PO WITH ADHS RE DENTAL SLTS 08.PDF

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ARIZONA STATE CONTRACT
oe
CONTRACT RELEASE C.Dr.13-
ProcureAZ Purchase Order No.: ADHS13-037845:6
Organizational Reference No.: P00000066073
Issued: 01/11/2016
Vendor Number: 000010983 Arizona Department of Health Services
Maricopa County PubIlc Health Bureau of Women and Children's Health
4041 N. Central Avenue, #1400 El 150 N. 18th Avenue, Suite 320
Phoenix, AZ 85012 Phoenix, AZ 85007
US
Email: procure@azdhs.gov
Contract No.: ADHS13-037845 (602) 364-1400
Title: OOH - 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
IT
(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: 2016--OHFCFH3998-4381--HS3038--H873510-6811--6811-PHS-WCH---- Payment Terms: Net 30
------ --NSA
Shipping Terms:
Delivery Calendar Day(s)A.R.O.; 0
Item Description I 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 - Der child
Class-Item 948-28
2 1200.00 EA $ 70.00 $ 84,000.00
THIS LINE TO PAY FROM OHFCFH3998 """ FUNDING: Oral Health Fund
- Sealant *"*" CFDA: None **** THIS LINE TOTAL = $8,400.00 **"" Dental
sealant services - Der child
Class-Item 948-28
3 79.00 EA $ 70.00 $ 5,530.00
THIS LINE TO PAY FROM DDNCFH3849**** FUNDING: Oral Health
Donation Fund **** CFDA: None **** THIS LINE TOTAL = $5,530,00 *****
Dental sealaut seryiRes - Der child

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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
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
TOTAL: $ 278,730.00
Approved By: Cynthia Ronguillo
Phone No.: (602) 364-1513

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ATTACHED TO AND A PART OF:
Purchase Order ADHS13-037845:6
OOH-Dental Sealant Services
C-86-13-064-3-08
IN WITNESS WHEREOF, the parties agree to enter into this Agreement 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