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Page 1 of 3 ARIZONA STATE CONTRACT CONTRACT RELEASE ProcureAZ Purchase Order No.: ADHS13-037845:6 Organizational Reference No.: PO0000066073 Issued: 01/11/2016 C-86-13-064-3-09 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--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 PO EFFECTIVE 1/1/16 - 12/31/16 **** CONTRACT EFFECTIVE 1/1/13 - 2029.00 EA $ 70.00 $ 142,030.00 12/31/17 **** THIS LINE TO PAY FROM FEDCFH1869 / 0917 **** FUNDING: MCH Block Grant **** CFDA: 93.994 **** THIS LINE TOTAL = $142,030.00 **** TOTAL PURCHASE ORDER AMOUNT = $278,730.00 ***** Dental sealant services - per child Class-Item 948-28 2 526.00 EA $ 70.00 $ 36,820.00 THIS LINE TO PAY FROM OHFCFH3998 **** FUNDING: Oral Health Fund - Sealant **** CFDA: None **** THIS LINE TOTAL = $8,400.00 ***** Dental sealant services - per child Class-Item 948-28 3 56.00 EA $ 70.00 $ 3,920.00 THIS LINE TO PAY FROM DDNCFH3849 **** FUNDING: Oral Health Donation Fund **** CFDA: None **** THIS LINE TOTAL = $5,530.00 ***** Dental sealant services - per child Page 2 of 3 ARIZONA STATE CONTRACT CONTRACT RELEASE Class-Item 948-28 4 1.00 EA $ 13,323.00 $ 13,323.00 THIS LINE TO PAY FROM FEDCFH1869 / 0917 **** FUNDING: MCH Block Grant **** CFDA: 93.994 **** THIS LINE TOTAL = $13,323.00 ***** Cost Effectiveness Evaluation Class-Item 948-28 5 1.00 EA $ 13,323.00 $ 13,323.00 THIS LINE TO PAY FROM FEDCFH1869 / 0917 **** 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 $ 13,324.00 $ 13,324.00 THIS LINE TO PAY FROM FEDCFH1869 / 0917 **** FUNDING: MCH Block Grant **** CFDA: 93.994 **** THIS LINE TOTAL = $13,324.00 ***** Program Implementation Analysis and Assessment Class-Item 948-28 7 180.00 HR $ 33.00 $ 5,940.00 THIS LINE TO PAY FROM FEDCFH6027 / 0816 **** FUNDING: Oral Health Workforce Grant **** CFDA: 93.236 **** THIS LINE TOTAL = $5,940.00 **** Oral Health Data Collection, Dental Hygienist - per hour/per provider Class-Item 948-28 8 70.00 HR $ 18.00 $ 1,260.00 THIS LINE TO PAY FROM FEDCFH6027 / 0816 **** FUNDING: Oral Health Workforce Grant **** CFDA: 93.236 **** THIS LINE TOTAL = $1,260.00 ***** Oral Health Data Collection, Dental Assistant - per hour/per provider Class-Item 948-28 9 1297.00 EA $ 70.00 $ 90,790.00 THIS LINE ADDED VIA CHANGE ORDER TO COVER SERVICES FROM 7/1/16 - 12/31/16 **** TO PAY FROM OHFCFH3998 **** THIS LINE TOTAL $90,790.00 *** Dental sealant services - per child Class-Item 948-28 10 77.00 EA $ 70.00 $ 5,390.00 THIS LINE ADDED VIA CHANGE ORDER TO COVER SERVICES FROM 7/1/16 - 12/31/16 **** TO PAY FROM FEDCFH1869 / 0917 **** THIS LINE TOTAL $5,390.00 ***Dental sealant services - per child Class-Item 948-28 11 23.00 EA $ 70.00 $ 1,610.00 THIS LINE ADDED VIA CHANGE ORDER TO COVER SERVICES FROM 7/1/16 - 12/31/16 **** TO PAY FROMDDNCFH3849 **** THIS LINE TOTAL $1,610.00 ***Dental sealant services - per child TOTAL: $ 327,730.00 Approved By: Cynthia Ronquillo Phone No.: (602) 364-1513 Page 3 of 3 ATTACHED TO AND A PART OF: Modified Purchase Order ADHS13-037845:6 OOH-Dental Sealant Services C-86-13-064-3-09 IN WITNESS WHEREOF, the parties agree to enter into this Agreement and its Amendments: FOR AND ON BEHALF OF MARICOPA COUNTY By_____________________________ Clint Hickman, Chairman, Board of Supervisors _______________________________ Date ATTEST: _______________________________ Clerk of the Board _______________________________ Date APPROVED AS TO FORM: _______________________________ Attorney for Maricopa County _______________________________ Date