ADHS PO NO 5 RE DENTAL SEALANT SERVICES.PDF

ARIZONA STATE CONTRACT
CONTRACT RELEASE
ProcureAZ Purchase Order No.: ADHS13-037845:5
Organizational Reference No.: PO0000000606
fssued: 07/10/2015
Vendor Number: 000010983 Arizona Department of Health Services
Maricopa County Public Health Bureau of Women and Children's Health
4041 N. Central Avenue, #1400 150 N. 18th Avenue, Suite 320
NI
im | Phoenix, AZ 85012 Phoenix, AZ 85007
US
Email: procure@azdhs.gov
Contract No.: ADHS13-037845
(602) 364-1400
Title: 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
(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--438 1--HS3038--HS73510-681 1---PHS-WCH----------- Payment Terms: Net 30
-HSA
Shipping Terms:
Delivery Calendar Day(s) A.R.O.: 0
ltem Description | Requisition Quantity Unit Unit Price Total
Class-ltem 948-28
1 864,00 EA $ 70.00 $ 60,480.00
THIS IS A REPLACEMENT PO FOR ADHS13-037845:4 /EB211743 ***
FEDERAL FUNDING CFDA 93.994 *** TO PAY FROM FEDCFH1869/ 0916
aeeexewe*** Dental sealant services - per child
Class-ltem 948-28
2 787,00 EA $ 70.00 § 55,090,00
NON FEDERAL FUNDING *** TO PAY FROM CHFCFH3998 - 2016 ***
Dental sealant services - per child
Class-ltem 948-28
3 76.00 EA $ 70.00 $ 5,320.00
NON FEDERAL FUNDING *** TO PAY FROM DDNCFH3849 - 2007
**Dental sealant services - per child
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ARIZONA STATE CONTRACT
i
CONTRACT RELEASE
Sa
Class-ltem 948-28
6 1.00 EA $ 43,323.00 $ 13,323.00
ADDED VIA CHANGE ORDER *** TO PAY FROM FEDCFH1869/ 0916 ***
FEDERAL FUNDING CFDA93.994 **************** Cost Effectiveness
Evaluation
Class-ltem 948-28
7 1.00 EA $ 13,323.00 $ 13,323.00
ADDED VIA CHANGE ORDER *** TO PAY FROM FEDCFH1869/ 0916 ***
FEDERAL FUNDING CFDA93,994 #2 Customer Satisfaction
Survey and Assessment Results
Class-item 948-28
8 4.00 EA $ 13,324.00 $ 13,324.00
ADDED VIA CHANGE ORDER *** TO PAY FROM FEDCFH1869/ 0916 ***
FEDERAL FUNDING CFDA93.994 ******""* Program Implementation
Analysis and Assessment
Class-ltem 948-28
9 350,00 EA $ 70.00 $ 24,500.00
LINE TO ADD ADDITIONAL FUNDING VIA CHANGE ORDER **** TO PAY
FROM FEDCFH1869 / 0916 **** Dental sealant services - per child
TOTAL: $ 185,360.00
Approved By: cynthia Ronquillo
Phone No.: (602) 364-1513
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Division of Public Health Services
Office of the Assistant Director
Public Health Prevention Services
zona
150 N. 18" Ave, Suite 320 DOUGLAS A, DUCEY, GOVERNOR
Departmen of Phoenix, Arizona 85007 CARA M. CHRIST, MD DIRECTOR
Health Services BBMsewabe
(602) 364-1494 FAX
11/23/2015
Vincent Torres, RDH, MHI
Program Supervisor, Office of Oral Health
Maricopa County Department of Public Health
1645 East Roosevelt St. Phoenix, Arizona 85006
RE: Contract # ADHS-13-037845
This letter is in reference to PO No. ADHS13-037845:5, contract term 1/1/2013 through 12/31/2017, for
Dental Sealant Services. The current PO funding is available for services provided 7/1/2015 through
12/31/2015.
The Office of Oral Health is looking forward to working with you.
Sincerely,
ctlf
pe
Julia Wacloff, RDH, MSPH
Chief, Office of Oral Health
Bureau of Women’s and Children’s Health
Arizona Department of Health Service
Health and Wellness for All Arizonans
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ATTACHED TO AND A PART OF: C-86-13-064-3-06
Purchase Order ADHS13-137845:5
Arizona Department of Health Services
Dental Sealant Services
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
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