| Line Item Description: BPO for specialty oral services beyond the scope of general dentistry, at a rate based on the attached fee schedule not to exceed the amount of this purchase order. Ryan White is always the payor of last resort. Treatment plan must be authorized for an eligible client by the Ryan White Lead Agency AIDS Program Office before service is rendered. Each month, Dental Claim Form (DCF) must be properly filled out, and contain 1) a description and procedure codes of all delivered services for the invoice period, 2) tooth number for extraction, 3) total amount due per service rendered, 4) total invoice amount, 5) invoice number, 6) invoice date, 7) period of services, 8) along with an itemized signed statement for all dental claim forms. Payment request will only be AUTHORIZED for approved services that have been rendered, in accordance with the fee schedule. All monthly invoices are mailed to the Ryan White Lead Agency- AIDS Program Office within ten (10) days of the following month at Florida Department of Health, Attn: Lorie S. Johnson, 921 North Davis St. Bldg. A MC 39, Jacksonville, FL, 32209. Financial Consequences If the complete invoices are not received in our office by the 10th of the following month (as mentioned above) there will be financial consequences as follows: 1. 15 days of late submission: payment will be reduced by 10% 2. 30 days of late submission: payment will be reduced by 15% 3. Over 45 days of late submission: invoices will not be paid. |
| Method of Procurement: Exempt, health services including examination, diagnosis, treatment, prevention, medical consultation, or administration [s. 287.057(3)(e)5., F.S.] |
Line Split Details:
| Split Accounting Line Number: 1 |
| FLAIR Contract ID: |
| Org. Code and Description: 64361635240 - |
| Object Code and Description: 132002 - |
| Account Code: 64-20-2-141001-64200700-16-100777-00 |
| Split Amount: $15,000.00 |
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