PURCHASE ORDER RE DENTAL SEALANT SVC WITH ADHS.PDF

e-R-15-0k- C
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ARIZONA STATE CONTRACT
CONTRACT RELEASE
ProcureAZ Purchase Order No.: ADHS13-037845:4
Organizational Reference No.; E0211713
Issued; 01/08/2015
Vendor Number: 000010983 Arizona Department of Health Services
Maricopa County Public Health Bureau of Women and Children's Health
1001 N CENTRAL AVE 150 N. 18th Avenue, Suite 320
STE 500 Phoenix, AZ 85007
Phoenix, AZ 85004 US
Email: procuregazdhs.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: 15-99501-45301-6811— --- ------ Payment Terms: Net 30
Shipping Terms:
Solicitation (Bid) No.: Delivery Calendar Day(s)A.R.C.: 0
Item Description I Requisition Quantity Unit Unit Price Total
Class-Item 948-28
1 2029.00 EA $ 70.00 $ 142,030.00
PO EFFECTIVE 1/1/15 - 12/31/15 "** CONTRACT EFFECTIVE 1/1/14 -
12/31118 """ Dental sealant services per child ******* FUNDING LINE 99501/
45301/ 68111 15 (CFDA 93.9941
Class-Item 948-28
2 1200.00 EA $ 70.00 $ 84,000.00
Dental sealant services - per child "****** FUNDING LINE 73511/ 45301/
6611/12
Class-Item 948-28
3 142.00 EA $ 70.00 $ 9,940.00
Dental sealant services - per child ******" FUNDING LINE 94773/ 453011
6811/07

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ARIZONA STATE CONTRACT
CONTRACT RELEASE
Class-Item 948-28
4 1.00 EA $ 13,323,00 $ 13,323,00
Cost Effectiveness Evaluation *******FUNDING LINE 99501/ 45301/ 68111
15
Class-Item 948-28
5 1.30 EA $ 13,323.00 $ 13,323.00
Customer Satisfaction Survey and Assessment Results *******FUNDING
LINE 99501/ 45331/ 6811/15
Class-Item 948-28
6 1.00 EA $ 13,324.03 $ 13,324.00
Program Implementation Analysis and Assessment """*"'" FUNDING LINE
99501/ 45301/ 6811/ 15
Class-Item 948-28
7 154.00 HR $ 33.00 $ 5,082.00
Oral Health Data Collection, Dental Hygienist - per hour/per provider "*****
FUNDING LINE 99501/ 45000/ 8811/ 15
Class-Item 948-28
8 154.00 HR $ 18.00 $ 2,772.00
Oral Health Data Collection, Dental Assistant - per hour/per provider *****"*
FUNDING LINE 99501/ 45000/ 6811/ 15
TOTAL: $ 283.794.00
Approved By: Dee 1/Lahos
Phone No,: (602) 364-1425

C-86-13-064-3-05 ATTACHED TO AND A PART OF
Purchase Order ADHS13-037845:4
Dental Sealant Services
IN WITNESS WHEREOF, the parties agree to enter into this Contract 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