CTR063756 A1 MARICOPA COUNTY (004).PDF

INTERGOVERNMENTAL AGREEMENT (IGA) 
 
Amendment  
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
 
150 N. 18th Ave., Suite 530 
Phoenix, Arizona 85007 
Contract No.: CTR063756 
IGA Amendment No: 1 
Procurement Officer: 
Gracie Torrecillas 
 
Page 1 of 2 
Revised 05/29/2024 
 
ORAL HEALTH DENTAL SEALANT SERVICES 
 
It is mutually agreed that the Intergovernmental Agreement referenced is amended as follows: 
 
1. Pursuant to Terms and Conditions, Provision Six (6) Contract Changes, subsection 6.1 Amendments, the Contract is 
hereby revised with the following: 
 
1.1. The Price Sheet is revised and replaced.  
 
 
 
 
 
 
ALL CHANGES ARE REFLECTED IN RED 
 
All other provisions of this agreement remain unchanged. 
Maricopa County Public Health 
 
 
Contractor Name:  
 
County Authorized Signature 
301 W Jefferson St 9th Floor 
 
 
Address:  
 
Print Name 
Phoenix 
Arizona 
85003 
 
 
City 
State 
Zip 
 
Title and Date 
 
Pursuant to A.R.S. § 11-952, the undersigned public agency attorney has determined 
that this Intergovernmental Agreement is in proper form and is within the powers and 
authority granted under the laws of Arizona 
This Intergovernmental Agreement Amendment shall be 
effective the date indicated.  The Public Agency is hereby 
cautioned not to commence any billable work or provide any 
material, service or construction under this IGA until the IGA has 
been executed by an authorized ADHS signatory.  
 
State of Arizona 
 
Signature 
Date 
 
Signed this                          day  of                                  2024. 
 
 
Print Name 
 
Procurement Officer 
 
 
Contract No.: CTR063756, which is an Agreement between public agencies, has been 
reviewed pursuant to A.R.S. § 11-952 by the undersigned Assistant Attorney, who has 
determined that it is in proper form and is within the powers and authority granted 
under the laws of the State of Arizona.  
 
 
 
Signature 
Date 
 
Assistant Attorney General 
Print Name

INTERGOVERNMENTAL AGREEMENT (IGA) 
 
Amendment  
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
 
150 N. 18th Ave., Suite 530 
Phoenix, Arizona 85007 
Contract No.: CTR063756 
IGA Amendment No: 1 
Procurement Officer: 
Gracie Torrecillas 
 
Page 2 of 2 
Revised 05/29/2024 
 
PRICE SHEET (Fixed Price) 
 
Type of Service 
Unit Rate 
Unit of Measure 
DENTAL SEALANT SERVICES 
Total cost per sealant to include the following:  
• 
Sealant dental staff and services including travel, supplies, training, 
indirect/direct costs. 
• 
Administrative personnel coordination of Sealant program and participation in 
an External Advisory Group. 
• 
Cost of Dentist providing standing orders for public health hygienist. 
$80.00 
Sealant applied 
per child 
FLUORIDE VARNISH SERVICES 
$8.00 
Per fluoride 
application 
ORAL HEALTH DATA COLLECTION, DENTAL HYGIENIST 
$30.00 
Per hour per 
Provider 
ORAL HEALTH DATA COLLECTION, DENTAL ASSISTANT 
$18.00 
Per hour per 
Provider 
SILVER DIAMINE FLUORIDE 
  $50.00 
Per Child 
TRAINING – DENTAL HYGIENIST 
  $30.00 
Per hour per 
Provider 
TRAINING - DENTAL ASSISTANT/COORDINATOR 
  $18.00 
Per hour per 
Provider 
PROGRAM OUTREACH 
Time spent on program outreach activities, participation in workgroups and all 
administrative duties listed under the coordinator tasks 
  $18.00 
Per Hour 
STATE STANDING ORDER DENTIST 
$1,500.00 
          Per Year 
Authorization for Provision of Services: Authorization for purchase of services under this Agreement shall be made only 
upon ADHS issuance of a Purchase Order that is signed by an authorized agent. The Purchase Order will indicate the 
Contract number and the dollar amount of funds authorized. The Contractor shall only be authorized to perform services up 
to the amount of the Purchase Order. No further obligation shall exist on behalf of ADHS unless: 
 
a) The Purchase Order is changed or modified with an official ADHS Procurement Change Order, and/or 
b) An additional Purchase Order is issued for purchase of services under this Contract.