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COST SUMMARY FORM <br /> ONE-YEAR PROPOSAL - 2002/2003 <br /> <br />Total annual cost for inmate medical services. $722~040.00 <br />(Including Staffing Cost Option "A") <br /> <br /> Breakdown information: <br /> Staffing Cost "A" (7% inc.) $559,049. <br /> Staffing Cost "B' $576~956. <br /> Pharmaceutical cost $ 40~600. <br /> Supply cost (10% inc.) $16,123. <br /> <br /> Other $106,268. <br />Additional Services (Section 13.0) <br /> <br /> Per unit repair cost for Dentures, Plates & Partials $200.00 <br /> <br /> Per study cost for mobile x-ray service $48./$58. <br /> (Including Radiologist interpretation, transcription <br /> and delivery) <br /> <br /> Cost per patient visit for Ophthalmology $150.00 <br /> Cost per patient visit for OB/GYN $150.00 <br /> <br /> Cost per visit for Emergency Psychiatric Crisis $50.00 <br /> Intervention & Evaluation <br /> <br /> Monthly administrative fee for billing services $400.00 <br /> <br />BIDDERS STATEMENT: I have read, understood and agree to the terms and conditions <br />on all pages of the Request for Proposal. Upon request, I will transfer and deliver goods <br />or services to the City in accordance with said terms and conditions. <br /> <br />Correctional Managed Care Medical Corporation <br />Complete Legal Name of Company <br /> <br />2040 S. Santa Cruz St., Suite 100 Anaheim, California <br />Bu;~Address J City/State <br /> <br /> DireetorofOperations <br />Sig'n~mre of A-uthoriz~d Age!l;l.~Title <br /> <br />(714) 937-0477 <br />Phone Number <br /> <br /> 92805 <br /> Zip Code <br /> <br />Rhoberta Paz <br />Printed Name <br /> <br /> <br />