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EXHIBIT A <br />COST SUMMARY FORM <br />Total annual cost for inmate medical services. $1,273,732.00 <br />Contract Year: 2012 <br />Breakdown information: <br />Staffing Cost $980,095. <br />Pharmaceutical cost $ 31,500. <br />Supply cost $ 26,250. <br />Other $235,887. <br />Additional Services (Section 13.0) <br />Per unit repair cost for Dentures, Plates & Partials $200.00 <br />Per study cost for mobile x -ray service $85.00 <br />(Including Radiologist interpretation, transcription <br />and delivery) <br />Cost per patient visit for Ophthalmology $150.00 <br />Cost per patient visit for OB /GYN $150.00 <br />Cost per visit for Emergency Psychiatric Crisis $50.00 <br />Intervention & Evaluation <br />Monthly administrative fee for billing services $400.00 <br />PROPOSER'S STATEMENT: I have read, understood and agree to the terms and <br />conditions on all pages of the Request for Proposal. Upon request, I will transfer and <br />deliver goods or services to the City in accordance with said terms and conditions. <br />Correctional Managed Care Medical Corporation (714) 528 -5800 <br />Complete Legal Name of Company Phone Number <br />4211 E. La Palma Avenue Anaheim, California 92807 <br />Business Address City /State Zip Code <br />ignature of <br />— Title <br />Director of <br />25B -5 <br />Rhoberta Paz <br />Printed Name <br />