AMD 1 RE IMMUNIZATION SVCS WITH ADHS.PDF

ARIZONA DEPARTMENT
OF HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 150 N. 18th Avenue, Suite
260
Phoenix, Arizona 85007
Procurement Officer:
Contract No.: ADHS18-177694 Amendment No.: 1
Delilah Gonzalez
Immunization Services
Pursuant to Uniform Terms and Conditions, Provision (6) Contract Changes, (6.1) Amendments, Purchase Orders, and
Change Orders, it is mutually agreed that the Intergovernmental Agreement referenced is amended as follows:
1. The Price Sheet is revised and replaced with the Price Sheet in this Amendment No. 1.
ALL OTHER PROVISIONS OF THIS AGREEMENT REMAIN UNCHANGED.
Contractor Name: Authorized Signature
MARICOPA COUNTY BY AND THROUGH ITS MARICOPA
COUNTY PUBLIC HEALTH
4041 N. CENTRAL AVE., SUITE 1400 .
Address: Print Name
PHOENIX ARIZONA 85012
City State Zip Title
This Intergovernmental Agreement Amendment shall be
Pursuant to A.R.S. § 11-952, the undersigned public agency attorney has determined effective the date indicated. The Public Agency is hereby
that this Intergovernmental Agreement is in proper form and is within the powers and cautioned not to commence any billable work or provide any
authority granted under the laws of Arizona material, service or construction under this IGA until the IGA
has been executed by an authorized ADHS signatory.
State of Arizona
Signature Date
Signed this day of 20__.
Print Name Title
Procurement Officer
Attorney General Contract No.: P0012014000078 _, which is an Agreement RESERVED FOR USE BY THE SECRETARY OF STATE
between public agencies, has been reviewed pursuant to A.R.S. § 11-952 by
the undersigned Assistant Attorney, who has determined that it is in proper
form and is within the powers and authority granted under the laws of the
State of Arizona.
Signature Date
Assistant Attorney General
Print Name Title
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ARIZONA DEPARTMENT
OF HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 150 N. 18th Avenue, Suite
PRICE SHEET 260
Phoenix, Arizona 85007
Contract No.: ADHS18-177694 Amendment No.: 1 Procurement Officer:
Delilah Gonzalez
Effective July 1, 2018
Immunization Visit for
children zero (0) to eighteen
(18) years of age who meet Quarterly
$50.00 Per Visit
VFC eligibility requirements.
Do not include visits for
insured children.
Immunization Visit for adults
nineteen (19) years of age Quarterly,
and older who meet VFA when specific
$50.00 Per Visit
eligibility requirements. Do VFA funds are
not include visits for insured available
adults
Immunization Completion
report for children zero (0) to
Per Series
twenty-four (24) months of Quarterly $100.00
age for the 4:3:1:3:3:1:4 Completion As approved by
series ADHS and
Perinatal Hepatitis B Case authorized by
Quarterly $300.00 Per Case purchase order
Management – Prenatal
Perinatal Hepatitis B Case
Quarterly $200.00 Per Case
Management – Postnatal
Immunization Visit for Flu
Vaccine, in children and When specific
adults who meet VFC and pan flu vaccine
$50.00 Per Visit
VFA eligibility requirements. funds are
Do not include visits for available
insured children or adults.
IDR Submission –
Preparation and Submittal of
School/Child Care IDR by Each/per grade
Optional $250.00
CHD nurse or in cooperation level IDR
with school/child care
personnel
IDR Validation – On-site visit
to schools/child care facilities Each/per grade
Optional $50.00
to validate IDR submission level validation
data
*Prices may be reviewed and adjusted annually over the term of the contract.
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