFIRE Cash 6,000,000 Priority Net Working Capital 16,000,000
CONFIRE Net Working Capital 6,000,000
$ 63,000,000 $ 63,000,000
Allocation of Shared Overhead

(6) If the Proposer’s corporate/parental structure is larger than only the provision of ambulance service for San Bernardino
County’s Comprehensive Service Area, this statement shall include disclosing the full cost allocation of all shared overhead
services charged to the San Bernardino County ambulance service for the Comprehensive Service Area (including rationale).
Typical overhead services include but are not limited to risk management, insurance, purchasing, maintenance, rent, legal
and human resources, or other functions if those functions are not solely dedicated to ambulance service in the
Comprehensive Service Area. Proposers will disclose, if applicable, the interest or use rate at which the parent / corporate
entity loans money or services to the subsidiary corporation providing ambulance services to the San Bernardino County
Comprehensive Service Area.
276
@ NF/RE
MOBILE HEALTH
CONFIRE EMS, as the proposer, is not allocating any corporate or other overhead pursuant
to the proposed cost structure provided in Exhibit 8.
Interest or Use Rate from Parent to Subsidiary

(7) Proposers will disclose, if applicable, the interest or use rate at which the parent / corporate entity loans money or services
to the subsidiary corporation providing ambulance services to the San Bernardino County Comprehensive Service Area.
This item is not applicable to CONFIRE. Priority Ambulance’s Weighted Average Cost of
Capital is 13% and includes 9% interest for capital purchased for the San Bernardino County
EMS system in the cost per unit hour.
Start-Up Costs
(8) Using the Excel spreadsheet provided in Exhibit 8, provide the above information for the start-up costs for each year of the
five (5) years of operation. Additionally, provide complete information on projected revenue from ambulance service billing
for each of the five (5) years. If revenue from ambulance service billing does not cover expected costs of operations, document
the projected source of revenue to offset the loss and provide a projected timeframe to recoup losses. “Full Cost” means all
costs attributable to the provision of service.
CONFIRE EMS Exhibit 8 shows that revenues from ambulance service billing will cover
expected costs of operations.
(9) Proposer will provide a statement indicating the proposer will comply with all of the financial reporting requirements,
payments and service charges, and profit and ambulance rate adjustments as identified in Exhibit 14.
CONFIRE EMS agrees to comply with all financial reporting requirements, payments and
service charges, and profit and ambulance rate adjustments as identified in Exhibit 14.
277
@ NF/RE
MOBILE HEALTH
EXHIBIT 3
From: Williams, Pamela <[email protected]>

Date: Tuesday, June 6, 2023 at 10:44 AM
To: [email protected] <[email protected]>, [email protected]
<[email protected]>, [email protected] <[email protected]>,
[email protected] <[email protected]>, [email protected]
<[email protected]>, [email protected] <[email protected]>, [email protected]
[email protected] <[email protected]>, [email protected] <[email protected]>,
Park, Brian <[email protected]>, [email protected] <[email protected]>, [email protected]
<[email protected]>, Tony Myrell <[email protected]>, [email protected]
[email protected] <[email protected]>, Rice, Michael <[email protected]>,
[email protected] <[email protected]>, Wagner, Thomas <[email protected]>,
McCafferty, Diana <[email protected]>
Cc: Munoz, Daniel <[email protected]>, Anaya, Amber <[email protected]>,
Hernandez, Leonard - CAO <[email protected]>, Bailey, Shannon
<[email protected]>
Subject: EXT: Update: Ambulance RFP Update
ATTENTION: This email originated from outside of GMR and may or may not be legitimate. Although we do our best to
screen phishing and malicious emails, please use extra caution before opening any attachments or clicking on any links
unless you are absolutely sure the source can be trusted. If in doubt about the legitimacy of this email, please forward it to
[email protected] for validation. You can also, report the email by using the Mimecast or Outlook Report Phishing button.
EMS Stakeholders,
I would like to take this opportunity to provide you with an update regarding the County’s Ambulance RFP. Upon
conclusion of the evalua on panel’s review and scoring of the submi ed proposals, the two proposals received
substan ally equivalent scores. Therefore, under advisement from the County’s Purchasing and legal team, the County
will begin contract nego a ons with the two finalists. Staﬀ will make a recommenda on to the Board based on the
outcome of those nego a ons. As you can imagine, contract nego a ons may take a considerable amount of me.
Therefore, our RFP meline will be updated accordingly to ensure that our team has suﬃcient me to conduct these
nego a ons to give both proposers adequate me to develop contracts that best meet the county’s needs.
We will provide addi onal updates as we move along. Please let me know if you have any ques ons.
2
Best regards,
Pamela S. Williams
Chief of Administration
County Administrative Office
Phone: 909-387-4377
385 N. Arrowhead Ave., 5th Floor
Our job is to create a county in which those who reside and invest can prosper and achieve well-being.
www.SBCounty.gov
3
EXHIBIT 4
777 E Rialto Ave, San Bernardino, CA 92415 | Phone: 909.387.2070
www.SBCounty.gov
RNARDINO Pete Mendoza

Purchasing Department Director
UNTY
October 27, 2023
Micheal Romo
American Medical Response
7925 Center Ave
Rancho Cucamonga, CA 91730
[email protected]
SUBJECT: NOTICE OF INTENT TO AWARD REQUEST FOR PROPOSAL (RFP) No.

ICEMA23-ICEMA-4811
The San Bernardino County Purchasing Department has completed the evaluation process for
proposals received in response to ICEMA23-ICEMA-4811 Ground Ambulance Services. Based
on the evaluation, AMR received the highest score and will receive the independent evaluation
committee’s recommendation for award as stated in the RFP.
However, because the difference in scores is substantially equivalent, draft contracts from each
proposer will be presented to the Board of Supervisors for consideration and ultimate award.
Neither staff nor the evaluation panel can legally bind the Board. Pursuant to law and County
Policy, the Board is vested with the sole discretion and ultimate authority to select and approve a
contract for services which best meets the needs of the County and the public.
We will be contacting you soon with details regarding the scheduled Board date that the contracts
will be presented. If you have any questions concerning this letter, please reach out to me at
(909) 777-0722 or [email protected].
Thank you,
Ariel Gill
Supervising Buyer
CC: CONFIRE
BOARD 01-' SUPERVISORS

COL. PAUL COOK (RET.) JESSE ARMENDAREZ DAWN ROWE CURT H AGMAN JOE BACA, JR.
Vice Chairman, First District Second District Chair, Third District Fourth District Fifth District
EXHIBIT 5
ATHENE LAW LLP
November 3, 2023
VIA HAND DELIVERY

AND VIA E-MAIL ([email protected])
Pete Mendoza, Purchasing Director

RE: Letter of Protest

RFP # ICEMA23-ICEMA-4811
Advanced Life Support and Basic Life Support Ground Ambulance Services, Interfacility and
Critical Care Transport Services for Exclusive Operating Areas in San Bernardino County
Director Mendoza:
American Medical Response of Inland Empire (“AMR”) submits this Letter of Protest with respect to the
above-referenced Request for Proposal (“RFP”) issued by the County of San Bernardino (the “County”).
This letter is submitted pursuant to the protest procedures at RFP section 2.14 on the grounds that the
County has 1) failed to follow the selection procedures and adhere to requirements specified in the RFP
and its addendums, and 2) otherwise violated State and/or Federal law. AMR’s protest is timely because
this letter is submitted within ten (10) calendar days of the issuance date of the October 27, 2023, Notice
of Intent to Award (“NOIA”).
I. Overview
AMR is an experienced ambulance provider that has faithfully served the County and its citizens since the
late 1970s. AMR has been providing ALS emergency services as a grandfathered ambulance transport
provider under contract with the County, which has never utilized a competitive process for ambulance
services until now.
On October 27, 2023, the County of San Bernardino Purchasing Department (“County Purchasing”) issued
a NOIA notifying AMR that despite AMR having received the highest score in the RFP scoring, it would
present both AMR’s draft contract and that of a competing bidder, Consolidated Fire Agencies
(“CONFIRE”), to the San Bernardino County Board of Supervisors (“County BOS”) “for consideration and
ultimate award.” Consistent with the terms of the RFP and state law, the County may only negotiate with
and award a contract to the proposer with the highest score – which is AMR. The County’s contract
negotiations with CONFIRE and its intent to submit CONFIRE’s contract to the County BOS for
address: 5432 Geary Blvd., #200 San Francisco, CA 94121, tel: 415-686-7531, email: [email protected]
Pete Mendoza, County of San Bernardino Purchasing Department
Re: RFP # ICEMA23-ICEMA-4811
November 3, 2023
Page 2 of 7
consideration of ultimate award is arbitrary and capricious for failure to comply with the procedures and
requirements published in the RFP and is in violation of State and/or Federal law. 1
II. BACKGROUND
A. THE EMS ACT AND ICEMA
California’s statute governing emergency medical services (“EMS”), referred to as the EMS Act, created a
two-tiered system for EMS regulation. At the State level, the EMS Act created the Emergency Medical
Services Authority (“EMSA”), charged with setting standards for and coordinating EMS activities
throughout the state. 2 At the local level, the EMS Act created local emergency medical services agencies
(“LEMSAs”), which have the exclusive authority to “plan, implement, and evaluate an emergency medical
services system.” 3 The County has designated the Inland Counties Emergency Medical Agency (“ICEMA”)
as its LEMSA. 4
Pursuant to section 1797.224 of the California Health and Safety Code (“section 1797.224”), ICEMA may
create one or more exclusive operating areas (“EOAs”) “if a competitive bidding process is utilized to select
the provider or providers of the services pursuant to the plan.” The competitive bidding process is
approved by the EMSA. 5 Accordingly, ICEMA established an EMS plan that includes EOAs for ground
ambulance services in the County.6 For the purposes of the RFP, ICEMA unified eleven existing EOAs,
which it refers to as the “Comprehensive Service Area” (“COA”).7 Prior to now, ICEMA has exercised its
authority under section 1797.224 to authorize AMR as the exclusive operator of these EOAs as AMR had
consistently served the County of San Bernardino in this way since January 1, 1981.
B. THE RFP
On December 20, 2022, the County departed from its historical practice and published ICEMA’s EMSA-
approved RFP to solicit written proposals for the provision of ground ambulance transportation services,
interfacility transports and critical care transports within the COA as required under section 1797.224.
RFP section 2.12(B) sets forth the following process for selection:
The County will establish a non-biased Proposal Review Committee. Each

member of the Committee will evaluate and score the proposals based
on the criteria specified in the solicitation scoring sheet. The scores from
all the evaluators will be calculated to arrive at a final score for each
proposal. All Proposals will be evaluated and scored by the Committee
and will be invited to participate in an oral presentation of their proposal.
1
AMR reserves its rights to pursue all methods to compel the County to comply with the RFP and applicable law.
2
Health and Saf. Code § 1797.100 et seq.
3
Health and Saf. Code § 1797.204; RFP at p.1.
4
Health and Saf. Code § 1797.200.
5
RFP § 1.7(A).
6
Health and Saf. Code §§ 1797.76, 1797.85, 1797.103, 1797.105, 1797.224, and 1797.226.
7
RFP at p. 1.
November 3, 2023
Page 3 of 7
The Committee will recommend the highest scoring Proposer for final
negotiation of contract terms.
(Emphasis added.)
The RFP is clear that “a contract will be awarded based on the highest scoring proposal received.” 8
(Emphasis added.) The RFP also provides that contract “negotiations may be conducted with the Proposer
of the highest-ranked proposal.” 9 The County may only commence negotiations with the next highest
rated proposer if the County terminates negotiations with the highest-ranked proposer for “failure to
negotiate” pursuant to RFP section 2.13(B)(1). The County only sends a Notice of Intent to Award (“NOIA”)
after the completion of contract negotiations. 10 The RFP permits the County to reject proposals or “to
terminate this RFP process at any time.” 11
C. THE COUNTY’S SELECTION PROCESS
AMR and CONFIRE were the only providers to submit a proposal in response to the RFP. On June 6, 2023,
the County informed EMS stakeholders that “the two proposals received substantially equivalent scores,”
that “the County will begin contract negotiations with the two finalists,” and that County “staff will make
a recommendation to [County BOS] based on the outcome of those negotiations.”
After conducting contract negotiations with both proposers, on October 27, 2023, the County sent a NOIA
announcing that “AMR received the highest score and will receive the independent evaluation
committee’s recommendation for award as stated in the RFP.” (Emphasis added.) However, “because
the difference in scores is substantially equivalent, draft contracts from each proposer will be presented
to Board of Supervisors for considerations and ultimate award.” Further, “the Board is vested with the
sole discretion and ultimate authority to select and approve a contract for services which best meets the
needs of the County and the public.”
GROUNDS
Ill. - --- FOR
- PROTEST
---
A. THE COUNTY HAS FAILED TO FOLLOW THE RFP’S PROCEDURES AND REQUIREMENTS
The County must strictly adhere to the standards that it announced, and the State approved, in the RFP.
As has been acknowledged by the California Court of Appeal, “[b]ecause of the potential for abuse arising
from deviations from strict adherence to [competitive bidding] standards, ... the letting of public contracts
universally receives close judicial scrutiny....” 12 A competitive bid process, such as the one employed here,
must be fair, unbiased and free from an appearance of favoritism and bias. 13 Thus, the County cannot act
8
RFP § 2.13D
9
RFP § 2.13(A)
10
RFP § 2.13(C)
11
RFP at p. 1.
12
Schram Construction, Inc. v. Regents of the Univ. of Calif. (2010) 187 Cal.App.4th 1040, 1052.
13
See Advanced Real Estate Services, Inc. v. Super. Ct. (2011) 196 Cal.App.4th 338, 353.
November 3, 2023
Page 4 of 7
in a manner that is “arbitrary, capricious, entirely lacking in evidentiary support, or inconsistent with
proper procedure[,]” such as making decisions in a manner different than was publicized in the RFP. 14
AMR received the highest score from the non-biased Proposal Review Committee. The unambiguous
terms of the RFP required that the County enter contract negotiations with “with the Proposer of the
highest-ranked proposal.” The County therefore had no authority to enter into contract negotiations
with CONFIRE. The unambiguous terms of the RFP now require that “a contract will be awarded based
on the highest scoring proposal received[.]” (Emphasis added.) County Purchasing is knowingly violating
this RFP requirement by presenting both contracts to the County BOS for determination of ultimate
award.
The RFP does not make exceptions for scores that are close or “substantially equivalent.” Regardless of
whether the final scoring margin is narrow or wide, the RFP is unambiguous that the highest scoring
proposer will be awarded a contract, and AMR unequivocally received the highest score in the RFP
process. When two candidates vie for a single supervisor position, election rules dictate that the
candidate with the most votes wins regardless of whether margin of victory is one vote or one thousand.
Likewise, the rules governing this process declare the outcome in favor of AMR regardless of the margin
of victory, and do not permit the County BOS to change that outcome. Any other outcome is unfair,
unjust, and illegal – in other words, arbitrary and capricious. County Purchasing has a ministerial duty
to adhere to the RFP process; it is not permitted to engage in contract negotiations with CONFIRE or
present the bid by CONFIRE to the County BOS.
If the County is dissatisfied with the selection process, the RFP authorizes the County to terminate the
RFP process at any time. 15 The RFP and general principles of Constitutional and administrative law,
however, do not permit the County to deviate from adhering to the RFP’s procedures and requirements
that have already been approved by the State.
The County’s elevation of CONFIRE’s proposal despite that proposal’s lower score from the independent
Proposal Review Committee creates an appearance of favoritism and bias toward the fire agency, and
puts politics over the health and safety of its citizens. The County is therefore at risk of acting in an
arbitrary and capricious manner because it has not adhered to the safeguards put in place to prevent bias
and other arbitrary factors from influencing the bid selection.
B. THE COUNTY IS IN VIOLATION OF STATE AND/OR FEDERAL LAW
The County has violated the EMS Act. First, section 1797.224 requires a “competitive process” to be
utilized for non-grandfathered portions of the county. This process is approved by the State through the
EMSA. Any deviation from the procedures and requirements set forth in the RFP and approved by the
State is therefore a violation of State law. For instance, endowing the County BOS with decisional
14
Schram Construction, Inc. v. Regents of Univ. of Calif., supra, 187 Cal.App.4th at 1052
15
RFP § 2.1
November 3, 2023
Page 5 of 7
authority outside the scope of the RFP-scoring process contravenes the “competitive process” and
violates both the intent and plain meaning of the statute.
Second, advancing both contracts for consideration infringes on ICEMA’s role as the governing entity with
“exclusive authority over and sole responsibility for planning, implementing, and evaluating the County’s
EMS System.” 16 When the County designated ICEMA as its LEMSA, it delegated all EMS Act authority to
that agency. 17 This is by legislative design – under the supervision of their medical directors, a LEMSA is
charged with the duty to broadly assert medical control over all aspects of local EMS systems. 18 It cannot
share its responsibilities with political bodies or departments. 19, 20
Moreover, deviation from the RFP has serious potential federal antitrust repercussions due to issues that
underlie the State’s process for conferring exclusivity to a single EMS provider. The United States Supreme
Court has articulated “state action” immunity from the Sherman Antitrust Act, meaning that state and
local authorities are immune from antitrust lawsuits for anticompetitive actions taken pursuant to “clearly
articulated and affirmatively expressed state policy.” 21 Conversely, the Supreme Court held in Community
Communications Company, Inc. v. City of Boulder, Colorado (1982) 455 U.S. 40, that local governmental
authorities do not enjoy such immunity where the anti-competitive behavior is not clearly articulated in
state policy allowing it. 22
The RFP process undertaken by the County is required under the EMS Act and is approved by the EMSA
pursuant to its authority in Health and Safety Code sections 1797.224 and 1797.85 – State statutes that
are clearly articulated and designed to protect counties from federal antitrust liability. The State
legislature enacted these statutes in the wake of the Supreme Court’s decision in Boulder, finding that
“the provision of effective and efficient emergency medical care” had been “hindered by the confusion
and concern” in the counties resulting from the Court’s decision. Therefore, the statutes were enacted
to “prescribe and exercise the degree of state direction and supervision over emergency medical services
as will provide for state action immunity under federal antitrust laws.” 23 By violating those state laws, the
County exposes itself to federal antitrust liability.
16
RFP at p.1.
17
County of Butte, Butte v. Emergency Medical Services Authority (2010) 187 Cal.App.4th 1175.
18
Health and Saf. Code §§ 1797.218, 1797.220; 1798(a).
19
Memorial Hospitals Assn. v. Randol (1995) 38 Cal.App.4th 1300, 1314 (the creation of an EOA is a LEMSA
function and involves “a professional, not a political, determination”).
20
Where the Legislature has granted limited authority in the County of Board of Supervisors, it has done so
explicitly. See generally Health & Saf. Code § 1797.230. In this process, the County BOS anemically approved
Resolution 2023-161 on August 22, 2023, to satisfy the requirements for awarding a new EMS contract to a fire
agency found at Health and Safety Code section 1797.230(c), apparently only to support County Purchasing’s
decision to present CONFIRE’s bid to the County BOS. While AMR questions whether this belated resolution meets
the requirement of section 1797.230, it certainly amplifies the appearance of bias from county self-dealing should
the County proceed with considering a contract with CONFIRE.
21
City of Lafayette v. Louisiana Power & Light Co. (1978) 435 U.S. 389, 410.
22
Community Communications Company, Inc. v. City of Boulder, Colorado (1982) 455 U.S. 40, 58.
23
Health and Saf. Code § 1797.6.
November 3, 2023
Page 6 of 7
Conclusion
IV ._
Based on the above, AMR submits this protest on the grounds that the County has not followed the
procedures and requirements set forth in the RFP and has violated the State’s EMS Act. To resolve these
violations, AMR urges County Purchasing to reverse its decision of presenting CONFIRE’s proposal to the
County BOS for consideration of ultimate approval. Consistent with the RFP, County Purchasing should
only present AMR’s proposal.
If you have any questions or would like to speak directly, I can be contacted at 415-686-7531.
Sincerely,
Felicia Y Sze, Esq.

Athene Law, LLP
ccs:
VIA U.S. MAIL AND EMAIL

Emergency Medical Services Authority
Attn: Elizabeth Basnett, Director
11120 International Drive, Suite 200
Rancho Cordova, CA 95670
[email protected]
[email protected]
VIA U.S. MAIL ONLY

Inland Counties Emergency Medical Agency
Attn: Daniel Munoz, Interim EMS Administrator
1425 South D St.
San Bernardino County Counsel

Attn: John Tubbs, Deputy County Counsel
385 N. Arrowhead Ave.
EXHIBIT 6
777 East Rialto Avenue, San Bernardino, CA 92415 I Phone: 909.387.2074 Fax: 909.387.2099
www.SBCounty.gov
Pete Mendoza
SAN BERNARDINO Purchasing Director
COUNTY
November 28, 2023
American Medical Response of Inland Empire

Clo Athene Law LLP
5432 Geary Blvd., #200
San Francisco, CA 94121
Re: Protest of RFP # ICEMA23-ICEMA-4811

Advanced Life Support and Basic Life Support Ground Ambulance Services,
lnterfacility and Critical Care Transport Services for Exclusive Operating Areas in San
Bernardino County
Dear American Medical Response of Inland Empire,
The San Bernardino County Purchasing Department has completed its review of your appeal dated
November 3, 2023, regarding Request for Proposal ("RFP") # ICEMA23-ICEMA-48 l l Advanced
Life Support and Basic Life Support Ground Ambulance Services, Interfacility and Critical Care
Transport Services for Exclusive Operating Areas in San Bernardino County. Thank you for your
time and interest in this process. Please know that we value our vendor relationships, and we
appreciate you expressing your concern.
A protest of award can only be brought on the following grounds:

• Failure of San Bernardino County to follow the selection procedures and adhere to
requirements specified in the RFP or any addenda or amendments.
• There has been a violation of conflict of interest as provided by California Government Code
Section 87100 et seq.
• A violation of State or Federal law.
The appeal alleges that "the County has I) failed to follow the selection procedures and adhere to
requirements specified in the RFP and its addendums, and 2) otherwise violated State and/or
Federal law."
American Medical Response of Inland Empire ("AMR") asserts that the County may only
negotiate with and award a contract to the proposer with the highest score, and may not negotiate
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PAGE 2 of 3
with other proposers or submit more than one proposed contract to the County Board of
Supervisors ('"BOS") for consideration.
As AMR is aware, the BOS, which is the sole approving authority for San Bernardino County, has
not yet awarded an ambulance services contract. Neither the Proposal Review Committee, nor a
county department or staff, possesses the authority to bind the County BOS to a contract selection,
award and contract approval. As stated in RFP section 2 .13, the County is not prohibited from
negotiating with more than one potentially selected proposers ("[t]he County may require the
potential Proposer(.-.) selected to participate in negotiations." Emphasi.., added.) Ifthe County may
negotiate with more than one proposer, staff may necessarily present more than one proposal to
the BOS for consideration.
Following County policy, a department may release an RFP, but staff's recommendation for award
is not binding on the County as the BOS has not taken any action to otherwise delegate its sole
selection and approval authority. Due to this discretionary authority possessed solely by the BOS,
any ambiguous or contradicting language in a department issued RFP, notice or correspondence,
which purportedly binds or obligates the BOS to a predetermined decision is a directory provision
only and not a mandatory provision. This is why, as referenced by AMR's protest letter, the
statutory provisions within Assembly Bill 3891 are "declaratory of existing law regarding a
county's powers and authority to contract for emergency ambulance services", which "are within
the exclusive jurisdiction of the county's board of supervisors".
Moreover, the intent of the RFP is expressed in RFP section 1.3.A:
The County intends to award an initial five (5) year contract to the highest scoring
Proposer whose proposal conforms to the RFP and whose proposal presents the
greatest value to the residents and visitors in the San Bernardino County
Comprehensive Service Area. The Proposal Review Committee (Committee) will
evaluate all proposals based on the evaluation criteria score sheet as established in
this RFP. The County realizes that criteria other than price is important and will
award a contract based on the highest scoring proposal that demonstrates the best
value and meets the needs ofthe County. (Italics added.)
RFP section 2.1 further explains the intent of the RFP: "The County intends to award a contract to
the respondent whose proposal meets all of the Request for Proposals (RFP) criteria and receives
the highest score from the scoring sheet as evaluated by the Proposal Review Committee
(Committee) and best meets the needs o,f the County. (Italics added.)". This decision cannot be
pre-determined and has yet to be decided by the BOS. Thus, both proposals will be before the
BOS for the County's binding award and contract approval.
11
1 AMR Protest Letter fn. 20, referencing CA Health & Safety Code ("H&S ) section 1797.230.
PAGE 3 of 3
Accordingly, the competitive selection process is not complete until the BOS exercises its sole
jurisdiction and discretionary authority by selecting, awarding, and approving the proposal that
demonstrates the best value and meets the needs of the County. The citizens of San Bernardino
County are entitled to be heard on this selection in an open meeting since the intent of the RFP is
to select the proposal which presents the greatest value to the residents and visitors in San
Bernardino County (RFP section 4.1).2
The above are the competitive terms approved the State EMS Authority pursuant to H&S Code
section 1797.224, which terms and competitive process inherently must be read consistently with
existing law regarding a county's powers and authority to contract for emergency ambulance
services, and not contravene the exclusive jurisdiction of the county's board of supervisors.
Alleged inconsistencies with existing law and authority within the RFP cannot be interpreted as
mandatory unauthorized obligations on the County BOS. As such, this State approved competitive
process violates neither State nor Federal law. 3
After reviewing your appeal, RFP, addendums, and related information it has been determined that
the alleged grounds for protest are insufficient. The appeal is respectfully denied, and the County
will move forward with the competitive selection and award process. Both proposers are invited
to present their proposals and negotiated contract terms to the BOS.
If you have any questions, please do not hesitate to contact me

(kinshasa.hamilton(a)pur.sbcountv. g ov).
Sincerely,
KG
KC Hamilton
Procurement Compliance Officer
(909) 387-2067
cc: Pete Mendoza, Director
2 The public's input on both proposals is of great importance considering the de minimus 4-point difference out of
1720 possible points.
3 AM R's Protest letter alleges violation of the state EMS Act and Federal Anti-Trust Law.
EXHIBIT 7
ATHENE LAW LLP
November 30, 2023
VIA HAND DELIVERY

AND VIA E-MAIL ([email protected])
Lynna Monell
Clerk of the Board of Supervisors
Sa n Bernardino County
RE: Notice of Protest

RFP # ICEMA23-ICEMA-4811
Advanced Life Support and Basic Life Support Ground Ambulance Services, lnterfacility and
Critical Care Transport Services for Exclusive Operating Areas in San Bernardino County
Dear Ms. Monell:
American Medical Response of Inland Empire ("AMR") submits this Notice of Protest regarding the above-
referenced Request for Proposal ("RFP") issued by t he County of San Bernardino (the "County"). This
protest is being presented to the Board of Supervisors ("Board") for review and decision pursuant to t he
procedures set forth at RFP section 2.14. Enclosed with this Notice is the Letter of Protest and associated
attachments submitted by AMR to the County's Purchasing Department on November 3, 2023 (Exhibit 1).
The Letter of Protest is incorporated into t his Notice as though fully set forth herein. Also enclosed is t he
Purchasing Department's November 28, 2023, response letter denying AM R's protest (Exhibit 2).
AMR protests on the grounds that t he County has 1) failed to follow the selection procedures and adhere
to requirements specified in the RFP and its addendums, and 2) otherwise violated State and/or Federal
law.
Specifically, t he RFP is unambiguous that "a contract w ill be awarded based on the highest scoring
proposal received." The RFP further specifies that the County may only conduct contract negotiations
"with the Proposer of the highest-ranked proposal." Two providers submitted proposals in response to
the RFP: AMR and the Consolidated Fire Agencies ("CONFIRE"). A non-biased review comm ittee rated
AM R's proposal highe r than CONFIRE's based on scoring criteria set forth in the RFP and approved by the
State's Emergency Medical Services Authority. Despite AM R's proposal receiving the highest score, the
County commenced contract negotiations with both AMR and CONFIRE, and now intends t o present both
proposals and contracts to the Board for consideration and ultimate award.
The County, the Inland Counties Emergency Medical Services Authority ("ICEMA"), and this Board have a
ministeria l, nondiscretionary duty to act in accordance with the RFP, which is a State-approved
"competitive process" for selecting an exclusive emergency med ical services {" EMS" ) provider under
adarP 5432 Geary Blvd., #200 San Francisco, CA 94121, tel 415-686-7531, f rnd·I [email protected]
Lynna Monell, Clerk of the Board of Supervisors, County of San Bernardino
November 30, 2023
Page 2 of 3
Hea lth and Safety Code section 1797.224. The RFP's rules and procedures constitute safeguards to
prevent bias and conflicts of interest from influencing the bid selection. By negotiating with CON FIRE -
the losing bidder- and presenting such contract to the Board for consideration of award, the County acts
in direct violation of those rules. Such actions are arbitrary and capricious, violate the State's EMS Act
and expose the County to Federal antitrust liability.
The Purchasing Department's Response provides no legally valid justification for violating the RFP's rules
and procedures. Further, the Purchasing Department misreads the RFP as permitting the County to
conduct contract negotiations with multiple bidders. The RFP is specific that negotiations may only be
"conducted with the Proposer of the highest-ranked proposal." 1 The County may only commence
negotiations with the next highest rated proposer if the County terminates negotiations with the highest -
ranked proposer for "failure to negotiate" pursuant to RFP section 2.13( B)(l). Here, the specific
procedures for contract negotiation control over the general statement cited by County Purchasing. 2
The Purchasing Department also misinterprets the RFP as granting the Board discretiona ry authority to
set aside the RFP's non-biased scoring process and select a winning bidder based solely on a subjective
"determination of the proposal that demonstrates t he best value and meets the needs of the County."
This ignores the RFP's explicit mandate that "a contract will be awarded based on the highest scoring
proposal received." AMR's proposa l received the highest score based on appraisals by non-biased
evaluators; the Board cannot award a contract to another bidder under this RFP without violating this
provision and, consequently, the EMS Act.
AMR respectfully requests that this protest be resolved before t he Board meets to award the contract.
AMR has participated in the RFP process and negotiations in good faith 3 and will continue to do
so. Accordingly, AMR respectfully requests t hat the Board advise AMR on t he process, procedures, and
sta ndards for resolving the appea l of the protest. To be clear, AMR still intends to present its proposal to
the Board during the December 5, 2023, Board meeting, as to the merits of its winning proposal.
If you have any questions or would like to speak directly, I can be contacted at 415-686-7531.
Sincerely,
Felicia Y Sze, Esq.

Athene Law, LLP
1
RFP § 2.13(A).
2
See People v. Barrett (2003) 109 Cal.App.4th 437, 450.
3
We stand by our original proposal dated April 6, 2023. While County Purchasing sent a last-minute demand on
Tuesday evening that AMR sign a contract before final resolution of the protest, under th e terms of th e RFP, such
execution is unnecessary. Additionally, County Purchasing insisting on two different parties signing a contra ct creates
legal issues and complications. AMR will act expeditiously on the execution of a contract (attached as Exhibit 3) upon
the County's reso lution of th e protest in favor of full compliance with the RFP and laws.
adclre 5432 Geary Blvd., #200 San Francisco, CA 94121, tel. 415-686-7531, em ail : [email protected]
Lynna Monell, Clerk of the Board of Supervisors, County of San Bernard ino
November 30, 2023
Page 3 of 3
cc:
VIA U.S. MAIL AND EMAIL
Emergency Medical Services Authority
Attn: Elizabeth Basnett, Director
11120 International Drive, Suite 200
Rancho Cordova, CA 95670
[email protected]
[email protected]
San Bernardino County Counsel

Attn: John Tubbs, Deputy County Counsel
[email protected]
VIA U.S. MAIL

Inland Counties Emergency Med ical Agency
Attn: Daniel Munoz, Interim EMS Administrator
1425 So uth D St.
Sa n Berna rdino, CA 92408
Pete Mendoza, Purchasing Director

address: 5432 Geary Blvd., #200 San Francisco, CA 94121, tel: 415-686-7531, email. [email protected]
EXHIBIT 8
Larson LLP 555 South Flower Street, 30th Floor P 213.436.4888
LARSON I larsonllp.com Los Angeles, CA 90071 F 213.623.2000
Stephen G. Larson
Direct: 213.436.4864
[email protected]
December 19, 2023
VIA E-MAIL AND HAND DELIVERY
Lynna Monell John Tubbs II

Clerk of the Board Deputy County Counsel
San Bernardino County Board of Supervisors Office of the County Counsel
385 N. Arrowhead Ave. 385 No. Arrowhead Avenue, 4th Floor
San Bernardino, CA 92415 San Bernardino, CA 92415
E-Mail: [email protected] E-Mail: [email protected]
Re: Notice of Brown Act Violation and Demand to Cure or Correct (California Government
Code § 54960.1)
Dear Ms. Monell:
In accordance with California Government Code section 54960.1, this letter shall serve as
American Medical Response of Inland Empire’s (“AMR”) formal demand that the San
Bernardino County Board of Supervisors (the “Board”) immediately cure or correct the Board’s
December 5, 2023 legislative actions made in express violation of the Brown Act, Government
Code section 54950 et seq., as further described herein. 1
On November 3, 2023, AMR submitted a Letter of Protest in connection with the County’s
Request for Proposal # ICEMA23-ICEMA-4811 (the “RFP”), wherein AMR notified the County
of its failure to: (i) follow the selection procedures and adhere to the requirements specified in its
RFP, and (ii) otherwise act in accordance with applicable state and federal law. Thereafter, on
November 30, 2023, AMR submitted a Notice of Protest further specifying the County’s
violations in connection with the RFP. AMR’s protest was based on the County’s decision to
submit Consolidated Fire Agencies’ (“CONFIRE”) proposed contract for the provision of
ambulance services to the Board for consideration of ultimate award—notwithstanding AMR
having received the highest score as part of the RFP’s evaluation process.
The proposed contracts for both AMR and CONFIRE were ultimately submitted to the Board for
consideration during its December 5, 2023 regular meeting. The official Agenda issued prior to
the meeting indicated, as Agenda Item # 80, that the Board would formally approve one of the
two competing contracts; however, the Agenda failed to include AMR’s Notice of Protest as an
1
All further statutory citations are to the California Government Code.
December 19, 2023
Page 2
item for consideration before the Board. Nevertheless, at the December 5, 2023 meeting, the
Board voted to approve a motion to deny AMR’s protest and thereafter voted to award the
contract to CONFIRE.
The Brown Act expressly requires that a legislative body shall, at least 72 hours before a regular
meeting, post an agenda describing “each item of business to be transacted or discussed at the
meeting.” (Gov. Code, § 54954.2, subd. (a)(1).) Additionally, “[n]o action or discussion shall be
undertaken on any item not appearing on the posted agenda.” (Id., subd. (a)(3).)
The Board’s granting of the motion to deny AMR’s protest “was plainly a distinct item of
business” and was thus required to be “expressly disclosed on the agenda.” (San Joaquin Raptor
Rescue Center v. County of Merced (2013) 216 Cal.App.4th 1167, 1177.) Accordingly, as a
result of the Board’s failure to include AMR’s Notice of Protest in the December 5, 2023
Agenda, the Board’s denial of AMR’s protest and subsequent adoption of the CONFIRE contract
were made in clear violation of the Brown Act, section 54954.2. 2
Pursuant to section 54960.1, subdivisions (b) and (c), notice is hereby given that AMR formally
demands that the Board shall, within 30 days of receipt of this letter, cure or correct the
aforementioned violation and inform my office in writing of the Board’s compliance with this
demand. Should the Board fail to adequately correct the violation, AMR intends to vigorously
pursue all available remedies, including but not limited to a petition for writ of mandate and/or
injunctive and declaratory relief.
We look forward to receipt of the Board’s response in accordance with section 54960.1.
Sincerely,
Stephen G. Larson
2
Notably, the immediately preceding agenda item for the December 5, 2023 meeting, Agenda
Item # 79, expressly provided for the consideration of any protest in connection with a separate
legislative proposal concerning changes to the San Bernardino County Fire Protection District.
Larson LLP
LARSON I larsonllp.com
EXHIBIT 9
ORGANIZATIONAL CAPACITY AND EXPERIENCE
Attachment 03 – Priority Contract & Organizational Experience
MARICOPA COUNTY, ARIZONA
In 2016, Priority entered Maricopa

County and the Phoenix-area market –
the fourth-largest county in the country –
after being granted a certificate of
necessity to provide a choice in a market
that previously had been a monopoly.
The operation was branded Maricopa
Ambulance to reflect the expansive
county, which covers more than 9,000
square miles of urban, suburban, rural
and desert land with a population of 4.5
million.
Over the next six years, Maricopa Ambulance built additional customized response models
with its fire department partners, including supplemental response to fire department
ambulance services and fully shared staffing.
In 2018, Maricopa
Ambulance was selected as
the exclusive 911 EMS
provider with Scottsdale
Fire Department, a deeply
integrated public-private
partnership model where
firefighter-paramedics ride
in on BLS ambulances,
allowing for ALS response capabilities.
348
@ NF/RE
MOBILE HEALTH
In January 2022, Maricopa Ambulance began serving the City of Chandler with a custom
ambulance fleet staffed with one EMT and a Chandler Fire & Rescue firefighter-paramedic.
The custom fleet includes specialized compartments and equipment for turnout gear and
breathing apparatus.
Please see the following for details and contracts for Maricopa County, Arizona, 911 contracts:
Contract: City of Scottsdale, Arizona
Community Makeup: 258,069 – Urban/Suburban/Rural Service Period: 2018-present
Type & Level of Primary 9-1-1 Ambulance Response – Contract Tom Shannon, Fire
Service: BLS (Fire Department provides ride- Administrator: Chief 480-312-8000
along ALS) [email protected]
Contract: City of Glendale, Arizona

Community Makeup: 252,381 – Urban/Suburban/Rural Service Period: 2019-present
Type & Level of Contract Ryan Freeburg, Fire Chief
Service: Administrator: 623-930-4400
Primary 9-1-1 Ambulance Response [email protected]
Contract: City of Chandler, Arizona

Community Makeup: 257,076 – Suburban/Rural Service Period: 2022-present
Type & Level of 9-1-1 Ambulance Response – Shared Contract Tom Dwiggins, Fire Chief
Service: staffing model with fire department Administrator: 480-782-2120
paramedics [email protected]
Contract: City of Goodyear, Arizona

Type & Level of Primary 9-1-1 Ambulance Response Contract Paul Luizzi, Fire Chief
Service: Administrator: 623-882-7109
[email protected]
Contract: City of Surprise, Arizona

Type & Level of Backup 9-1-1 Ambulance Response – ALS Contract Tom Abbott, Fire Chief
Service: (shared response with Surprise Fire Administrator: 623-222-5020
Department) [email protected]
349
@ NF/RE
MOBILE HEALTH
EXHIBIT 10
777 E Rialto Ave, San Bernardino, CA 92415 I Phone: 909.387.2070

www.SBCauttty.gov
SAN BERNARDINO Pete Mendoza

Purchasing Department Interim Director
COUNTY
April 7, 2023
Nathan Cooke
CONFIRE
1743 Miro Way
Rialto, CA 92376
[email protected]
SUBJECT: REQUEST FOR PROPOSAL (RFP) No. ICEMA23-ICEMA-4811
Your company submitted a proposal in response to the above-referenced RFP. After

thorough review of your RFP submission, we are missing the demonstration of your
subcontractor meeting the minimum qualification set forth in RFP Section Ill -
Qualifications, Experience and Evaluation Criteria, (B) Organizational Experience,
paragraph (1) on pages 24-25 of the document.
To continue with the process, please submit documentation demonstrating your

subcontractor's ability to meet the minimum qualifications set forth in the RFP, specifically
experience providing primary 911 ambulance services for a large urban area with a
population greater than 1,000,000.
Please submit documentation to [email protected] by 5:00PM PST,

Tuesday, April 11, 2023. We look forward to your response.
"n fl ·n n
Sincerely,
~Jlj)l1_ ~
Michelle Churchill
Supervising Buyer
HOA RP OI· SLPER\'ISOl{S

COL p AUL COOK (RET) JESSE ARlv!ENDAREZ DAWN RowE Cmn HAGMAN J OR BACA, JR. .~
V,ce Cha.uman, Forst D1str1~\ Second Dist net C:haor. Thtrd Dostr,ct fo"rth District I tfth Distu,t ■ I
EXHIBIT 11
Apple Valley Fire Protection District
Chino Valley Independent Fire District
Colton Fire Department
Loma Linda Fire Department
Rancho Cucamonga Fire Protection District
Redlands Fire Department
Rialto Fire Department
San Bernardino County Fire Protection District
Consolidated Fire Agencies Victorville Fire Department
1743 W. Miro Way, Rialto, CA 92376-8630
Phone 909-356-2302 Fax 909-356-3809
April 11, 2023
Michelle Churchill, Supervising Buyer

San Bernardino Purchasing Department
RE: Response to April 7 Request for Documentation Related to RFP # ICEMA23-ICEMA-4811
Dear Ms. Churchill:
Consolidated Fire Agencies (CONFIRE) received your letter dated April 7, 2023, where you stated the
following:
Your company submitted a proposal in response to the above referenced RFP. After thorough
review of your RFP submission, we are missing the demonstration of your subcontractor
meeting the minimum qualification set forth in RFP Section III – Qualifications, Experience and
Evaluation Criteria, (B) Organizational Experience, paragraph (1) on pages 24-25 of the
document.
[P]lease submit documentation demonstrating your subcontractor’s ability to mee the minimum
qualifications set forth in the RFP, specifically experience providing primary 911 ambulance
services for a large urban area with a population greater than 1,000,000.
CONFIRE presents the following additional documentation regarding CONFIRE and its subcontractor
Priority Ambulance, LLC’s Organizational Experience, in satisfaction of the Minimum Qualifications in the
RFP.
Section III – Qualifications, Experience and Evaluation, 3.1 Minimum Qualifications, (B) Organizational
Experience, paragraph (1) provides:
Five (5) years within the last seven (7) years, continuously engaged in providing 911 ALS
transport services as required by a contract in the United States as a primary 911 ambulance
services provider at the ALS, IFT and CCT levels for a large Urban area with a population greater
than 1,000,000, including a mix of urban, suburban, rural and wilderness areas. This
requirement can be met through a subcontractor.
BOARD OF DIRECTORS
Dan Leary…. Apple Valley John DeMonaco…. Chino Valley
John Echevarria…. Colton Phill Dupper…. Loma Linda
Lynne Kennedy…. Rancho Cucamonga Denise Davis…. Redlands
Andy Carrizales…. Rialto Joe Baca, Jr.…. San Bernardino County
Elizabeth Becerra…. Victorville
As illustrated in both CONFIRE’s proposal and this supplemental response, CONFIRE and its
subcontractor Priority Ambulance, meet the minimum qualifications set forth in the above referenced
RFP. First,
1. Supporting Documentation for CONFIRE’S Subcontractor, Priority Ambulance, LLC

CONFIRE EMS’s subcontracted partner is Priority Ambulance, which is one of the largest
ambulance services in the country. Priority Ambulance’s largest operating company in the
nation is Maricopa Ambulance, which serves the vast Maricopa County/metro-Phoenix area.
Maricopa County is the fastest growing county by numeric growth in the United States and is a
large urban area with a mix of urban, suburban, rural and wilderness/desert areas. In 2023,
Maricopa County’s population is estimated at 4.6 million citizens.
On July 20, 2017, Maricopa Ambulance was granted Certificate of Necessity (CON) Number 147
issued by the State of Arizona Department of Health Services. CON Number 147 not only grants
authority by the State of Arizona to provide 9-1-1 ALS and BLS levels of ground ambulance
services anywhere in the CON service area, but also requires Maricopa Ambulance to respond to
all 9-1-1 ALS and BLS calls to which they are dispatched. The CON covers almost the entirety of
Maricopa County and its 4.6 million people.
Maricopa Ambulance has also been serving specific municipalities in Maricopa County under
contract as a primary 9-1-1 ALS ambulance service provider since 2018, for more than five
continuous years within the last seven years. Maricopa Ambulance’s exclusive 9-1-1 ALS
contracts for ground ambulance services in Maricopa County encompass multiple cities with a
combined total population of more than 1 million.
Additionally, Maricopa Ambulance has provided ALS, BLS and CCT interfacility transport services
continuously over the last seven years under contracts with major hospitals, healthcare systems,
and related facilities throughout the entire 9,224-square-mile footprint of Maricopa County
since 2016.
It is noteworthy that the Priority Ambulance family of ambulance companies across the United
States provides contracted 9-1-1 ALS and BLS ground ambulance services under 62 distinct
contracts, serving populations totaling more than 3.2 million people.
It is also relevant that members of the Priority Ambulance leadership team who will be
intimately engaged in the San Bernardino County system share extensive experience operating
9-1-1 ALS, IFT, and CCT level ground ambulance services for large urban areas with populations
exceeding 1 million. These large urban areas include San Diego, California; Santa Clara County,
California; and Orange County, Florida.
Priority Ambulance, CONFIRE’s subcontractor, meets the population and transport

requirements detailed in Section III – Qualifications, Experience and Evaluation, 3.1 Minimum
Qualifications, (B) Organizational Experience.
2
2. Supporting Documentation for CONFIRE
CONFIRE JPA represents 15 of the longest-serving fire and EMS agencies within San Bernardino
County, each with a continuous history of protecting their communities for five years within the
last seven years. CONFIRE member agencies employ more than 850 paramedics and 400 EMTs in
San Bernardino County and provide more than 212,000 responses to 9-1-1 EMS calls annually.
The mix of JPA partners within the CONFIRE EMS organization in San Bernardino County meets
the population and transport requirements detailed in Section III – Qualifications, Experience
and Evaluation, 3.1 Minimum Qualifications, (B) Organizational Experience.
As we have demonstrated above, CONFIRE’s subcontract partner Priority Ambulance is highly

experienced and qualified to provide 9-1-1 services at the ALS, IFT and CCT levels for San Bernardino
County based on the company’s continuous experience for five years within the last seven years in
Maricopa County, Arizona, a large urban area with a population of 4.6 million people, including a mix of
urban, suburban, rural and wilderness/desert areas.
We appreciate the opportunity to clarify CONFIRE’s subcontractor qualifications and thank you for your
time and attention to this matter.
Respectfully,
Nathan Cooke, Interim Director
3
EXHIBIT 12
Exhibit 8 - CONFIRE Financial Model -FINAL.xlsx Output
Description Year 1 Year 2 Year 3

# of trips Gross Revenue Net Collections # of trips Gross Revenue Net Collections # of trips Gross Revenue Net Collections # of trips
All Patient Charges
Medicare 81,251 $ 320,015,216 $ 36,599,763 82,279 $ 340,267,111 $ 37,062,808 83,321 $ 361,808,641 $ 37,532,542 84,379
Medicaid 60,662 $ 241,395,850 $ 2,408,558 61,429 $ 256,672,385 $ 2,439,030 62,208 $ 272,921,725 $ 2,469,942 62,997
Commercial Insurance 19,105 $ 76,079,600 $ 64,739,487 19,347 $ 80,894,234 $ 68,836,471 19,592 $ 86,015,463 $ 73,194,350 19,841
Private Pay & Other 13,280 $ 52,307,299 $ 2,623,973 13,448 $ 55,617,523 $ 2,790,029 13,619 $ 59,138,541 $ 2,966,659 13,791
Subtotal - All Patient Charges 174,298 $ 689,797,966 $ 106,371,780 176,503 $ 733,451,253 $ 111,128,337 178,740 $ 779,884,369 $ 116,163,493 181,008
Other Revenues
QUAF Revenue - $ - $ - - $ - $ - - $ - $ - -
PPIGT Revenue 40,945 $ 45,834,360 $ 45,834,360 41,354 $ 48,126,078 $ 48,126,078 41,768 $ 50,532,382 $ 50,532,382 42,186
All Other Revenue - $ - $ - - $ - $ - - $ - $ - -
Subtotal - Other Revenues 40,945 $ 45,834,360 $ 45,834,360 41,354 $ 48,126,078 $ 48,126,078 41,768 $ 50,532,382 $ 50,532,382 42,186
Total Net Revenues $ 152,206,140 $ 159,254,415 $ 166,695,875
Operating Expenses:
Salaries and Wages $ 793,184 $ 852,673 $ 916,623
Payroll Taxes & Employee Benefits $ 427,415 $ 459,471 $ 493,932
Purchased Services
Partnership/Subcontracting $ 107,652,970 $ 115,726,942 $ 124,406,463
EMS Agency Oversight and Monitoring Services $ 1,800,000 $ 1,800,000 $ 1,800,000
Centralized EMD Dispatch Center $ 976,005 $ 976,005 $ 976,005
Firstwatch Initial Charge $ 100,850 $ - $ -
Firstwatch Annual Charge $ 17,356 $ 18,658 $ 20,057
ImageTrend Annual Charge $ 180,000 $ 193,500 $ 208,013
Other Purchased Services $ 419,740 $ 451,221 $ 485,062
Subtotal - Purchased Services $ 111,146,921 $ 119,166,326 $ 127,895,600
Estimated Response Time Penalties $ 250,000 $ 250,000 $ 250,000
General & Administrative $ 21,388,315 $ 22,356,272 $ 23,489,617
Vehicles $ - $ - $ -
Medical Supplies / Equipment $ - $ - $ -
Other Operating Expenses $ - $ - $ -
Interest Expense $ 600,000 $ 600,000 $ 600,000
Total Operating Expenses $ 134,605,835 $ 143,684,741 $ 153,645,771
Income from Operations $ 17,600,305 $ 15,569,674 $ 13,050,103
Page 1 of 2
Exhibit 8 - CONFIRE Financial Model -FINAL.xlsx Output
Description Year 4 Year 5

Gross Revenue Net Collections # of trips Gross Revenue Net Collections
All Patient Charges
Medicare $ 384,719,545 $ 38,008,785 85,451 $ 409,090,663 $ 38,491,959
Medicaid $ 290,204,019 $ 2,501,283 63,798 $ 308,587,791 $ 2,533,079
Commercial Insurance $ 91,462,242 $ 77,829,255 20,093 $ 97,256,170 $ 82,759,563
Private Pay & Other $ 62,883,386 $ 3,154,518 13,967 $ 66,866,907 $ 3,354,349
Subtotal - All Patient Charges $ 829,269,192 $ 121,493,841 183,309 $ 881,801,532 $ 127,138,950
Other Revenues
QUAF Revenue $ - $ - - $ - $ -
PPIGT Revenue $ 53,059,001 $ 53,059,001 42,608 $ 55,711,951 $ 55,711,951
All Other Revenue $ - $ - - $ - $ -
Subtotal - Other Revenues $ 53,059,001 $ 53,059,001 42,608 $ 55,711,951 $ 55,711,951
Total Net Revenues $ 174,552,842 $ 182,850,902
Operating Expenses:
Salaries and Wages $ 985,370 $ 1,059,272
Payroll Taxes & Employee Benefits $ 530,976 $ 570,800
Purchased Services
Partnership/Subcontracting $ 133,736,948 $ 143,767,219
EMS Agency Oversight and Monitoring Services $ 1,800,000 $ 1,800,000
Centralized EMD Dispatch Center $ 976,005 $ 976,005
Firstwatch Initial Charge $ - $ -
Firstwatch Annual Charge $ 21,561 $ 23,178
ImageTrend Annual Charge $ 223,613 $ 240,384
Other Purchased Services $ 521,442 $ 560,550
Subtotal - Purchased Services $ 137,279,569 $ 147,367,337
Estimated Response Time Penalties $ 250,000 $ 250,000
General & Administrative $ 24,683,476 $ 25,941,215
Vehicles $ - $ -
Medical Supplies / Equipment $ - $ -
Other Operating Expenses $ - $ -
Interest Expense $ 600,000 $ 600,000
Total Operating Expenses $ 164,329,392 $ 175,788,623
Income from Operations $ 10,223,450 $ 7,062,278
Page 2 of 2

AMR v. San Bernardino County Lawsuit

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AMR v. San Bernardino County Lawsuit

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Case 5:24-cv-00267 Document 1 Filed 02/02/24 Page 1 of 27 Page ID #:1

1 Stephen G. Larson (SBN 145225)

9 Attorneys for Petitioner and Plaintiff

13 AMERICAN MEDICAL RESPONSE OF Case No. 5:24-CV-00267

15 Petitioner and Plaintiff,

23 Defendants and Respondents.

25 CONSOLIDATE FIRE AGENCIES, a Joint

9 the next exclusive five-year contract with the County.

20 process in order to award the contract to its pre-ordained preferred provider—CONFIRE—

22 by the County was not truly competitive at all.

23 4. The independent, non-biased review committee administering the RFP process

5 narrow confines of their antitrust immunity.

8 Board of Supervisors deliberately disregarded the glaring deficiencies in CONFIRE’s proposal

11 7. As demonstrated by the outright failure to adhere to the mandatory requirements of

16 would ultimately benefit the County.

17 8. As a result of Defendants’ anti-competitive conduct, AMR will be forced to cease

22 State of California and doing business in California.

24 subdivision of the State of California.

26 governing the County.

1 Safety Code section 1797.200.

8 only as to the Third Cause of Action.

15 the appropriate allegations, when ascertained.

16 JURISDICTION AND VENUE

19 pursuant to 28 U.S.C. § 1367.

21 proper pursuant to 28 U.S.C. § 1391.

2 March 31, 2024.

3 California’s Emergency Medical Services Act and Federal Antitrust Immunity

8 immediate medical care. Health & Safety Code § 1797 et seq.

13 delivery of EMS within a specified geographic area. Id., §§ 1797.94, 1797.200.

16 and equipment—like emergency medical technicians, paramedics, and ambulances—for effective

21 or office having primary responsibility for administration of emergency medical services in a

23 duties under the EMS Act.

4 Safety Code, §§ 1797.76, 1797.206, 1797.250, 1797.252, 1797.254.

8 certain emergency ambulance services or providers of emergency services. Id., §§ 1797.74,

16 on or before January 1, 1981. Id.

24 trade in violation of the Sherman Antitrust Act.

25 29. However, a narrow exception to antitrust liability exists where anticompetitive

21 on November 29, 2022 for the RFP.

26 each proposal. (Id.).

27 34. The specified evaluation criteria consisted of the following categories:

3 criteria would be evaluated were detailed throughout the RFP.

7 with the highest-scoring bidder for failure to negotiate. (Id.).

17 The Selection Process

25 emergency ambulance services currently performed by AMR, including ambulance transport

5 provider, Priority Ambulance, LLC (“Priority")

6 41. As evidenced by CONFIRE’s proposal, while it would be the primary contracting

13 the same minimum qualifications enumerated therein. (Ex. 1, p. 24).

16 around June 2023.

22 outcome of those negotiations. (Ex. 3).

6 federal law. (See Ex. 5).

3 exhaustion of this remedy no additional recourse is available.” (Ex. 1, p. 23).

24 award the exclusive contract for ambulance services to CONFIRE. 2

15 CONFIRE Was Unqualified to Participate in the RFP Process

20 55. Based on a review of the materials included therein, it is undisputable that

24 County’s recommendation for further negotiation and ultimate award.

4 services continuously for five of the last seven years. (Id.).

6 organizational experience necessary to meet these requirements. CONFIRE instead attempted to

15 portion of Maricopa County. (Id.).

20 requirements of the RFP.

11 service area population of 1,000,000 required under the RFP. (Id.).

14 interfacility transport services—both of which are mandated by the RFP’s organizational

15 experience requirement. (Id.).

21 further consideration, it must “submit documentation demonstrating your subcontractor’s ability to