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PROPRIETARY <br />CORRECTIONAL <br />MANAGED CARE <br />COST SUMMARY FORM <br />Total annual cost for inmate medical services. $1,000.518.00 <br />(Including Staffing Cost Option "A") <br />Breakdown information: <br />Staffing Cost "A" $785,684. <br />Staffing Cost "B" $835,884. <br />Staffing cost "C" $885,260. <br />Pharmaceutical cost $ 30,000. <br />Supply cost $ 14,657. <br />Other $170,177. <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 <br />of Authorized <br />City/State <br />Director of <br />Rhoberta Paz <br />Zip Code <br />Printed Name <br />