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COST SUMMARY FORM <br />Total annual cost for inmate medical services. $1,663,732.00 <br />(Including Staffing Cost) <br />Breakdown information: <br />Staffing Cost $1.181,214 <br />Pharmaceutical cost $ 85.000.00 <br />Supply cost $ 86,250.00. <br />Other $311.268.00 <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 $150.00 <br />Cost per visit for Emergency Psychiatric Crisis 5$ 0.00 <br />Intervention & Evaluation <br />Monthly administrative fee for billing services $500.00 <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 />Correctional Managed Care Medical Corporation (714) 635-4700 <br />Complete Legal Name of Company Phone Number <br />1475 S. State College Blvd Anaheim, California 92806 <br />Business Address City/State Zip Code <br />Director of Finance Niza Guerrero <br />Signature of Authorized Agent - Title Printed Name