NICP WITH ADHS FOR NWBRN (07).PDF

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ARIZONA STATE CONTRACT
CONTRACT RELEASE
ProcureAZ Purchase Order No.: ADHS14-074958:3
Organizational Reference No.: PO0000129550
Issued: 07/13/2016
C-86-15-021-3-07
V Vendor Number: 000010983 Arizona Department of Health Services
E Maricopa County Public Health S Bureau of Women and Children's Health
N 4041 N. Central Avenue, #1400 H 150 N. 18th Avenue, Suite 320
Phoenix, AZ 85012 I Phoenix, AZ 85007
D US
O P Email: procure@azdhs.gov
R
T
O
Contract No.: ADHS14-074958 (602) 364-1400
Title: HRPP Community Nursing
MAIL INVOICE IN DUPLICATE TO:
B Arizona Department of Health Services
I Bureau of Women and Children's Health
150 N. 18th Avenue, Suite 320
L Phoenix, AZ 85007
L US
Email: procure@azdhs.gov
T
O
(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: 2017--GENCFH0296--4341--1000--HS43010-6841--6841-PHS-WCH-------- Payment Terms: Net 30
----HSA
Shipping Terms: N/A
Delivery Calendar Day(s) A.R.O.: 0
Item Description Requisition Quantity Unit Unit Price Total
Class-Item 948-64
PO EFFECTIVE 7/1/16 - 6/30/17 *** CONTRACT EFFECTIVE 7/1/14 -
1 6/30/17 *** STATE FUNDING *** THIS LINE TO PAY FROM GENCFH0296/ 1.00 QTR $ 92,925.00 $ 92,925.00
2017 *** CONTRACTOR TO INVOICE ACCORDING TO CONTRACT
PRICE SHEET *** THIS CONTRACT CONTAINS QUARTERLY
ENCUMBRANCES *** TOTAL CONTRACT AMOUNT = $555,000.00
*********************HRPP/NICP COMMUNITY HEALTH NURSING
SERVICES
Class-Item 948-64
2 1.00 TOTAL $ 123,300.00 $ 123,300.00
THIS LINE TO PAY FROM FEDCFH1781 / 0917 *** FEDERAL FUNDING:
MCH BLOCK GRANT CFDA 93.994 ***HRPP/NICP COMMUNITY HEALTH
NURSING SERVICES
Class-Item 948-64
3 1.00 TOTAL $ 60,000.00 $ 60,000.00
THIS LINE TO PAY FROM FEDCFH1787 / 0917 *** FEDERAL FUNDING:
MCH BLOCK GRANT SPECIAL NEEDS CFDA 93.994 ***HRPP/NICP

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ARIZONA STATE CONTRACT
CONTRACT RELEASE
COMMUNITY HEALTH NURSING SERVICES
Class-Item 948-64
4 1.00 EA $ 100,925.00 $ 100,925.00
LINE TO ADD 2ND QTR FUNDING *** STATE FUNDING *** THIS LINE TO
PAY FROM GENCFH0296/ 2017 *** QUARTERLY AMOUNT = $92,925.00
+ ADDITIONAL AMOUNT OF $8,000.00 ********** HRPP/NICP
COMMUNITY HEALTH NURSING SERVICES
Class-Item 948-64
5 1.00 EA $ 92,925.00 $ 92,925.00
LINE TO ADD 3RD QTR FUNDING *** HRPP/NICP COMMUNITY HEALTH
NURSING SERVICES
Class-Item 948-64
6 1.00 EA $ 145,425.00 $ 145,425.00
LINE TO ADD ADDL DOLLARS AND 4TH QTR FUNDING ******
HRPP/NICP COMMUNITY HEALTH NURSING SERVICES
Class-Item 948-64
7 1.00 EA $ 8,985.00 $ 8,985.00
LINE ADDED VIA CHANGE ORDER - FUNDING THRU 6/30/17 **** TO
PAY FROM GENCFH0296 - STATE FUNDING *******************
HRPP/NICP COMMUNITY HEALTH NURSING SERVICES
Class-Item 948-64
8 1.00 EA $ 4,000.00 $ 4,000.00
LINE ADDED VIA CHANGE ORDER - FUNDING THRU 6/30/17 **** TO
PAY FROM FEDCFH1781 / 0917 *** FEDERAL FUNDING -
CFDA 93.994************* HRPP/NICP COMMUNITY HEALTH NURSING
SERVICES
Class-Item 948-64
9 1.00 EA $ 4,000.00 $ 4,000.00
LINE ADDED VIA CHANGE ORDER - FUNDING THRU 6/30/17 **** TO
PAY FROM FEDCFH1787 / 0917 *** FEDERAL FUNDING - CFDA
93.994*************HRPP/NICP COMMUNITY HEALTH NURSING
SERVICES
Class-Item 948-64
10 1.00 EA $ 18,015.00 $ 18,015.00
LINE ADDED VIA CHANGE ORDER - FUNDING THRU 6/30/17 **** TO
PAY FROM EMSCFH5653 *** HRPP/NICP COMMUNITY HEALTH
NURSING SERVICES
TOTAL: $ 650,500.00
Approved By: Dee Vlahos
Phone No.: (602) 364-1425

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ATTACHED TO AND A PART OF:
Purchase Order ADHS14-074958:3
HRPP/NICP Community Nursing
C-86-145-021-3-07
IN WITNESS WHEREOF, the parties agree to enter into this Agreement and its Amendments:
FOR AND ON BEHALF
OF MARICOPA COUNTY
By_____________________________
Denny Barney, Chairman, Board of Supervisors
_______________________________
Date
ATTEST:
_______________________________
Clerk of the Board
_______________________________
Date
APPROVED AS TO FORM:
_______________________________
Attorney for Maricopa County
_______________________________
Date
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