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<br />. <br /> <br />. <br /> <br />. <br /> <br />COST SUMMARY FORM <br />ONE-YEAR PROPOSAL - 2003/2004 <br /> <br />Total annual cost for inmate medical services. <br /> <br />$794.244.00 <br /> <br />Breakdown information: <br /> <br />Staffing Cost <br /> <br />$614.954. <br /> <br />Pharmaceutical cost <br /> <br />Supply cost <br /> <br />.$ 40.600. <br />$ 18.542. <br /> <br />Other <br /> <br />$120.148. <br /> <br />Additional Services (Section 13.0) <br /> <br />Per unit repair cost for Dentures, Plates & Partials <br /> <br />$200.00 <br /> <br />Per study cost for mobile x-ray service <br />(Including Radiologist interpretation, transcription <br />and delivery) <br /> <br />$85.00 <br /> <br />Cost per patient visit for Ophthalmology <br /> <br />$150.00 <br /> <br />Cost per patient visit for OB/GYN <br /> <br />$150.00 <br />$50.00 <br /> <br />Cost per visit for Emergency Psychiatric Crisis <br />Intervention & Evaluation <br /> <br />Monthly administrative fee for billing services <br /> <br />$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 />(714) 937-0477 <br />Phone Number <br /> <br />2040 S. Santa Cruz Street, Suite 100 <br />Business dd ess <br /> <br /> <br />Anaheim <br />City/State <br /> <br />92805 <br />Zip Code <br /> <br />Director of Operations <br /> <br />Rhoberta Paz <br />Printed Name <br /> <br />EXHIBIT A <br />