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Exhibit A <br />COST SUMMARY FORM <br />Total annual cost for inmate medical services. <br />(Including Staffing Cost Option "A ") <br />Breakdown information: <br />Staffing Cost "A" <br />Staffing Cost `B" (optional) <br />Pharmaceutical cost <br />Supply cost <br />Other <br />Additional Services (Section 13.0) <br />Per unit repair cost for Dentures, Plates & Partials <br />Per study cost for mobile x -ray service <br />(Including Radiologist interpretation, transcription <br />and delivery) <br />Cost per patient visit for Ophthalmology <br />Cost per patient visit for OB /GYN <br />Cost per visit for Emergency Psychiatric Crisis <br />Intervention & Evaluation <br />Monthly administrative fee for billing services <br />(Optional) <br />PROPOSER'S STATEMENT: I have read, understood and agree to the terms and conditions on all pages of the <br />Request for Proposal. Upon request, I will transfer and deliver goods or services to the City in accordance with <br />said terms and conditions. <br />Complete Legal Name of Company <br />Business Address <br />Phone Number <br />City/State Zip Code <br />Signature of Authorized Agent — Title Printed Name <br />21 <br />25J -99 <br />