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Page 1 of 3 ARIZONA STATE CONTRACT CONTRACT RELEASE ProcureAZ Purchase Order No.: ADHS13-037845:7 Organizational Reference No.: PO0000191388 Issued: 01/18/2017 C-86-13-064-3-12 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.: ADHS13-037845 (602) 364-1400 Title: OOH - Dental Sealant Services 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--OHFCFH3998--4381--HS3038--HS73510-6811---PHS-WCH----------- Payment Terms: Net 30 -HSA Shipping Terms: Delivery Calendar Day(s) A.R.O.: 0 Item Description Requisition Quantity Unit Unit Price Total Class-Item 948-28 1 33.00 EA $ 70.00 $ 2,310.00 PO EFFECTIVE 1/1/17 - 12/31/17 **** CONTRACT EFFECTIVE 1/1/13 - 12/31/17 **** THIS LINE TO PAY FROM OHFCFH3998 **** FUNDING: Oral Health Fund **** CFDA: NONE **** THIS LINE TOTAL = $ 2,310.00 ********** Dental sealant services - per child Class-Item 948-28 2 120.00 HR $ 33.00 $ 3,960.00 THIS LINE TO PAY FROM FEDCFH6027 / 0817 **** FUNDING: Oral Health Workforce Grant **** CFDA: 93.236 **** THIS LINE TOTAL = $3,960.00 ******** Oral Health Data Collection, Dental Hygienist - per hour/per provider Class-Item 948-28 3 48.00 HR $ 18.00 $ 864.00 THIS LINE TO PAY FROM FEDCFH6027 / 0817 **** FUNDING: Oral Health Workforce Grant **** CFDA: 93.236 **** THIS LINE TOTAL = $864.00 ******** Oral Health Data Collection, Dental Assistant - per hour/per provider Page 2 of 3 ARIZONA STATE CONTRACT CONTRACT RELEASE Class-Item 948-28 4 3000.00 EA $ 70.00 $ 210,000.00 THIS LINE TO PAY FROM FEDCFH1870 / 0918 **** FUNDING: MCH Block Grant **** CFDA: 93.994 **** THIS LINE TOTAL = $210,000.00 **** Dental sealant services - per child Class-Item 948-28 5 1.00 EA $ 13,323.00 $ 13,323.00 THIS LINE TO PAY FROM FEDCFH1870 / 0918 **** FUNDING: MCH Block Grant **** CFDA: 93.994 **** THIS LINE TOTAL = $13,323.00 ***** Customer Satisfaction Survey and Assessment Results Class-Item 948-28 6 1.00 EA $ 13,323.00 $ 13,323.00 THIS LINE TO PAY FROM FEDCFH1870 / 0918 **** FUNDING: MCH Block Grant **** CFDA: 93.994 **** THIS LINE TOTAL = $13,323.00 **** Cost Effectiveness Evaluation Class-Item 948-28 7 1.00 EA $ 13,324.00 $ 13,324.00 THIS LINE TO PAY FROM FEDCFH1870 / 0918 **** FUNDING: MCH Block Grant **** CFDA: 93.994 **** THIS LINE TOTAL = $13,324.00 ***** Program Implementation Analysis and Assessment TOTAL: $ 257,104.00 Approved By: Cynthia Ronquillo Phone No.: (602) 364-1513 Page 3 of 3 ATTACHED TO AND A PART OF: Purchase Order ADHS13-037845:7 OOH-Dental Sealant Services C-86-13-064-3-12 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