HomeMy WebLinkAbout2003-238 r
CONTRACT BETWEEN 0 " oQ S
INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS
AND
STATE OF FLORIDA DEPARTMENT OF HEALTH
FOR OPERATION OF
THE INDIAN RIVER COUNTY HEALTH DEPARTMENT
CONTRACT YEAR 20034004
This agreement ("Agreement" ) is made and entered into between the State of Florida ,
Department of Health ( "State " ) and the Indian River County Board of County
Commissioners ( "County") , through their undersigned authorities , effective October 1 ,
2003 ,
RECITALS
A . Pursuant to Chapter 154 , F . S . , the intent of the legislature is to "promote ,
protect , maintain , and improve the health and safety of all citizens and visitors of this state
through a system of coordinated county health department services . "
Be County Health Departments were created throughout Florida to satisfy this
legislative intent through "promotion of the public' s health , the control and eradication of
preventable diseases , and the provision of primary health care for special populations . "
C . Indian River County Health Department ( "CHD " ) is one of the County Health
Departments created throughout Florida . It is necessary for the parties hereto to enter into
this Agreement in order to assure coordination between the State and the County in the
operation of the CHD .
NOW THEREFORE , in consideration of the mutual promises set forth herein , the
sufficiency of which are hereby acknowledged , the parties hereto agree as follows :
1 . RECITALS . The parties mutually agree that the forgoing recitals are true and
correct and incorporated herein by reference .
2 . TERM . The parties mutually agree that this Agreement shall be effective from
October 1 , 2003 , through September 30 , 2004 , or until a written agreement replacing this
Agreement is entered into between the parties , whichever is later, unless this Agreement
is otherwise terminated pursuant to the termination provisions set forth in paragraph 8 ,
below .
3 . SERVICES MAINTAINED BY THE CHD . The parties mutually agree that the CHD
shall provide those services as set forth on Part III of Attachment II hereof, in order
to
maintain the following three levels of service pursuant to Section 154 . 01 (2 ) , Florida
Statutes , as defined below:
a . " Environmental health services " are those services which are organized and
operated to protect the health of the general public by monitoring and regulating activities
in the environment which may contribute to the occurrence or transmission of disease .
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Environmental health services shall be supported by available federal , state and local
funds and shall include those services mandated on a state or federal level . Examples of
environmental health services include , but are not limited to , food hygiene , safe drinking
water supply , sewage and solid waste disposal , swimming pools , group care facilities ,
migrant labor camps , toxic material control , radiological health , occupational health .
b . " Communicable disease control services " are those services which protect the
health of the general public through the detection , control , and eradication of diseases
which are transmitted primarily by human beings . Communicable disease services shall
be supported by available federal , state , and local funds and shall include those services
mandated on a state or federal level . Such services include , but are not limited to ,
epidemiology, sexually transmissible disease detection and control , HIV/AIDS ,
immunization , tuberculosis control and maintenance of vital statistics .
C , " Primary care services " are acute care and preventive services that are made
available to well and sick persons who are unable to obtain such services due to lack of
income or other barriers beyond their control . These services are provided to benefit
individuals , improve the collective health of the public , and prevent and control the spread
of disease . Primary health care services are provided at home , in group settings , or in
clinics . These services shall be supported by available federal , state , and local funds and
shall include services mandated on a state or federal level . Examples of primary health
care services include , but are not limited to : first contact acute care services ; chronic
disease detection and treatment ; maternal and child health services ; family planning ;
nutrition ; school health ; supplemental food assistance for women , infants , and children ;
home health ; and dental services .
4 . FUNDING . The parties further agree that funding for the CHD will be handled as
follows :
a . The funding to be provided by the parties and any other sources are set forth in Part
II of Attachment II hereof. This funding will be used as shown in Part I of Attachment 11 .
L The State's appropriated responsibility (direct contribution excluding any state fees,
Medicaid contributions or any other funds not listed on the Schedule C) as provided in
Attachment ll , Part II is an amount not to exceed $2 , 706 , 196 State General
Revenue, Other State Funds and Federal Funds listed on the Schedule C) , The State's
obligation to pay under this contract is contingent upon an annual appropriation
by the Legislature .
h. The County' s appropriated responsibility (direct contribution excluding any fees,
other cash or local contributions) as provided in Attachment 11 , Part 11 is an amount not
to exceed $ 786 , 519 (amount listed under the "Board of County Commissioners Annual
Appropriations section of the revenue attachment) .
b . Overall expenditures will not exceed available funding or budget authority ,
whichever is less , (either current year or from surplus trust funds ) in any service category.
Unless requested otherwise , any surplus at the end of the term of this Agreement in the
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County Health Department Trust Fund that is attributed to the CHD shall be carried
forward to the next contract period .
c . Either party may establish service fees as allowed by law to fund activities of the
CHD . Where applicable , such fees shall be automatically adjusted to at least the
Medicaid fee schedule . Fees are listed in Attachment II Part II of this contract and in the
Environmental Health Fee Schedule that is provided by the Environmental Health Program
Office . The estimated annual environmental health fee revenues accruing to the County
Health Department Trust Fund are listed on Attachment VI .
d . Either party may increase or decrease funding of this Agreement during the term
hereof by notifying the other party in writing of the amount and purpose for the
change in funding . If the State initiates the increase/decrease , the CHD will revise
the Attachment II and send a copy of the revised pages to the County and the
Department of Health , Bureau of Budget Management . If the County initiates the
increase/decrease , the County shall notify the CHD . The CHD will then revise the
Attachment II and send a copy of the revised pages to the Department of Health ,
Bureau of Budget Management .
e . The name and address of the official payee to who payments shall be made is :
County Health Department Trust Fund
Indian River County
Attn : Accounts Receivable
1900 27th Street
Vero Beach , FI 32960-3383
5 , CHD DIRECTOR/ADMINISTRATOR . Both parties agree the director/administrator
of the CHD shall be a State employee or under contract with the State and will be under
the day-to-day direction of the Deputy State Health Officer. The director/administrator
shall be selected by the State with the concurrence of the County . The
director/administrator of the CHD shall insure that non -categorical sources of funding are
used to fulfill public health priorities in the community and the Long Range Program Plan .
A report detailing the status of public health as measured by outcome measures and
similar indicators will be sent by the CHID director/administrator to the parties no later than
October 1 of each year (This is the standard quality assurance "County-State Goal Achievement" report
located on the Department of Health Intranet).
6 , ADMINISTRATIVE POLICIES AND PROCEDURES . The parties hereto agree that
the following standards should apply in the operation of the CHD :
a . The CHD and its personnel shall follow all State policies and procedures , except to
the extent permitted for the use of county purchasing procedures as set forth in
subparagraph b . , below . All CHD employees shall be State or State-contract personnel
subject to State personnel rules and procedures . Employees will report time in the Client
Information System/Health Management Component compatible format by program
component as specified by the State .
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b . The CHD shall comply with all applicable provisions of federal and state laws and
regulations relating to its operation with the exception that the use of county purchasing
procedures shall be allowed when it will result in a better price or service and no statewide
Department of Health purchasing contract has been implemented for those goods or
services . In such cases , the CHD director/administrator must sign a justification therefore ,
and all county-purchasing procedures must be followed in their entirety, and such
compliance shall be documented . Such justification and compliance documentation shall
be maintained by the CHD in accordance with the terms of this Agreement . State
procedures must be followed for all leases on facilities not enumerated in Attachment IV .
c . The CHD shall maintain books , records and documents in accordance with those
promulgated by the Generally Accepted Accounting Principles (GAAP ) and Governmental
Accounting Standards Board (GASB ) , and the requirements of federal or state law . These
records shall be maintained as required by the Department of Health Policies and
Procedures for Records Management and shall be open for inspection at any time by the
parties and the public , except for those records that are not otherwise subject to disclosure
as provided by law which are subject to the confidentiality provisions of paragraph 6 . i . ,
below. Books , records and documents must be adequate to allow the CHD to comply with
the following reporting requirements :
i. The revenue and expenditure requirements in the Florida Accounting
System Information Resource ( FLAIR ) .
ii. The client registration and services reporting requirements of the
minimum data set as specified in the most current version of the Client
Information System/Health Management Component Pamphlet ;
iii. Financial procedures specified in the Department of Health ' s Accounting
Procedures Manuals , Accounting memoranda , and Comptroller' s
memoranda ;
iv. The CHD is responsible for assuring that all contracts with service
providers include provisions that all subcontracted services be reported
to the CHD in a manner consistent with the client registration and
service reporting requirements of the minimum data set as specified in
the Client Information System/Health Management Component
Pamphlet.
d . All funds for the CHD shall be deposited in the County Health Department Trust
Fund maintained by the state treasurer. These funds shall be accounted for separately
from funds deposited for other CHDs and shall be used only for public health purposes in
Indian River County .
e . That any surplus/deficit funds , including fees or accrued interest, remaining in the
County Health Department Trust Fund account at the end of the contract year shall be
credited/debited to the state or county, as appropriate , based on the funds contributed by
each and the expenditures incurred by each . Expenditures will be charged to the program
accounts by state and county based on the ratio of planned expenditures in the core
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contract and funding from all sources is credited to the program accounts by state and
county. The equity share of any surplus/deficit funds accruing to the state and county is
determined each month and at contract year-end . Surplus funds may be applied toward
the funding requirements of each participating governmental entity in the following year.
However, in each such case , all surplus funds , including fees and accrued interest , shall
remain in the trust fund until accounted for in a manner which clearly illustrates the amount
which has been credited to each participating governmental entity. The planned use of
surplus funds shall be reflected in Attachment ll , Part I of this contract , with special capital
projects explained in Attachment V .
f. There shall be no transfer of funds between the three levels of services without a
contract amendment unless the CHD director/administrator determines that an emergency
exists wherein a time delay would endanger the public's health and the Deputy State
Health Officer has approved the transfer. The Deputy State Health Officer shall forward
written evidence of this approval to the CHD within 30 days after an emergency transfer.
g . The CHD may execute subcontracts for services necessary to enable the CHD to
carry out the programs specified in this Agreement. Any such subcontract shall include all
aforementioned audit and record keeping requirements .
h . At the request of either party , an audit may be conducted by an independent CPA
on the financial records of the CHD and the results made available to the parties within
180 days after the close of the CHD fiscal year. This audit will follow requirements
contained in OMB Circular A- 133 and may be in conjunction with audits performed by
county government . If audit exceptions are found , then the director/administrator of the
CHD will prepare a corrective action plan and a copy of that plan and monthly status
reports will be furnished to the contract managers for the parties .
L The CHD shall not use or disclose any information concerning a recipient of
services except as allowed by federal or state law or policy.
J . The CHD shall retain all client records , financial records , supporting documents ,
statistical records , and any other documents ( including electronic storage media ) pertinent
to this Agreement for a period of five (5 ) years after termination of this Agreement . If an
audit has been initiated and audit findings have not been resolved at the end of five (5 )
years , the records shall be retained until resolution of the audit findings .
k . The CHD shall maintain confidentiality of all data , files , and records that are
confidential under the law or are otherwise exempted from disclosure as a public record
under Florida law. The CHD shall implement procedures to ensure the protection and
confidentiality of all such records and shall comply with sections 384 . 29 , 381 . 004 , 392 . 65
and 456 . 057 , Florida Statutes , and all other state and federal laws regarding
confidentiality . All confidentiality procedures implemented by the CHD shall be consistent
with the Department of Health Information Security Policies , Protocols , and Procedures ,
dated September 1997 , as amended , the terms of which are incorporated herein by
reference . The CHD shall further adhere to any amendments to the State ' s security
requirements and shall comply with any applicable professional standards of practice with
respect to client confidentiality.
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I . The CHD shall abide by all State policies and procedures , which by this reference
are incorporated herein as standards to be followed by the CHD , except as otherwise
permitted for some purchases using county procedures pursuant to paragraph 6 . b . hereof.
m . The CHD shall establish a system through which applicants for services and current
clients may present grievances over denial , modification or termination of services . The
CHD will advise applicants of the right to appeal a denial or exclusion from services , of
failure to take account of a client' s choice of service , and of his/her right to a fair hearing to
the final governing authority of the agency. Specific references to existing laws , rules or
program manuals are included in Attachment I of this Agreement .
n . The CHD shall comply with the provisions contained in the Civil Rights Certificate ,
hereby incorporated into this contract as Attachment III .
o . The CHD shall submit quarterly reports to the county that shall include at least the
following :
i. The DE385L1 Contract Management Variance Report and the DE580L1
Analysis of Fund Equities Report ;
ii. A written explanation to the county of service variances reflected in the
DE385L1 report if the variance exceeds or falls below 25 percent of the planned
expenditure amount . However, if the cumulative amount of the variance
between actual and planned expenditures does not exceed three percent of the
cumulative expenditures for the level of service in which the type of service is
included , a variance explanation is not required . A copy of the written
explanation shall be sent to the Department of Health , Bureau of Budget
Management .
p . The dates for the submission of quarterly reports to the county shall be as follows
unless the generation and distribution of reports is delayed due to circumstances beyond
the CND ' s control :
i. March 1 , 2004 for the report period October 1 , 2003 through
December 31 , 2003 ;
/is June 1 , 2004 for the report period October 1 , 2003 through
March 31 , 2004 ;
iii. September 1 , 2004 for the report period October 1 , 2003
through June 30 , 2004 ; and
iv. December 1 , 2004 for the report period October 1 , 2003
through September 30 , 2004 .
7 . FACILITIES AND EQUIPMENT . The parties mutually agree that :
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a . CHD facilities shall be provided as specified in Attachment IV to this contract and
the county shall own the facilities used by the CHD unless otherwise provided in
Attachment IV.
b . The county shall assure adequate fire and casualty insurance coverage for County-
owned CHD offices and buildings and for all furnishings and equipment in CHD offices
through either a self- insurance program or insurance purchased by the County.
c . All vehicles will be transferred to the ownership of the County and registered as
county vehicles . The county shall assure insurance coverage for these vehicles is
available through either a self- insurance program or insurance purchased by the County .
All vehicles will be used solely for CHD operations . Vehicles purchased through the
County Health Department Trust Fund shall be sold at fair market value when they are no
longer needed by the CHD and the proceeds returned to the County Health Department
Trust Fund ,
8 . TERMINATION .
a . Termination at Will . This Agreement may be terminated by either party without
cause upon no less than one- hundred eighty ( 180 ) calendar days notice in writing to the
other party unless a lesser time is mutually agreed upon in writing by both parties . Said
notice shall be delivered by certified mail , return receipt requested , or in person to the
other party' s contract manager with proof of delivery .
b . Termination Because of Lack of Funds . In the event funds to finance this
Agreement become unavailable , either party may terminate this Agreement upon no less
than twenty-four (24 ) hours notice . Said notice shall be delivered by certified mail , return
receipt requested , or in person to the other party' s contract manager with proof of delivery .
c . Termination for Breach . This Agreement may be terminated by one party, upon no
less than thirty (30 ) days notice , because of the other party' s failure to perform an
obligation hereunder. Said notice shall be delivered by certified mail , return receipt
requested , or in person to the other party' s contract manager with proof of delivery .
Waiver of breach of any provisions of this Agreement shall not be deemed to be a waiver
of any other breach and shall not be construed to be a modification of the terms of this
Agreement .
9 . MISCELLANEOUS . The parties further agree :
a . Availability of Funds . If this Agreement , any renewal hereof, or any term ,
performance or payment hereunder, extends beyond the fiscal year beginning July 1 ,
20049 it is agreed that the performance and payment under this Agreement are contingent
upon an annual appropriation by the Legislature , in accordance with section 287 . 0582 ,
Florida Statutes .
b . Modification . This Agreement and its Attachments contain all of the terms
and conditions agreed upon between the parties . Modifications of this Agreement shall be
enforceable only when reduced to writing and signed by all parties .
C , Contract Managers . The name and address of the contract managers for
the parties under this Agreement are as follows :
For the State : For the County :
Ernesto G . Rubio Jason Brown
Name Name
Business Manager Budget Manager
Title Title
1900 27th Street 1840 25t' Street
Vero Beach , FL 32960-3383 Vero Beach , FL 32960-3365
Address Address
772-794-7464 772-567-8000 ext 1214
Telephone Telephone
If different contract managers are designated after execution of this Agreement , the name ,
address and telephone number of the new representative shall be furnished in writing to
the other parties and attached to originals of this Agreement .
d . Captions . The captions and headings contained in this Agreement are for
the convenience of the parties only and do not in any way modify, amplify , or give
additional notice of the provisions hereof.
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In WITNESS THEREOF , the parties hereto have caused this 44 page agreement to be
executed by their undersigned officials as duly authorized effective the 1St day of October, 2003 .
BOARD OF COUNTY COMMISSIONERS STATE OF FLORIDA
FOR INDIAN RIVER COUNTY DEPARTMENT OF HEALTH
SIGNED BY SIGNED BY : '3, — C -c – es
NAME : Kenneth R . Macht NAME : ohn O . Ac
wunobi M . D . M . B .A.
TITLE : Chairman TITLE : Secretary
DATE : September 16 , 2003 DATE . 9 . 2 q . 0 -k
ATTESTED TO ..
SIGNED BY : SIGNED BY . a�
NAME : NAME . J an . Kline R. N . M . P . H .
TITLE . TITLE : CHD Director/Administrator
DATE : DATE : _ 9 S c>
APPROVED .
7 c tif 6rrmrin0 � trqtofl
APPROVED AS TO FORM
AND GAL SUFFICI CY
BY
MARIAN E . FELL
ASSISTANT COUNTY ATTORNEY
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ATTACHMENT
INDIAN RIVER COUNTY HEALTH DEPARTMENT
PROGRAM SPECIFIC REPORTING REQUIREMENTS AND PROGRAMS REQUIRING
COMPLIANCE WITH THE PROVISIONS OF SPECIFIC MANUALS
Some health services must comply with specific program and reporting requirements in addition to the Personal Health
Coding Pamphlet ( DHP 50-20 ) , Environmental Health Coding Pamphlet ( DHP 50-21 ) and FLAIR requirements because
of federal or state law, regulation or rule . If a county health department is funded to provide one of these services , it
must comply with the special reporting requirements for that service . The services and the reporting requirements are
listed below:
Service Requirement
1 . Sexually Transmitted Disease Requirements as specified in FAC 64D-3 and F . S . 384 and
Program the CHID Guidebook Internal Operating Policy STD 6 and 7 .
2 , Dental Health Monthly reporting on DH Form 1008' .
3 , Special Supplemental Nutrition Service documentation and monthly financial reports as
Program for Women , Infants specified in DHM 150-24* and all federal , state and county
and Children . requirements detailed in program manuals and published
procedures .
4 . Healthy Start/ Requirements as specified in the Healthy Start Standards
Improved Pregnancy Outcome and Guidelines 1998 and as specified by the Health Start
Coalitions in contract with each county health department .
5 . Family Planning Periodic financial and programmatic reports as specified
by the program office and in the CHID Guidebook , Internal
Operating Policy FAMPLAN 14*
6 . Immunization Periodic reports as specified by the department regarding
the surveillance/investigation of reportable vaccine
preventable diseases , vaccine usage accountability, the
assessment of various immunization levels and forms
reporting adverse events following immunization and
Immunization Module quarterly quality audits and duplicate
data reports .
7 . Chronic Disease Program Requirements as specified in the Community Intervention
Program (CIP ) and the CHID Guidebook .
8 . Environmental Health Requirements as specified in DHP 50-4* and 50-21 *
9 . HIV/AIDS Program Requirements as specified in Florida Statue 384 .25 and
64D-3 . 016 and 3 . 017 F .A. C . and the CHID Guidebook . Case
reporting on CDC Forms 50 .426 (Adult/ Adolescent) and
50 .42A ( Pediatric) . Socio-demographic data on persons
tested for HIV in CHID clinics should be reported on Lab
Request Form 1628 or Post-Test Counseling Form 1633 .
These reports are to be sent to the Headquarters HIV/AIDS
office within 5 days of the initial post-test counseling
appointment or within 90 days of the missed post-test
counseling appointment .
ATTACHMENT I (Continued )
10 . School Health Services HRSM 150-25", including the requirement for an annual plan
as a condition for funding .
`or the subsequent replacement if adopted during the contract period .
ATTACHMENT II
INDIAN RIVER COUNTY HEALTH DEPARTMENT
PART I . PLANNED USE OF COUNTY HEALTH DEPARTMENT TRUST FUND BALANCES
Estimated State Share Estimated County Share
of CHD Trust Fund of CHD Trust Fund
Balance as of 09/30/03 Balance as of 09/30/03 Total
1 . CHD Trust Fund Ending Balance 09/30/03 391 ,361 407 , 335 798 ,696
2 . Drawdown for Contract Year
October 1 , 2003 to September 30 , 2004 729190 589347 1309537
3 . Special Capital Project use for Contract Year
October 1 , 2003 to September 30 , 2004
4 . Balance Reserved for Contingency Fund 319 , 171 3489988 6689159
October 1 , 2003 to September 30 , 2004
Note : The total of items 2 , 3 and 4 must equal the ending balance in item 1 .
Funds designated for Special Capital Projects must be used for capital projects and durable goods without significant recurring costs .
Examples of projects
meeting this criteria include construction and renovation of facilities and associated infrastructure ; purchase of information system hardware/software
and
purchase of telecommunications equipment. Examples of items not meeting this criteria include grant funds for direct services such as tobacco
prevention
and provision of child safety seats; staff salaries; retirement obligations; rent/leases and funds held in anticipation of Medicaid paybacks
and/or budget
reductions. Special capital project amounts in "3" above should reflect the total amount of funds anticipated to be expended for special
capital projects during
the contract year. This includes funds to complete unfinished projects from previous years as well as for projects initiated during the
contract year. More
detailed Special Capital Project information , including description , cost by each project and anticipated completion date must be listed
in Attachment V.
Pursuant to 154 .02 , F . S . , At a minimum , the trurst fund shall consist of: an operating reserve , consisting of 8 . 5 percent of
the annual operating budget,
maintained to ensure adequate cash flow from nonstate revenue sources .
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ATTACHMENT III
INDIAN RIVER COUNTY HEALTH DEPARTMENT
CIVIL RIGHTS CERTIFICATE
The applicant provides this assurance in consideration of and for the purpose of obtaining federal grants , loans ,
contracts (except contracts of insurance or guaranty) , property, discounts , or other federal financial assistance to
programs or activities receiving or benefiting from federal financial assistance . The provider agrees to complete
the Civil Rights Compliance Questionnaire , DH Forms 946 A and B (or the subsequent replacement if adopted
during the contract period ) , if so requested by the department .
The applicant assures that it will comply with :
1 . Title VI of the Civil Rights Act of 1964 , as amended , 42 U . S . C . , 2000
Et seq . , which prohibits
discrimination on the basis of race , color or national origin in programs and activities receiving
or
benefiting from federal financial assistance .
2 . Section 504 of the Rehabilitation Act of 1973 , as amended , 29 U . S . C . 794 , which prohibits discrimination
on the basis of handicap in programs and activities receiving or benefiting from federal
financial
assistance .
3 . Title IX of the Education Amendments of 1972 , as amended , 20 U . S . C . 1681 et seq . , which
prohibits
discrimination on the basis of sex in education programs and activities receiving or benefiting from
federal financial assistance .
4 . The Age Discrimination Act of 1975 , as amended , 42 U . S . C . 6101 et seq . , which prohibits discrimination
on the basis of age in programs or activities receiving or benefiting from federal financial assistance .
5 . The Omnibus Budget Reconciliation Act of 1981 , P . L . 97-35 , which prohibits discrimination on the basis
of sex and religion in programs and activities receiving or benefiting from federal financial assistance .
6 . All regulations , guidelines and standards lawfully adopted under the above statutes . The applicant agrees
that compliance with this assurance constitutes a condition of continued receipt of or benefit from federal
financial assistance , and that it is binding upon the applicant, its successors , transferees , and assignees
for the period during which such assistance is provided . The applicant further assures that all contracts ,
subcontractors , subgrantees or others with whom it arranges to provide services or benefits to
participants or employees in connection with any of its programs and activities are not discriminating
against those participants or employees in connection with any of its programs and activities are not
discriminating against those participants or employees in violation of the above statutes , regulations ,
guidelines , and standards . In the event of failure to comply, the applicant understands that the grantor
may, at its discretion , seek a court order requiring compliance with the terms of this assurance or seek
other appropriate judicial or administrative relief, to include assistance being terminated and further
assistance being denied .
ATTACHMENT IV
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FACILITIES UTILIZED BY THE COUNTY HEALTH DEPARTMENT
Facility
Description Location Owned By
Clinic , Dental Vital Statistics , 1900 27th Street County of
Environmental Health , WIC , Vero Beach , FL 32960-3383 Indian River
Administrative Headquarters
39 , 200 sq . ft .
Gifford Health Center 469028 th Court School District of
7 , 600 sq . ft . Vero Beach , FL 32967- 1330 Indian River County
As of November 01 , 2003
Gifford Health Center 467528 th Court Indian River County
10 , 642 sq ft Vero Beach , FL 32967- 1330 Hospital District
Co-Located Site :
WIC 12196 County Road 512 Fellsmere Medical
Fellsmere , FL 32948-5463 Center
ATTACHMENT V
INDIAN RIVER COUNTY HEALTH DEPARTMENT
DESCRIPTION OF USE OF CHD TRUST FUND BALANCES
FOR SPECIAL CAPITAL PROJECTS, IF APPLICABLE
( From Attachment II , Part 1 )
Include detailed Special Capital Project information , including description , cost by each project and
anticipated completion date on this attachment .
No Special Capital Projects are planed for the year .
DESCRIPTION OF SPECIAL CONTRACTS
( From Attachment 11 , Part III )
Please list separately
Special contracts are contracts for services for which there are no comparable services in the
county health department core programs ; no service codes in Departmental coding manuals ;
projects that are locally designed and have no standard statewide set of services and therefore
cannot be accounted for within existing county health department programs . These contracts
are coded to FLAIR Level 5 of 599 and include some contracts formerly handled at the district
offices such as epilepsy , Project WARM , community planning and special family planning and
teen mother projects .
No special contracts are planned .
ATTACHMENT VI
INDIAN RIVER COUNTY HEALTH DEPARTMENT
ESTIMATE OF ENVIRONMENTAL HEALTH FEES
FISCAL YEAR 2003 - 2004
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM ' Accrukiq to C�
.
AMOUNT AMOUNT L4/L5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fun
PUBLIC SWIMMING POOLS AND BATHING PLACES
1 . Annual Permit - Up to (and including) 25,000 gallons 75.00 67.50 XX-360 DK 001145 000100 CD 81<000 1 20-2-141001
64200700 1306000000 6,413
1a. Transfer to headquarters 7. 50 99-910 SM 001205 000100 RV K3000 10-2-021042 64200600 00 1302000000
2. More than 25,000 gallons 160.00 144.00 XX-360 DK 001145 000100 CD 81<000 20-2-141001 64200700 1306000000
18, 152
2a. Transfer to headquarters 16 .00 99-910 SM 001205 000100 RV K3000 10-2-021042 64200600 00 1 1302000000
3. Exempted Condo Pools (over 32 units) 50 .00 45.00 XX-360 DK 001145 000100 CD 81<000 20-2-141001 64200700
1306000000 1 , 980
3a . Transfer to headquarters 5. 00 99-910 SM 001205 000100 RV K3000 10-2-021042 64200600 00 1302000000
OTHER FEES
Collected by the 13 delegated counties
Broward , Dade , Duval, Hillsborough , Lee, Manatee,
Collier, Palm Beach , Pinellas , Polk, Sarasota , Volusia, Escambia.
Permits and variances for Okaloosa, Santa Rosa, Walton , Bay,
Homes , and Washington Counties are processed by Escambia
County and variances and permits for Pasco County are processed
by Pinellas County as follows :
1 . Plan review (new construction) 275.00 275.00 XX-360 DK 001092 000100 CD 81<000 20-2-141001 64200700 1306000000
2. Plan review for modification of original construction 100 .00 100.00 XX-360 DK 001092 000100 CD 8K000 20-2-141001 64200700
1306000000
3. Plan/application review for bathing place development 275.00 275.00 XX-360 DK 001092 000100 CD 8K000 20-2-141001 64200700
1306000000
4. Initial operating permit 125.00 125.00 XX-360 DK 001092 000100 CD 8K000 20-2-141001 64200700 1306000000
5. Variance applications 240 .00 216.00 XX-360 DK 001092 000100 CD 8K000 20-2-141001 64200700 1306000000
5. a. Transfer to Headquarters 24 . 00 99-910 SM 001205 000100 RV K3000 10-2-021042 64200600 00 1302000000
All other counties are to send the fee to Bureau of Water
Programs in Tallahassee or the Environmental Engineering
section in Orlando as follows :
1 . Plan review ( new construction ) 275 . 00 275 . 00 00-000 SM 001044 000100 RV K3000 10-2-020142 64200600 00
1302000000
2 . Plan review for modification of original construction 100 . 00 100 .00 00-000 SM 001044 000100 RV K3000 10-2-020142
64200600 00 1302000000
3 . Plan/application review for bathing place development 275 . 00 275 . 00 00-000 SM 001044 000100 RV K3000 10-2-020142
64200600 00 1302000000
4 . Initial operating permit 125 . 00 125 . 00 00-000 SM 001044 000100 RV K3000 10-2-020142 64200600 00
1302000000
5 . Variance applications 240 .00 240 .00 00-000 SM 001044 000100 RV K3000 10-2-020142 64200600 00 1302000000
MOBILE HOME 8. RECREATIONAL VEHICLE PARKS
( FEES ARE PRORATED ON A QUARTERLY BASIS )
1 . Annual permit for 5 to 14 spaces 50.00 45.00 XX-354 DK 001113 000100 Cf8KOOO 20-2-141001 64200700 1306000000 6
75
1a. Transfer to headquarters 5 . 00 99-910 MP 001113 000100 R 10-2-021042 64200600 00 1302000000
3. 50 pe2. Annual permit for 15 to 171 spaces space XX-354 DK 001113 000100
C 20-2-141001 64200700 1306000000 59852
" Must use County Health Department 81 (01 -67) Page 1 9/9/2003
EN
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Accruing
to CHD`
AMOUNT AMOUNT L4/L5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund
2a. Transfer to headquarters 10% 99-910 MP 001113 000100 RV UQ000 10-2-021042 64200600 00 1302000000
3. Annual permit for 172 and above spaces 600 .00 540.00 XX-354 DK 001113 000100 CD 8K000 20-2-141001 64200700
1306000000 5, 940
3a. Transfer to headquarters 60 . 00 99-910 MP 001113 000100 RV 00000 10-2-021042 64200600 00 1302000000
MIGRANT LABOR CAMPS
1 . Annual permit for facilities with 550 occupants 125.00 125.00 XX-352 DK 001139 000100 CD 8K000 20-2-141001 64200700
1306000000 125
2. Annual permit for facilities with 51 -100 occupants 225.00 225.00 XX352 DK 001139 000100 CD 8K000 20-2-141001 64200700
1306000000 -
3. Annual permit for facilities with over 100 occupants 500 .00 500.00 XX-352 DK 001139 000100 CD 8K000 20-2-141001 64200700
" 1306000000 -
BIOMEDICAL WASTE GENERATORS
1 . Initial permit P55.00
55.00 XX364 DK 001140 000100 CD 8K000 20-2-141001 64200700 1306000000 550
2. Renewal of annual permit except physician office generating
less than 25lbs/30 days) postmarked by October 1 55.00 XX-364 DK 001140 000100 CD 8K000 20-2-141001 64200700 1306000000
6,820
2. Renewal of annual permit except fatalities generating
(less than 25lbs/30 days) postmarked after October 1 . 75.00 XX-364 DK 001140 000100 CD 81<000 20-2-141001 64200700
" 1306000000 750
3. Storage facilities permit postmarked by October 1 55.00 55.00 XX-364 DK 001140 000100 CD 8K000 20-2-141001 64200700
` 1306000000
3. Storage facilities permit postmarked after October 1 75.00 75.00 XX-364 DK 001140 1 000100 CD 81<000 20-2-141001 64200700
1306000000 75
4. Treatment facilities operating permit by October 55.00 55.00 XX-364 DK 001140 000100 CD 81<000 20-2-141001 [64200700
200700 1306000000
4. Treatment facilities operating permit after October 1 75.00 75.00 XX364 DK 001140 000100 CD 8K000 20-2-141001200700
1306000000
5. Transporter registration (one vehicle) postmarked by 10/1 55.00 55.00 XX364 DK 001140 000100 CD 8K000 20-2-141001 1306000000
5. Transporter registration (one vehicle) after 10/1 75.00 75.00 XX-364 DK 001140 000100 CD 8K000 20-2-141001200700
130600000055
6. Transporter registration additional vehicle 10 .00 10.00 XX-364 DK 001140 000100 CD 8K000 20-2-141001 200700
1306000000
TANNING FACILITIES
1 . Annual license fee 150.00 135.00 XX369 DK 001144 000100 CD 8K000 20-2-141001 64200700 1306000000 11755
1a . Transfer to headquarters 15 . 00 99-910 TN 001144 000100 RV R9000 10-2-021042 64200600 00 1302000000
2. Fee for each additional device 55.00 49.50 XX-369 DK 001144 000100 CD 81<000 20-2-141001 64200700 1306000000
891
2. a. Transfer to headquarters 5 . 50 99-910 TN 001144 000100 RV R9000 10-2-021042 64200600 00 1302000000
3. Late fee 25.00 25.00 XX-369 DK 001092 000100 CO 8K000 20-2-141001 642007001 1306000000 25
BODY PIERCING
1 . Annual License Fee 150.00 135.00 XX-349 DK 001149 000100 CD 81<000 20-2-141001 64200700 1306000000 270
1a. Transfer to headquarters 15. 00 99-910 iE 001149 000100 RV PIERS 10-2-021042 64200600 00 1302000000
2. Temporary Establishment 75.00 67.50 XX-349 DK 001149 000100 CD 81<000 20-2-141001 64200700 1306000000
2a. Transfer to headquarters 7 . 50 99-910 iE 001149 000100 RV PIERS 10-2-021042 64200600 00 1302000000
3. Late fee 100.00 100 .00 XX-349 DK 001149 000100 CD 81<000 20-2-141001 64200700 " 1306000000
FOOD ESTABLISHMENTS
1 . Annual Permit for Fraternal/Civic 160.00 144.00 XX-348 DK 001132 000100 CD 8K000 20-2-141001 64200700 1306000000
1 872
1a. Transfer to headquarters 16 . 00 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
2. Annual Permit School Cafeteria Operating for
9 months or less 130.00 117.00 XX-348 DK 001132 000100 CD 81<000 20-2-141001 64200700 1306000000 31159
2a. Transfer to headquarters 13. 00 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
3. Annual Permit School Cafeteria Operating for more
than 9 months 160.00 144 .00 )(X348 DK 001132 000100 CD 81<000 20-2-141001 64200700 1306000000
3a. Transfer to headquarters 16 . 00 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
" Must use County Health Department 1131 (01 -67) Page 2 9/9/2003
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM ACCruing
to C
AMOUNT AMOUNT L4/L5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund '-
4. Annual Permit for Hospital/Nursing Food Service 210.00 189.00 XX-348 DK 001132 000100 CD 81<000 20-2-141001 64200700
" 1306000000 1 ,512
4a. Transfer to headquarters 21 .00 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
5. Annual Permit for Movie Theaters 160.00 144.00 XX-348 DK 001132 000100 CD I 81<000 20-2-141001 64200700 1
1306000000 144
5a. Transfer to headquarters 16 . 00 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
6. Annual Permit for Jails/Prisons 210.00 189.00 XX-348 DK 001132 000100 CD 81<000 20-2-141001 64200700 1306000000
378
6a . Transfer to headquarters 21 . 00 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
7. Annual Permit for Bars/Lounges (Drink Service Only) 160.00 144.00 XX-348 DK 001132 000100 CD 81<000 20-2-141001 64200700
1306000000 1 872
7a. Transfer to headquarters 16 . 00 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
8. Annual Permit for Residential Facilities 110.00 99.00 XX-348 DK 001132 000100 CD 81<000 20-2-141001 64200700 `
1306000000 19683
8a. Transfer to headquarters 11 . 00 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
9 . Annual Permit for Child Care Centers without C&F license 85.00 76.50 XX-348 OK 001132 000100 CD 81<000 20-2-141001
64200700 1306000000
9a. Transfer to headquarters 8 . 50 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
10. Annual Permit for Limited Food Service 85.00 76.50 XX-348 DK 001132 000100 CD 81<000 20-2-141001 64200700
1306000000 383
10a. Transfer to headquarters 8 . 50 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
11 . Annual Permit Other Food Service 160 .00 144.00 XX-348 DK 001132 000100 CD 81<000 20-2-141001 64200700 "
1306000000 288
Ila. Transfer to headquarters 16 . 00 99-910 FP 001132 000100 RV 10000 10-2-021042 64200600 00 1302000000
12. Plan Review $35/hour $35/hour XX-348 DK 001092 000100 CD 81<000 20-2-141001 64200700 1306000000
70
13. Food Worker Training 10. 00 10 .00 XX-348 DK 001092 000100 CD 81<000 20-2-141001 64200700 ' 1306000000
14. Request for Inspection 40 .00 40.00 XX-348 DK 001092 000100 CD 81<000 20-2-141001 64200700 1306000000
15. Re-inspection (after the first reinspection ) 30 .00 30 .00 XX348 DK 001092 000100 CD 81<000 20-2-141001 64200700
1306000000
16 . Late Renewal 25 .00 25.00 XX-348 DK 001092 000100 CD 81<000 20-2-141001 64200700 1306000000 100
17 . Alcoholic Beverage Inspection Approval 30. 00 30 .00 XX-348 DK 001092 000100 CD 8K000 20-2-141001 64200700 '
1306000000 60
ONSITE SEWAGE DISPOSAL PROGRAM (OSTDS)
1 . Application for permitting of an onsite sewage 25.00 23.00 XX-361 DK 001092 000100 CD 81<000 20-2-141001 64200700
1306000000 39, 859
treatment and disposal system which includes
application and plan review for new and repair permits
1a. Transfer to headquarters 2. 00 99-910 ST 001203 000100 RV 1E000 10-2-021042 64200600 00 1302000000
2. Application for permitting of a new Performance-based treatment system 125.00 115 .00 XX-361 DK 001092 000100 CD 8K000 20-2-141001
64200700 1306000000
2a. Transfer to headquarters 10 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
3 . Site evaluation for a new system 60 .00 55. 20 XX-361 DK 001092 000100 CD 81<000 20-2-141001 64200700
1306000000 47, 527
3a. Transfer to headquarters 4 . 80 99-910 ST 001203 000100 RV lE000 10-2-021042 64200600 1 00 1 1302000000
4 . Site evaluation for a system repair or modification of system 40 .00 36 .80 XX-361 DK 001092 000100 CD 8K000 20-2-141001
64200700 1306000000 29, 330
4a. Transfer to headquarters 3. 20 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
5. Site re-evaluation , new or repair or modification 40 . 00 36 . 80 XX-361 DK 001092 000100 CD 81<000 20-2-141001
64200700 1306000000
5a. Transfer to headquarters 3 . 20 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
6 . Permit for new systems, or modification to system 55 .00 50 .60 XX-361 DK 001092 000100 rRV
8K000 20-2- 141001 64200700 1306000000 43, 567
6a. Transfer to headquarters 4 . 40 99-910 ST 001203 000100 1 E000 10-2-021042 64200600 00 1302000000
7 . New system or system modification installation inspection 55 . 00 50 .60 XX-361 DK 001092 000100 8K000 20-2-141001
64200700 ' 1306000000 47, 165
7a. Transfer to headquarters 4 .40 99-910 ST 001203 000100 1E000 10-2-021042 64200600 00 1302000000
8 . Research fee to be collected in addition , and concurrent with 5 . 00 5 . 00 99-910 RF 001201 000100 89000 10-2-021042
64200600 00 1302000000
" Must use County Health Department 11311 ( 01 -67 ) Page 3 9/9/2003
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Accruing
to CHD
AMOUNT AMOUNT L4/L5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund
the permit for a new system installation fee.
9. Repair permit issuance which includes inspection 50 .00 41 .40 XX361 DK 001092 000100 CD 81<000 20-2-141001 64200700
1306000000 30,925
9a. Transfer to headquarters 3 . 60 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
9b . Transfer to headquarters for training center 5. 00 99-910 TC 001067 000100 RV SEWTN 10-2-021042 64200600 00
1302000000
10. Inspection of system previously in use 50.00 46 .00 XX-361 DK 001092 000100 CD 81<000 20-2-141001 64200700
1306000000 3,680
10a. Transfer to headquarters 4 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
11 . Reinspection fee per visit for site inspections after system 25.00 23.00 XX361 DK 001092 000100 JRV
8K000 20-2-141001 64200700 1306000000
construction approval
11a. Transfer to headquarters 2 . 00 99-910 ST 001203 000100 1E000 10-2-02104264200600 00 1302000000
12. Installation reinspection of non-compliant system per 25 .00 23.00 XX-361 DK 001092 000100 81<000 20-2-141001
64200700 ' 1306000000 4,600
each site visit
12a . Transfer to headquarters 2. 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
13. System abandonment permit, includes permit 40. 00 36 .80 XX-361 DK 001092 000100 CD 81<000 20-2-141001 64200700
1306000000 2,208
issuance and inspection
13a. Transfer to headquarters 3 . 20 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
14 . Annual operating permit fee for systems in IM and 150 . 00 138 .00 XX-361 DK 001092 000100 CD 81<000 20-2-141001
64200700 1306000000 71038
equivalent areas, and for systems receiving commercial waste
14a. Transfer to headquarters 12. 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
15. Amendments or changes to the operating permit during 25.00 23 . 00 XX-361 DK 001092 000100 CD 81<000 20-2-141001
64200700 1306000000 46
the permit period per change or amendment
15a. Transfer to headquarters 2 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
16 . Aerobic treatment unit operating permit (biennial) 100 .00 92 . 00 XX-361 DK 001092 000100 CD 8K000 20-2-141001
64200700 ' 1306000000 184
16a. Transfer to headquarters 8 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
17 Biennial operating permit fee for performance-based treatment systems. 100 . 00 92 . 00 XX-361 DK 001092 000100 CD 8K000
20-2- 141001 64200700 1306000000
A prorated fee is to be charged beginning with second year of operation .
17a. Transfer to headquarters 8 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
18 Review of application due to proposed amendments or changes after 7500 69 . 00 XX-361 DK 001092 000100 CD I 81<000
20-2- 141001 64200700 1306000000
initial operating permit issuance for a performance-based treatment system
18a. Transfer to headquarters 6 .00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
19 Tank manufacturers inspection per annum 10000 50 . 00 XX-361 DK 001092 000100 CD 81<000 20-2- 141001 64200700
1306000000
19a . Transfer to headquarters 50 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
20 Septage disposal service permit per annum 50 . 00 4600 XX-361 DK 001092 000100 CD 81<000 20-2- 141001 64200700
1306000000 230
20a . Transfer to headquarters 4 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
21 Additional charge per pump out vehicle 2500 2300 XX-361 DK 001092 000100 CD 81<000 20-2- 141001 64200700
1306000000
21a. Transfer to headquarters 2 . 00 99-910 ST 001203 000100 RV 1E000 10-2-021042 64200600 00 1302000000
22 Portable or temporary toilet service permit per annum 5000 4600 XX -361 DK 001092 000100 CD 8K000 20-2- 141001
64200700 1306000000 92
22a. Transfer to headquarters 4 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
23 Additional charge per pump out vehicle 2500 2300 XX -361 DK 001092 000100 CD 81<000 20-2- 141001 64200700
1306000000 46
23a. Transfer to headquarters 2. 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
24 Septage stabilization facility inspection fee per annum 15000 13800 XX - 361DK 001092 000100 CD 81< 000 20 -2 - 141001
64200700 1306000000 92
" Must use County Health Department 181 ( 01 -67 ) Page 4 9/9/2003
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Accruing
to CH
AMOUNT AMOUNT 1.4/1.5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund
24a. Transfer to headquarters 12 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
24. Septage disposal site evaluation fee per annum 100.00 92.00 XX-361 DK 001092 000100 CD 81<000 20-2-141001 64200700
1306000000 23
24a. Transfer to headquarters 8 . 00 99-910 ST 001203 000100 RV 1 E000 10-2-021042 64200600 00 1302000000
24. Aerobic treatment unit maintenance entity permit per annum 25.00 23.00 XX-361 DK 001092 000100 CD 81<000 20-2-141001
64200700 1306000000
24a. Transfer to headquarters 2 . 00 99-910 ST 001203 000100 RV 1E000 10-2-021042 64200600 00 1302000000
25. Variance application for a single family residence per 150.00 75.00 XX-361 DK 001135 000100 CD 81<000 20-2-141001
64200700 1306000000
each lot or building site
25a. Transfer to headquarters 75 .00 99-910 CR 001204 000100 RV BY000 10-2-021042 64200600 00 1302000000
26. Variance application for a mufti-family or commercial 200.00 100.00 XX-361 DK 001135 000100 CD 81<000 20-2-141001 64200700
1306000000
building per each building site
26a. Transfer to headquarters 100 . 00 99-910 CR 001204 000100 RV BY000 10-2-021042 64200600 00 1302000000
27 . Inspection for construction of an injection well (FL Keys) 125 .00 125.00 XX361 DK 001092 000100 CD 81<000 1 20-2-141001
64200700 1306000000
FEE COLLECTED AT HEADQUARTERS - Onsite Sewage Program
1 . Application for Innovative product approval 500 . 00 For headquarters use only
2 . Application for registration including initial examination 75 . 00 For headquarters use only
3 . Initial registration 100 . 00 For headquarters use only
4 . Renewal registration 100 . 00 For headquarters use only
5 . Certificate of authorization each two year period 250 . 00 For headquarters use only
DRINKING WATER
1 . First Year Public Water Annual Operation Permit and 75.00 67.50 XX-357 DK 001166 000100 CD 81<000 20-2-141001
64200700 1306000000 68
Construction Permit - Limited Use
1a . Transfer to headquarters 7 . 50 99-910 64 001166 000100 RV M5000 10-2-021042 64200600 00 1302000000
2 . Second Year Public Water Annual Operation Permit - 39276
Limited Use 70 .00 63.00 XX-357 DK 001166 000100 CD 8K000 20-2-141001 64200700 " 1306000000
2a. Transfer to headquarters 7 . 00 99-910 64 001166 000100 RV M5000 10-2-021042 64200600 00 1302000000
3. Multi-Family Water Construction Permit - serving 3 or 4 40 .00 36.00 XX-357 DK 001165 000100 CD 81<000 20-2-141001 64200700
1306000000
non-rental residences
3a. Transfer to headquarters 4 . 00 99-910 64 001165 000100 RV M5000 10-2-021042 64200600 00 1302000000
4 . Initial Operating Permit Fee After March 31 of Any Year 35.00 31 .50 XX-357 DK 001166 000100 CD 8K000 20-2-141001
64200700 1306000000
4a . Transfer to headquarters 3 . 50 99-910 64 001166 000100 RV M5000 10-2-021042 64200600 00 1302000000
5 . Non-SDWA Lab Sample (Sample Collection/Review
of Analytical Resufts/Heafth Risk Interpretation ):
Bacterial Sample Collection 40 .00 40 .00 XX-357 DK 001142 000100 CD 81<000 20-2-141001 64200700 1306000000
Chemical Sample Collection 50 .00 50 .00 XX-357 DK 001142 000100 CD 8K000 20-2-141001 64200700 1306000000
Combined Chemical microbiological 55 . 00 55.00 XX-357 DK 001142 000100 CD 81<000 20-2-141001 64200700 1306000000
6 . Reinspection of Mufti-family Water System 25.00 25 .00 XX-357 DK 001092 000100 CD 81<000 20-2-141001 64200700
1306000000
7. Reinspection of Public Water System 40 . 00 40 .00 XX-357 DK 001092 000100 CD 81<000 20-2-141001 64200700
1306000000
8 . Delineated Area Clearance Fee 1 50. 00 50 .00 XX-357 DK 001092 000100 CD 8K000 20-2-141001 64200700 1306000000
9 . Limited Use Commercial Registered System 15.00 15 .00 XX-357 DK 001092 000100 CD 8K000 20-2-141001 64200700
' 1306000000 30
10 . Limited Use Commercial Public Water System 25 . 00 25 . 00 XX-357 DK 001092 000100 CD SK000 20-2-141001 64200700
1306000000 25
" Must use County Health Department 1131 (01 -67) Page 5 9/9/2003
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Accruing
to CH
AMOUNT AMOUNT L4/L5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund
Operating Permit Family Day Care Establishment
11 . Limited Use Commercial Public Water System Operating Permit 15.001 15.00 XX-357 DK 001092 000100 CD 81<000 20-2-141001 64200700
" 1306000000
Family Day Care Establishment After March 31 of Any Year.
Safe Drinking Water Act (Delegated Counties)
1 . Construction permit for each Category I through III treatment
plant, as defined in Rule 62-699.310 , F.A.C. . , with treatment
other than disinfection only.
a. Treatment plant - 5 MGD and above 71500 .00 79500.00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700
" 1306000000
b. Treatment plant - 1 MGD up to 5 MGD 61000 .00 61000 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700
1306000000
c. Treatment plant - 0.25 MGD up to 1 MGD 49000.00 41000 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700
" 1306000000
d . Treatment plant - 0. 1 MGD up to .025 MGD 2,000 .00 21000.00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001
64200700 ' 1306000000
e. Treatment plant - up to 0 . 1 MGD 1 ,000 .00 1 ,000.00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001
64200700 1306000000
2. Construction permit for each Category IV treatment plant, as
defined in Rule 62-699 . 310, F .A.C. . , with treatment other than
disinfection only.
a. Treatment plant - 5 MGD and above 71500 .00 7,500 . 00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700
1306000000
b . Treatment plant - 1 MGD up to 5 MGD 6 ,000 .00 6 ,000. 00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700
` 1306000000
c. Treatment plant - 0 .25 MGD up to 1 MGD 4 ,000 .00 4 ,000 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001
64200700 1306000000
d . Treatment plant - 0 . 1 MGD up to . 025 MGD 2,000 . 00 2,000 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001
64200700 1306000000
e. Treatment plant - 0 .01 up to 0. 1 MGD 1 ,000 . 00 1 ,000 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001
64200700rr3o
306000000
f. Treatment plant - up to 0 .01 MGD 400 .00 400 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2- 141001 64200700306000000
3 . Construction permit for each Category V treatment plant, as
defined in Rule 62-699 . 310 , F .A. C. . , - Disinfection Only
a. treatment plant - 5 MGD and above 5,000 . 00 5,000 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 642007006000000
b. Treatment plant - 1 MGD up to 5 MGD 3 ,000 .00 3,000 . 00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700
1306000000
c. Treatment plant - 0 .25 MGD up to 1 MGD 1 ,000 .00 1 ,000 . 00 XX-358 WC 001211 000100 CD SDWCH 2O-2- 141001
64200700 1306000000
d Treatment plant - 0 . 1 MGD up to .025 MGD 500 . 00 500 . 00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700
1306000000
e. Treatment plant - up to 0 . 1 MGD 300 . 00 300 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2- 141001 64200700
1306000000
Distribution and transmission systems, including raw water
lines into the plant, except those under general permit .
a . Serving a community public water system JE500 00 50000 XX-358 WC 1211 000100 CD SDWCH 2O-2-141001 64200700
1306000000
b . Serving a non-transient non-community public water systems 5000 35000 XX-358 WC 001211 000100 CD SDWCH 2O-2- 141001 642007001306000000
c Serving a non-community public water system 50 . 00 250 . 00 XX-358 WC 001211 000100 CD SDWCH 2O-2- 141001 64200700
1306000000
5 Construction permit for each public water supply well
a Well located in a delineated area pursuant to Chapter 62-524 ,
F A. C . 50000 500 . 00 XX -358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700 1306000000
b Any other public water supply well 25000 25000 XX -358 WC 001211 000100 CD SDWCH 2O-2- 141001 64200700 1306000000
6 Major modifications to systems that after the existing treatment
without expanding the capacity of the system and are not
considered substantial changes pursuant to
" Must use County Health Department IBI ( 01 -67 ) Page 6 9/9/2003
DESCRIPTION FEE DEPOSIT ORG ED OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Accruing
to CHQ "
AMOUNT AMOUNT L4/L5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund g "
ru
Rule 62-4.050(7) below.
a. 1MGD and above 21000.00 27000.00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700 1306000000
b. A MGD up to 1 MGD 11000.00 19000.00 XX-358 WC 001211 1 000100 CD ISDWCH 2O-2-141001 64200700 1306000000
c. 0.01 up to . 1 MGD 500.00 500 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700 1306000000
d . Up to 0.01 MGD 100 .00 100.00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700 1306000000
e. Lead and Copper Corrosion Fee 100 .00 100.00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700
1306000000
7. Minor modifications to systems that result in no change in the
treatment or capacity.
a. . 1 MGD and above 300 .00 300.00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700 1306000000
b. Up to 0. 1 MGD 100 .00 100.00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700 1306000000
8. Fines and Forfeitures Variable Variable XX-358 WC 012020 001200 CD SDWCH 2O-2-141001 64200700
1306000000
9 . General Penult Fee for any General Permit not specifically listed : 100 .00 100 .00 XX-358 WC 001211 000100 CD SDWCH
2O-2-141001 64200700Ig
a. General Permits requiring Professional Engineer or Professional 250 .00 250 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2-
141001 64200700
Geologist certification
a. General Permits not requiring Professional Engineer or 100 . 00 100 .00 XX-358 WC 001211 000100 CD SDWCH 2O-2-141001 64200700
Professional Geologist certification
Radioactive Materials Licenses - General
1 . Annual fee: static elimination devices $25. 00 For headquarters use only
2 . Annual fee: measuring, gauging and control devices $25.00 For headquarters use only
3. Annual fee: in vivo testing license $ 125 .00 For headquarters use only
4 . Annual fee: in vitro testing license $ 125 .00 For headquarters use only
5 . Annual fee: depleted uranium license $ 125 . 00 For headquarters use only
Radioactive Materials Licenses - Specific
Application Fees
1 Source Material.
a. Concentration of uranium from phosphate ores for the
production of uranium as "yellow cake" or powdered solid , $6 ,907 For headquarters use only
b . Concentration of uranium from phosphate ores for the
production of "green cake" or equivalent, moist or solid , $3 , 768
For headquarters use only
c All other specific source material licenses excluding depleted
uranium used as shielding and counterweights $544 For headquarters use only
2 Special Nuclear Material (SNM ).
a . SNM in sealed sources contained in devices in measuring systems. $653 For headquarters use only
b SNM not sufficient to form a critical mass , except as in 2 a ,
2c and 5 e $ 1 , 340 For headquarters use only
c SNM to be used as calibration and reference sources $205 For headquarters use only
3 Byproduct, naturally occurring or accelerator produced material
a Processing or manufacturing for commercial distribution or
industrial uses ; $ 2 , 923 For headquarters use only
b Processing or manufacturing and distribution of
" Must use County Health Department IBI ( 01 -67 ) Page 7 9/9/2003
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Accruing
to CH M#
AMOUNT AMOUNT L4/L5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT TrLmt Fund , _�`
radiopharmaceuticals. This category includes radiopharnacies. $29560 For headquarters use only
c. Industrial radiography performed only in an approved shielded
radiography installation, $ 1 ,558 For headquarters use only
d. Industrial radiography performed only at the address indicated
in the license, or at temporary job sites of the licensee; $ 19643 For headquarters use only
e. Radioactive materials in sealed sources for irradiation of
materials where the source is not removed from the shield and is
less than 10,000 curies; $605 For headquarters use only
f.(I ) Radioactive materials in sealed sources for irradiation of
materials when the source is not removed from the shield and is
greater than 10,000 curies and less than 100,000 curies, or where
the source is less than 100,000 curies and is removed from the
shield; $ 19414 For headquarters use only
(II ) Radioactive materials in sealed sources for irradiation of
materials when the source is equal to or greater than 100,000
curies and less than 1 ,000 ,000 curies; $3,659 For headquarters use only
(III ) Radioactive materials in sealed sources for irradiation of
materials when the source is greater than 1 ,000 ,000 curies; $99780 For headquarters use only
g . Distribution of items containing radioactive materials to
persons under a general license; $ 1 ,643 For headquarters use only
h. Distribution of exempt quantities or items containing naturally
occuring or accelerator produced material to persons exempt
from licensing; $ 19643 For headquarters use only TT
i. Well logging
(1 ) Sealed sources or sub-surface tracer studies $ 1 , 135 For headquarters use only
(II ) Sub-surface tracer studies and sealed sources $ 1 ,436 For headquarters use only
j. Nuclear Laundry-, $3,200 For headquarters use only
k. Industrial or medical research and development; $ 1 , 184 For headquarters use only
I.(1 ) Fixed and portable gauging devices $605 For headquarters use only
(11 ) In Vitro and clinical laboratory $725 For headquarters use only
(III ) Academic $978 For headquarters use only
IV) Possession of uranium or thorium , or their decay products, as
a result of mining or processing $978 For headquarters use only
(V) All other specific licenses except as otherwise noted $725 For headquarters use only
m . Licenses of broad scope
(1 ) Academic $3,200 For headquarters use only
(II ) Medical $3,200 For headquarters use only
(III ) Industrial or Research and Development $39200 For headquarters use only
n . Gas chromatography devices; $434 For headquarters use only
o. Reference or calibration sources equal to or less than one
"Must use County Health Department 61 (01 -67) Page 8 9/9/2003
DESCRIPTION FEE DEPOSIT ORGEO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Acing to CH
AMOUNT AMOUNT L4/1 CATEGORY GF-SF-FID ENTITY t COMPONENT Trust Fund . `
millicurie total; $314 For headquarters use only
p. Nuclear service licenses, such as leak testing, instrument
calibration, etc. ; $518 For headquarters use only
4. Waste disposal or processing
a. Commercial waste disposal or treatment facilities, including
burial or incineration; $275,842 For headquarters use only
b. All other commercial facilities involving compaction,
repackaging, storage or transfer, $27,084
For headquarters use only
c. Commercial treatment of radioactive materials for release to
unrestricted areas. $5,760 For headquarters use only
5. Medical use.
a. Teletherapy or high dose rate remote after loading devices; $ 1 ,414 For headquarters use only
b. Medical institutions including hospitals, except 5.a. and 5.e. ; $ 1 ,643 For headquarters use only
c. Private practice physicians except 5.a. and 5.d . ; $ 19184 For headquarters use only
d . Private practice physicians using only strontium 90 eye
applicators, materials authorized by Rule 64E-5 .631 , F .A. C. , and
materials authorized by Rule 64E-5 .630; F .A. C. $605 For headquarters use only
e. Nuclear powered pacemakers; $434 For headquarters use only
I. Mobile nuclear medicine services. $ 1 ,414 For headquarters use only
6 . Civil defense. $544 For headquarters use only
7 . Device, product, or sealed source safety evaluation .
a. Device evaluation , per device; $ 1 ,208 For headquarters use only
b . Sealed source design , per source. $528 For headquarters use only
Radioactive Materials Licenses - Specific
Annual Fees
1 . Source Material.
a. Concentration of uranium from phosphate ores for the
production of uranium as "yellow cake" or powdered solid , $ 11 ,942 For headquarters use only
b . Concentration of uranium from phosphate ores for the
production of "green cake" or equivalent, moist or solid ; $ 7 ,439 For headquarters use only
c. All other specific source material licenses excluding depleted
uranium used as shielding and counterweights $229 For headquarters use only
2 Special Nuclear Material (SNM ).
a . SNM in sealed sources contained in devices used in
measuring systems, $518 For headquarters use only
b SNM not sufficient to form a critical mass , except as in 2 a ,
above, and 2 c and 5 . e , below; $ 1 ,944 For headquarters use only
c SNM to be used as calibration and reference sources $ 109 For headquarters use only
3 Byproduct , naturally occurring or accelerator produced material
a Processing or manufacturing for commercial distribution or
" Must use County Health Department IBI ( 01 -67 ) Page 9 9/9/2003
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SIOCA FUND BUDGET IBI PROGRAM Accrut►KJ to
CHO
UNT
AMOUNT AMOL4/LS CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund ; --
industrial uses; $2,802 For headquarters use only
b. Processing or manufacturing and distribution of
radiopharmaceuticals. This category includes radiophar macies. $3,840 For headquarters use only
c. Industrial radiography performed only in an approved shielded
radiography installation, $29161 For headquarters use only
d . Industrial radiography performed only at the address indicated
in the license, or at temporary job sites of the licensee; $29657 For headquarters use only
e. Radioactive materials in sealed sources for irradiation of
materials where the source is not removed from the shield and is
less than 10,000 curies; $605 For headquarters use only
f (l ) Radioactive materials in sealed sources for irradiation of
materials when the source is not removed from the shield and is
greater than 10,000 curies and less than 100 ,000 curies, or where
the source is less than 100 ,000 curies and is removed from
the shield ; $ 1 ,630 For headquarters use only
(11 ) Radioactive materials in sealed sources for irradiation of
materials when the source is equal to or greater than 100,000 -4
curies and less than 1 ,000 ,000 curies; $39961 For headquarters use only
(III ) Radioactive materials in sealed sources for irradiation of
materials when the source is greater than 1 ,000,000 curies; $4,398 For headquarters use only
g. Distribution of items containing radioactive materials to persons
under a general license; $2, 150 For headquarters use only
h . Distribution of exempt quantities or items containing naturally
occurring or accelerator produced material to persons exempt
from licensing ; $2, 150 For headquarters use only
i. Well logging
(1 ) Sealed sources or sub-surface tracer studies $ 1 ,498 For headquarters use only
(II ) Sub-surface tracer studies and sealed sources $ 1 ,594 For headquarters use only
j. Nuclear Laundry; $5,651
For headquarters use only
k. Industrial or medical research and development; $ 1 ,474 For headquarters use only
I. (I ) Fixed and portable gauging devices $966 For headquarters use only
( ll ) In Vitro and clinical laboratory $918 For headquarters use only
(III ) Academic $ 1 , 171 For headquarters use only
IV ) Possession of uranium or thorium , or their decay products, as a
result of mining or processing $870 For headquarters use only
(V) All other specific licenses except as otherwise noted $ 1 ,002 For headquarters use only
m . Licenses of broad scope
(1 ) Academic $ 7 , 346 For headquarters use only
(11 ) Medical $5 ,474 For headquarters use only
(111 ) Industrial or Research and Development $4 ,568 For headquarters use only
" Must use County Health Department IBI ( 01 -67 ) Page 10 9/9/2003
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Accruing
to CHD �
AMOUNT AMOUNT L4/L5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund '' 3
n. Gas chromatography devices; $314 For headquarters use only
o. Reference or calibration sources equal to or less than one
millicurie total; $ 132 For headquarters use only
p. Nuclear service licenses, such as, leak testing , instrument
calibration, etc. ; $410 For headquarters use only
4. Waste disposal or processing
a. Commercial waste disposal or treatment facilities, including
burial or incineration; $250,555 For headquarters use only
b. All other commercial facilities involving compaction ,
repackaging , storage or transfer, $249971 For headquarters use only
c. Commercial treatment of radioactive materials for release to
unrestricted areas. $5,735 For headquarters use only
5. Medical use.
a. Teletherapy or high dose rate remote after loading devices; $ 19378 For headquarters use only
b. Medical institutions including hospitals, except category 5.a.
and 5.e. ; $ 1 ,908 For headquarters use only
c. Private practice physicians except category 5.a. and 5.d . ; $ 1 ,340 For headquarters use only
d . Private practice physicians using only strontium 90 eye
applicators, materials authorized by Rule 64E-5. 631 , F.A. C. , and
materials authorized by Rule 64E-5.630 ; F.A. C. $748 For headquarters use only
e. Nuclear powered pacemakers; $266 For headquarters use only
f. Mobile nuclear medicine services. $ 1 ,625 For headquarters use only
6 . Civil defense. $821 For headquarters use only
7 . Device, product, or sealed source safety evaluation .
a. Device evaluation , per device; NONE
b. Sealed source design , per source. NONE
Reclamation Fee 5% of annual For headquarters use only
licensing fee
X-Ray Machine Annual Registration Fees
1 . Medical, chiropractic, osteopathic, or naturopathic machines
- First tube $ 145 For headquarters use only
Each additional tube $85 For headquarters use only
2 Veterinary machines - First tube $50 For headquarters use only
Each additional tube $34 For headquarters use only
3 . Educational or industrial machines - First tube $47 For headquarters use only
Each additional tube $23 For headquarters use only
4 Dental or podiatry machines - First tube $31 For headquarters use only
Each additional tube $ 11 For headquarters use only
5 Medical accelerators $258 For headquarters use only
Each additional tube $ 148 For headquarters use only
" Must use County Health Department 81 ( 01 -67 ) Page 11 9/9/2003
DESCRIPTION FEE DEPOSIT ORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Accruing to
CHS
AMOUNT AMOUNT 1.4/1.5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund
6. Non-medical accelerators $81 For headquarters use only
Each additional tube $48 For headquarters use only
Radiologic Technologist Certifications
1 . Application and study guide (applicant also pays whatever fee
the testing service charges) $75 For headquarters use only
2. Application without study guide (applicant also pays whatever
fee the testing service charges) $50 For headquarters use only
3 . Application through endorsement (no test needed ) $45 For headquarters use only
4. Repeat examinations (applicant also pays whatever fee the
testing service charges) $35 For headquarters use only
5. Renewal - first category $55 For headquarters use only
Each additional category $40 For headquarters use only
6. Change in status from active to inactive $40 For headquarters use only
7. Late renewal fee $ 100 For headquarters use only
8 . Duplicate certificate $ 10 For headquarters use only
9. Listings and mailing labels, per name $0 .05 For headquarters use only
Setup charge $55 For headquarters use only
10 . Study guide $25 For headquarters use only
Pre and Post Mining Fees
1 . Gamma radiation exposure measurement ( 1 per acre) $7.50 For headquarters use only
2. Soil characterization measurement (1 per 20 acres) $320 For headquarters use only
3. Air monitoring measurements $ 165 For headquarters use only
4. Surface and ground water measurements $300 For headquarters use only
Low -Level Radioactive Waste Inspection Fee
Cubic foot of waste shipped (minimum fee = $50 per shipment) $ 1 .95 For headquarters use only
Low-Level Radioactive Waste Transport Fee
Annual transport permit $ 100 For headquarters use only
Water Analysis Fees
1 . Gross alpha $28 For headquarters use only
2. Gross beta $28 For headquarters use only
3. Radium 226 $ 110 For headquarters use only
4. Radium 228 $ 110 For headquarters use only
5. Uranium $ 110 For headquarters use only
6. Tritium $40 For headquarters use only
7. Strontium 89, strontium 90 $95 For headquarters use only
8. Iodine 131 $ 110 For headquarters use only
9. Photon emitters $ 128 For headquarters use only
Laboratory Certification Fees
1 . Safe drinking water certification $500 For headquarters use only
2. Clean water certification $500 For headquarters use only
"Must use County Health Department 1131 (01 -67) Page 12 9/9/2003
DESCRIPTION FEE DEPOSITORG EO OBJECT REVENUE SI OCA FUND BUDGET IBI PROGRAM Accruing
t0 CHD,
AMOUNT AMOUNT 1.4/1.5 CODE CATEGORY GF-SF-FID ENTITY COMPONENT Trust Fund
3. Resource conservation recovery $500 For headquarters use only
4. Field of testing application $200 For headquarters use only
" Must use County Health Department IN ( 01 -67 ) Page 13 9/9/2003
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -- Effective Oct 1 , 2003
VISIT DESCRIPTION E/M CODES 0% - A 17% - B 33% - C 50% - D 67% - E 83% - F 100% - G COST
Medical Visit - New Patient
99201 Level One $0 .00 $7 . 65 $ 16. 50 $22 . 50 $30 . 15 $37 . 35 $45 . 00 $45 . 00
99202 Level Two $0 . 00 $7 . 65 $ 16 . 50 $25 . 00 $33 . 50 $41 . 50 $50 .00 $50 . 00
99203 Level Three $0 . 00 $9 . 35 $ 18 . 15 $27 . 50 $36. 85 $45. 65 $55 . 00 $55 . 00
99204 Level Four $0 . 00 $ 10 .20 $ 19 . 80 $30 .00 $36 . 85 $49 . 80 $60 .00 $60 . 00
99205 Level Five $0 .00 $ 11 . 05 $ 18. 15 $32 .50 $43 . 55 $53 . 95 $65.00 $65 . 00
Nurse Protocol $0 . 00 $7 . 65 $ 14 . 85 $22 . 50 $30 . 15 $37 .35 $45 . 00 $45. 00
Medical Visit - Established Patient
99211 Level One $0 . 00 $5. 10 $9 . 90 $ 15 .00 $20 . 10 $24 . 90 $30 . 00 $30 . 00
99212 Level Two $0 . 00 $5 . 95 $ 11 . 55 $ 17 . 50 $23 .45 $29 . 05 $35 . 00 $35 . 00
99213 Level Three $0 . 00 $6 . 80 $ 13 . 20 $20 . 00 $26 . 80 $33 . 20 $40 . 00 $40 . 00
99214 Level Four $0 . 00 $7 . 65 $ 14 . 85 $22 . 50 $30 . 15 $37 . 35 $45 . 00 $45 . 00
99215 Level Five $0 . 00 $8. 50 $ 16 . 50 $25 .00 $33 . 50 $41 . 50 $50 . 00 $50 . 00
Nurse Protocol $0 .00 $5 . 10 $9 . 90 $ 15 . 00 $20 . 10 $24 . 90 $30 . 00 $30 . 00
School/Work Physicial (CHCU )* $0 . 00 $5. 10 $9. 90 $ 15 . 00 $20 . 10 $24 . 90 $30 . 00 $30 . 00
Immigration Physical** $0 .00 $8 . 50 $ 16 . 50 $25 . 00 $33 . 50 $41 . 50 $50 . 00 $50 . 00
* Medicaid "Child Health Check-Up" and routine physical includes applicable in-house laboratory services .
Must be established primary care patient to receive physical on sliding fee scale .
**Does not include immunizations or contracted laboratory services
Out of County Primary Care Fee* $0 . 00 $30 . 00 $30 . 00 $30 . 00 $30 . 00 $30 . 00 $30 . 00 $30 . 00
*Deposit for services . Must be paid prior to clinic visit with balance due at completion of visit.
Family Planning
Initial/Annual Family Planning Visit* $0 . 00 $ 13. 60 $26 .40 $40 . 00 $53 .60 $66 .40 $80 . 00 $80 . 00
Subsequent Family Planning Visit(s ) $0 . 00 $3 .40 $6 . 60 $ 10 . 00 $ 13 .40 $ 16 . 60 $20 . 00 $20 . 00
* Includes all applicable laboratory services
9/9/2003CLFEE2003-04 Page 1 of 7
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -- Effective Oct 1 , 2003
Procedures not included in office visit 0% = A 17% - B 33% - C 50% - D 67% - E 83% - F 100% -
G COST
IUD Insertion $0 . 00 $4 . 25 $8 .25 $ 12 . 50 $ 16. 75 $20 . 75 $25 . 00 $25 .00
IUD Removal $0 .00 $2 . 04 $3. 96 $6 . 00 $8 . 04 $9. 96 $ 12 . 00 $ 12 . 00
Norplant Removal (medical necessity) $0 . 00 $ 17.00 $33 . 00 $50 . 00 $67. 00 $83 .00 $ 100 . 00 $ 100 . 00
Ingrown Toenail Treatment $0 . 00 $ 1 . 02 $ 1 . 98 $3. 00 $4 . 02 $4. 98 $6 . 00 $6 . 00
Wart Treatment $0 .00 $ 1 . 70 $3. 30 $5 . 00 $6 . 70 $8 . 30 $ 10 .00 $ 10 . 00
Wart Treatment with Nitrogen Freeze $0 . 00 $3 .40 $6 . 60 $ 10 .00 $ 13.40 $ 16 . 60 $20 . 00 $20 . 00
Incision and Drainage $0 . 00 $4 . 25 $8 .25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00
Respiratory Treatment $0 .00 $4 .25 $8 . 25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00
Diaphragm Fitting $0 . 00 $4 . 25 $8 .25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00
Colposcopy (with biopsy) $0 . 00 $5. 95 $ 11 . 55 $ 17 . 50 $23 .45 $29 . 05 $35 . 00 $35 . 00
Colposcopy (without biopsy) $0 . 00 $2 . 55 $4 . 95 $7.50 $ 10 .05 $ 12 .45 $ 15 . 00 $ 15 . 00
Procedures with set charges 0% = A 17% - B 33% - C 50% - D 67% - E 83% - F 100% - G COST
Chest X-Ray $0 . 00 $5 .44 $ 10 . 56 $ 16 . 00 $21 .44 $26 . 56 $32 . 00 $32 . 00
HIV ( Includes Pre/Post Counseling ) $0 .00 $4 .25 $8 . 25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00
Tubal Ligation
Surgical $ 1 ,000 . 00 $ 19000 . 00 $ 19000 . 00 $ 1 , 000 .00 $ 1 ,000 . 00 $ 1 ,000 .00 $ 19000 . 00 $ 19000
.00
Band or Clip $ 19000 . 00 $ 10000 .00 $ 19000 . 00 $ 1 ,000 . 00 $ 1 ,000 . 00 $ 1 ,000 . 00 $ 1 ,000 .00 $ 19000
. 00
Postpartum $ 1 , 000 . 00 $ 19000 . 00 $ 19000 . 00 $ 1 ,000 . 00 $ 19000 .00 $ 11000 .00 $ 1 ,000 . 00 $ 19000
.00
Post Cesarean $ 1 ,000 . 00 $ 19000 . 00 $ 1 ,000 . 00 $ 1 , 000 . 00 $ 1 ,000 . 00 $ 19000 . 00 $ 19000 . 00 $
19000 . 00
Inpatient Per Diem $ 1 , 000 . 00 $ 19000 .00 $ 19000 . 00 $ 19000 . 00 $ 19000 . 00 $ 1 ,000 . 00 $ 19000 . 00 $
19000 . 00
Outpatient Fee $ 1 ,000 . 00 $ 1 ,000 . 00 $ 19000 . 00 $ 19000 .00 $ 1 ,000 .00 $ 11000 .00 $ 19000 .00 $ 19000
. 00
Vasectomy $450 . 00 $450 . 00 $450 . 00 $450 . 00 $450 . 00 $450 . 00 $450 . 00 $450 . 00
Nutritional Counseling - per hour $0 . 00 $4 . 25 $8 . 25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00
PPD TB Test $0 .00 $ 1 . 70 $3 . 30 $5.00 $6 . 70 $8 . 30 $ 10 .00 $ 10 . 00
Immunizations 0% - A 17% - B 33% - C 50% - D 67% - E 83% - F 100% - G COST
Influenza $0 .00 $3 . 06 $5 . 94 $9 . 00 $ 12 . 06 $ 14 . 94 $ 18 . 00 $ 18 . 00
Pneumococcal Pneumonia $0 .00 $3 .40 $6. 60 $ 10 . 00 $ 13 .40 $ 16 .60 $20 . 00 $20 . 00
Measles/Mumps/Rubella $0 . 00 $6 . 80 $ 13 . 20 $20 .00 $26.80 $33 . 20 $40 . 00 $40 .00
Tetanus $0 . 00 $2 . 55 $4 . 95 $7 . 50 $ 10 . 05 $ 12 .45 $ 15 . 00 $ 15 . 00
Injected Polio Vaccine $0 . 00 $5 . 10 $9. 90 $ 15 . 00 $20 . 10 $24 . 90 $30 . 00 $30 . 00
Varivax (Chicken Pox) $0 .00 $ 10 .20 $ 19 . 80 $30 .00 $40 .20 $49 . 80 $60 . 00 $60 . 00
Meningococcal $0 . 00 $ 11 . 05 $21 .45 $32 . 50 $43 . 55 $53 . 95 $65. 00 $65 . 00
9/9/2003CLFEE2003-04 Page 2 of 7
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -- Effective Oct 1 , 2003
Immunizations (Continued) 0% = A 17% - B 33% - C 50% - D 67% - E 83% m F 100% - G COST
Rabies Vaccine (per injection ) $ 125.00 $ 125 . 00 $ 125 . 00 $ 125 . 00 $ 125.00 $ 125 .00 $ 125.00 $ 125.
00
RIG - Per 2cc Vial $ 150 . 00 $ 150 .00 $ 150 . 00 $ 150 .00 $ 150 . 00 $ 150 .00 $ 150 . 00 $ 150
.00
Hepatitis A Vaccine (per injection ) $0 . 00 $5. 10 $9. 90 $ 15 . 00 $20 . 10 $24 . 90 $30 . 00 $30 . 00
Hepatitis B Vaccine (per injection ) $0 .00 $5 . 95 $ 11 . 55 $ 17 . 50 $23 .45 $29.05 $35. 00 $35. 00
Twinrix -Hep A & B (per injection ) $0 . 00 $8. 50 $ 16 . 50 $25.00 $33. 50 $41 . 50 $50 . 00 $50 . 00
Per CDC guidelines , vaccine for childhood immunizations are covered under the Vaccine for Children Program and are provided at
no cost
to children age 0- 18. Charges for communicable disease control issues will be waived with authorization . Tetanus availability
may be limited
due to supply.
Travel Immunizations (Sliding Fee Scale does not apply -- Per Injection)
Travel Immunization Consult Visit $25 .00
Hepatitis B Vaccine $35 . 00
Hepatitis A Vaccine $30 . 00
Hepatitis A Vaccine - Children $30 . 00
Twinrix (Hep A & B ) $50 . 00
Hep A Immune Globulin* $30 . 00 Per 2 ml dose
Lyme Vaccine $70 . 00
Meningococcal $65 . 00
Tetanus $ 15 .00
Typhoid $45 . 00
Yellow Fever $ 75 . 00
*As available
Dental Services (Sliding Fee Scale does not apply)
Oral Examination $ 16 . 00 Pin Retention - Per Tooth $2 . 00
Emergency Examination $ 15 . 00 Pulp Cap Direct* $ 11 .00
Periapical First Film $4 .00 Pulp Cap Indirect* $9 . 00
Periapical Addt'I Film $3 . 00 Therapeutic Pulpotomy* $40 . 00
Bitewing - Single Film $6 . 00 Space Maintainer - Fixed Unilateral $60 . 00
Bitewing - Two Films $9.00 Space Maintainer - Fixed Bilateral $ 100 . 00
Bitewing - Four Films $ 11 . 00 Single Tooth Extraction (Child ) $ 10 . 00
Prophylaxis $ 14 . 00 Single Tooth Extraction (Adult) $35 .00
Sedative Filling $ 15. 00 Addt'I Tooth Extraction (Child ) $ 10 . 00
Dental Services - Continued (Sliding Fee Scale does not apply)
Temporary Filling $36 . 00 Arch Scaling $40 . 00
Oral Hygiene Instructions $6 . 00 Alueolectomy $ 70 . 00
9/9/2003CLFEE2003-04 Page 3 of 7
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -- Effective Oct 1 , 2003
Topical Application of Fluoride $ 10 . 00 Addt'I Tooth Extraction (Adult) $25 . 00
Sealant - Per Tooth $ 10.00 Crown Build-Up $70.00
Amalgam - One Surface $31 . 00 Root Removal (Exposed Roots - Child ) $28 . 00
Amalgam - Two Surface $41 . 00 Root Removal (Exposed Roots - Adult) $40 .00
Amalgam - Three Surface $51 .00 Removal of Impacted Tooth (Soft Tissue ) $55. 00
Amalgam - Four or more $61 . 00 Removal of Impacted Tooth ( Partially Bony) $67 . 00
Resin - One Surface $31 .00 Removal of Impacted Tooth (Completely Bony) $67.00
Resin - Two Surface $41 . 00 Surgical Removal of Tooth $55 . 00
Resin - Three Surface $51 .00 Root Canal (Anterior) $ 148.00
Resin - Four or more $72 . 00 Root Canal (Bicuspid ) $ 190 . 00
Resin Elected - One Surface** $45 . 00 Root Canal ( Molar) $235 . 00
Resin Elected - Two Surface** $55.00 Permanent Crown* $225 . 00
Resin Elected - Three Surface** $70 . 00 Gold Crown ( Posterior)* $250 .00
Resin Elected - Four or more** $85. 00 Gold Tooth for Denture* $ 150 . 00
Anterior Composite Resin Crown $50 . 00 Upper Denture ( Full )* $310 .00
Recement Crown $ 15 . 00 Lower Denture ( Full )* $310 . 00
Prefabricated Steel Crown $56 . 00 Cast Metal Partial (Upper/Lower)* $350 .00
Adult Cleaning/Scaling $32 . 00 Acrylic Partial ( Upper/Lower)* $ 166 . 00
Root Planning per Quadrant $40 . 00 Acrylic Flipper* $ 125 . 00
*All lab fees must be collected before work can begin .
**If client requests Resin fillings .
Laboratory Services 0% - A 17% - B 33% - C 50% - D 67% - E 83% - F 100% - G COST
IN -HOUSE LAB
EKG $0 . 00 $4 . 25 $8 . 25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00
FBS ( Fasting Blood Sugar) $0 . 00 $0 . 85 $ 1 . 65 $2 . 50 $3 . 35 $4 . 15 $5 . 00 $5 . 00
Hematocrit $0 . 00 $2 . 38 $4 . 62 $7. 00 $9 . 38 $ 11 .62 $ 14 . 00 $ 14 . 00
KOH Slide $0 .00 $ 1 . 11 $2 . 15 $3. 25 $4 . 36 $5 .40 $6 . 50 $6 . 50
Pregnancy Test - Urine $0 . 00 $ 1 . 36 $2 .64 $4 . 00 $5 . 36 $6 . 64 $8 . 00 $8 . 00
Rapid Strep $0 . 00 $0 . 51 $0 . 99 $ 1 . 50 $2 . 01 $2 .49 $3 . 00 $3 . 00
Urine Dip Sticks $0 . 00 $0 . 51 $0 .99 $ 1 . 50 $2 . 01 $2 .49 $3 . 00 $3 . 00
Wet Mount $0 . 00 $ 1 . 02 $ 1 . 98 $3 . 00 $4 . 02 $4 .98 $6 . 00 $6 . 00
9/9/2003CLFEE2003-04 Page 4 of 7
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -- Effective Oct 1 , 2003
Contracted Laboratory Services
Maximum charge of $ 12 .00* $0 . 00 $2 .04 $3 . 96 $6.00 $8.04 $9 . 96 $ 12 . 00 $ 12 .00
*Includes $5 . 00 Lab Sample Collection Fee
NOTE : Tests which exceed a charge of $20 .00 will be billed individually on sliding fee scale percentage based on IRCHD
cost of lab service .
Pharmacy
Pharmaceutical items will be billed on a per pill basis at IRCHD cost. An itemized pharmaceutical listing is updated weekly
and is available
by contacting the cashier. Items received from the State Pharmacy as in-kind donation at no cost to IRCHD will not be
charged to the patient.
Medical Records Fees
Copy of Medical Record/per page $ 1 .00 per page for the first 25 pages ; $ .25 each additional page thereafter.
NOTE : Florida Statutes regarding release of medical records must be met prior to release of medical records to any source
. No fees are
charged to physician offices/other medical agents with the understanding that IRCHD will also be exempt from such payment.
Vital Statistics Fees
Birth Certificates $ 12 . 00
Additional Copies $8 . 00
Death Certificates $ 10 . 00
Research Fee ( per year) $3.00
Expedite Fee $5 . 00
Overnite Shipment $ 10 . 00
Birth Certificates are provided free of charge to the following only: Children & Families Case Workers who are involved in
a custody case .
Case Worker must present proper ID , completed application request and copy of the signed court petition . Only one certified
copy will be
provided per six (6) month period .
Environmental Health County Fees
Well Permit ( Potable) $75.00 Environmental Health Plan Review $75.00
Well Permit ( Irrigation ) $50 . 00 Environmental Assessment $ 150 . 00
Well Permit (2 Sites or more) $ 100 . 00 Grease Trap Construction Permit $75 . 00
Well Abandoment $0 . 00 Grease Trap Annual Operating Permit $50 .00
Well Permit Construction Variance $ 100 . 00 Hazardous Waste (SQG ) Annual Fee $50 . 00
Public Supply Well Permit $250 . 00 "After the Fact' OSTDS New System $400 . 00
Demolition Permit $50 .00 "After the Fact' OSTDS Repair Permit $230 .00
Demolition Permit $ 100 . 00 Bacteriological Water Sample ( Drinking Water) $20 . 00
Reinspection for Demolition Permit $25 . 00 Chemical Water Sample $5 . 00 - 25.00
Environmental Health Misc. Lab $20 . 00 Indoor Air Quality Permit $50 . 00
Environmental Health State Fees
Please see Attachment IV
9/9/2003CLFEE2003-04 Page 5 of 7
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE — Effective Oct 1 , 2003
Florida Administrative Code, Chapter 10D-121
For the purpose of family planning , sexually transmitted disease , or HIV/AIDS services only, minors seeking those services shall
be
considered a separate family for income eligibility determination purposes and shall be assessed fees for those services based upon
their
own personal gross income .
Any client who elects to waive the eligibility determination process shall be assigned to the full fee category. If there
is no fee for a service ,
income eligibility does not need to be determined , except for WIC .
The self-declaration statement shall include a signed acknowledgment that the statement is true at the time it is made , and
that the person
making the statement understands that the provider shall attempt to verify the statement. Verification can be secured by telephone
, in
written form , or by face-to-face contact, verification does not require a written document to confirm an applicant's or client's
statement.
If the provider is unable to verify wages paid or an employer will not verify wages paid , the self-declaratory statement provided
by the
applicant must be accepted as accurate .
Clients served by CHD's and their subcontractors shall not be denied services for tuberculosis , sexually transmitted disease , or
HIV/AIDS
communicable disease control because of failure or inability to pay a prescribed fee , regardless of their income .
Clients interviewed , examined , or tested at IRCHD's initiative because they are a contact to a case of communicable disease
or because
they are a member of a group at risk that is being investigated by the IRCHD shall not be charged a fee for the interview,
examination , or
testing ; these clients may be charged on a sliding fee scale for any treatment indicated , but they cannot be denied services
based
on inability to pay.
Clients served by IRCHD and their subcontractors shall not be denied family planning services for failure or inability to pay
a prescribed fee ,
regardless of their income; however, the family planning services of inserting Norplant, and male and female sterilization , shall
be limited
depending on the availability of funds to pay for these services .
Clients shall not be denied pregnancy testing for failure or inability to pay.
Clients may request a review of their fee charge on the basis that they have severe , unusual , and unavoidable expenses or
obligations that
substantially reduce their ability to pay and which warrant special consideration .
9/9/2003CLFEE2003-04 Page 6 of 7
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -- Effective Oct 1 , 2003
IRCHD POLICIES
School Year Policy Regarding Physicals: If a patient is already established at IRCHD as a primary care patient, physicals
will be given
based on sliding fee scale ; however, if they are new to the clinic for medical care , they must pay the advance fee of
$30 . 00 unless they
register as a primary care patient and transfer all current medical records to the health department.
County of Residence : ( Primary Care) If a patient has Medicaid , other confirmed medical coverage , or prepays out of county
charge , we will
see them in the clinic and bill for service . However, all sliding fee or zero pay patients must be seen at the health
department in the county of
their residence . Failure to show confirmation of county residence will result in payment of 100% until such confirmation is
obtained .
(Exception to this rule will be for treatment of communicable diseases and family planning services .
Insurance will not be billed for family planning services .
Employee medical care will be provided based on approved policy and procedure .
Hepatitis A & B vaccines are provided free of charge to ages 0- 18 per CDC Vaccine for Children guidelines . If a patient
has Medicaid
coverage . Medicaid will cover Hep A & B to age 21 . Vaccines will not be provided on a sliding fee scale for non-established
patients over
the age of 18. EXCEPTION : Vaccine will be provided free of charge or on reduced fee if vaccine is treatment for communicable
disease .
Anonymous HIV Testing : $25. 00 fee applies to all patients who request HIV test. However, test will be given regardless
of ability to pay.
Reduced fee will be accepted for hardship cases .
Per agreement with Partners in Women 's Health , a reduced fee of $ 10 .00 will be billed to those patients who are pregnant
and referred
to IRCHD for HIV testing .
Access to dental services will be limited to those patients who make 200% or less of the Federal Poverty Level . ( Effective
May 8 , 2002 )
9/9/2003CLFEE2003-04 Page 7 of 7