PURCHASE ORD RE DENTAL SEALANT SVC WITH ADHS.PDF

ARIZONA STATE CONTRACT Page 1 of 2
CONTRACT RELEASE
C-908- D60-3-oz
ProcureAZ Purchase Order No.: ADHS18-175153:1
Organizational Reference No.: P00000351194
Issued: 05/30/2018
Vendor Number: 000010983 Arizona Department of Health Services
Maricopa County Public Health Bureau of Women and Children's Health
4041 N. Central Avenue, #1400 150 N. 18th Avenue, Suite 320
Phoenix, AZ 85012 Phoenix, AZ 85007
US
Email; procure©azdhs.gov
Contract No.: ADHS18-175153 (602) 364-1400
Title: 00H - Dental Sealant Services
MAIL INVOICE IN DUPLICATE TO:
Arizona Department of Health Services
Bureau of Women and Children's Health
150 N. 18th Avenue, Suite 320
Phoenix, AZ 85007
US
Email: procure©azdhs.gov
(602) 364-1400
Release Instructions
TERMS AND CONDITIONS set forth in our Bid, Quotation, or Purchase Order
are incorporated herein by reference and become a part of this order.
Account Code: 2018--01-IFCFH3998--4381--HS3038--HS73510-6811--6811-PHS-WCH---- Payment Terms: Net 30
HSA
Shipping Terms:
\ Delivery Calendar Day(s) ARC.: 0
Item Description I Requisition Quantity Unit Unit Price Total
Class-Item 948-28
PO EFFECTIVE THRU 12/31/18 **** CONTRACT EFFECTIVE 1/1/18 -
12131/22 **** THIS LINE TO PAY FROM OHFCFH3998 ""** STATE FUNDS
****CFDA: NONE **** THIS LINE TOTAL = $91,960.00 *****""* DENTAL
1 SEALANT SERVICES - Total cost per sealant to Include the following 1226,00 EA $ 75.00 $ 91,950.00
(Sealant Applied Per Child):
1) Sealant dental staff and services including travel, supplies, training,
indirect/direct costs.
2) Administrative personnel coordination of Sealant program and
participation in an External Advisory Group.
3) Cost of Dentist providing standing orders for public health hygienist.
Class-Item 948-28
2 THIS LINE TO PAY FROM FEDCFH8027 / 081 8 **"* FEDERAL FUNDING 59.00 EA $ 30.00 $ 1,770.00
****CFDA: 93.236 **** THIS LINE TOTAL '4 $1,770.00 **** ORAL HEALTH
DATA COLLECTION, DENTAL HYGIENIST (Per Hour, Per Provider)

Page 2 of 2
ARIZONA STATE CONTRACT
CONTRACT RELEASE
Class-Item 948-28
3 35.00 EA $ 18.00 $ 630.00
THIS LINE TO PAY FROM FEDCFH6027 /0818 **** FEDERAL FUNDING
**** CFDA: 93.236 **** THIS LINE TOTAL = $630.00 **** ORAL HEALTH
DATA COLLECTION, DENTAL ASSISTANT (Per Hour, Per Provider)
, Class-Item 948-28
THIS LINE TO PAY FROM FEDCFH1870 / 0919 *""* FEDERAL FUNDING
**** CFDA: 93.994 THIS LINE TOTAL = $260,025.00 **** FFATA
REPORTING REQUIRED ***** DENTAL SEALANT SERVICES - Total cost
4 per sealant to include the following (Sealant Applied Per Child): 3467.00 EA $ 75.00 $ 260,025.00
1) Sealant dental staff and services including travel, supplies, training,
indirect/direct costs.
2) Administrative personnel coordination of Sealant program and
participation in an External Advisory Group.
3) Cost of Dentist providing standing orders for public health hygienist.
Class-Item 948-28
5 1.00 EA $ 13,324.00 $ 13,324,00
THIS LINE TO PAY FROM FEDCFH1870 / 0919 **** FEDERAL FUNDING
**** CFDA: 93.994 **** THIS LINE TOTAL = $13,324.00 **** FFATA
REPORTING REQUIRED ***** COST EFFECTIVENESS EVALUATION
Class-Item 948-28
6 1,00 EA $ 13324.00 , $ 13,324,00
THIS LINE TO PAY FROM FEDCFH1870 / 0919 **** FEDERAL FUNDING
**** CFDA: 93.994 **** THIS LINE TOTAL = $13,324.00 **** FFATA
REPORTING REQUIRED ***** CUSTOMER SATISFACTION SURVEY
AND ASSESSMENT RESULTS
Class-Item 948-28
7 1.00 EA $ 13,324.00 $ 13,324.00
THIS LINE TO PAY FROM FEDCFH1870 / 0919 **** FEDERAL FUNDING
**** CFDA: 93.994 **** THIS LINE TOTAL = $13,324.00 **** FFATA
REPORTING REQUIRED ***** PROGRAM IMPLEMENTATION ANALYSIS
AND ASSESSMENT
TOTAL: $ 394,347.00
Approved By: Cynthia Ronquillo
Phone No.: (602) 364-1513

C-86-18-060-3-02 ATTACHED TO AND A PART OF
Dental Sealant Program
Purchase Order No. ADHS18-175153:1
Contract No. ADHS18-175153
Office of Oral Health (00H) Dental Sealant Services
IN WITNESS WHEREOF, the parties agree to enter into this IGA and its
Amendments:
FOR AND ON BEHALF OF
MARICOPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM:
Attorney for Maricopa County
Date