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Okaloosa County BOCC — March 18, 2014 — Corizon Invoice 14508 — reading text
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C@RIZON
INVOICE Invoice: CZN000014508
invoice Date: March 11, 2014
Page: 1 of 1
Customer No: 90398
OKALOOSA COUNTY PURCHASING DEPT.
ATTN: JACK ALLEN
602 C-NORTH PEARL STREET
CRESTVIEW FL 32536 Payment Due: 4/10/2014
AMOUNT DUE: 386,863.79
For billing questions, please call: 800-729-0069 EXT.1338 Fed TIN# 23-2108853
For products and services rendered by Corizon Health, Inc. for the following dates of service:
Beginning: 10/01/2012
Ending: 09/30/2013
| Description Quantity UOM Unit Amt Net Amount |
Aggregate Cap as of 2/27/14 1.00 EA 386,863.79 386,863.79
This replaces invoice CZN000014394
_ Subtotal: 386.863.79
AMOUNT DUE: 386,863.79
Please Remit To: EFT Payment To:
Corizon Health, Inc. Account Number: 000112997168
12464 Collection Center Drive
Routing Number: 064000020
Chicago IL 60693
Please Document Any Variations In Amounts Not Paid in Full
Corizon Health
Invoice for Contract Year 2013
Okaloosa County, FL
Aggregate Report for Contract Year: October 1, 2012 through September 30, 2013
Aggregate Terms per Contract (backup attached):
Annual Aggregate Limit: 500,000.00
If > $500,000 but < $1,242,000 County to pay Corizon 20%
of difference between $1,242,000 and actual
500,000.00
Summary of Aggregate Calculation through 02/27/14
Paid Claims 533,297.37
Pharmacy 264,782.37
Total Paid through 02/24/11: 798,079.74
Yearly Aggregate Limit (Corizon Health responsibility) : 500,000.00
Total Corizon Health responsibility as of 02/27/14: 500,000.00
Amount in excess of Corizon Health responsibility 298,079.74
Plus: 20% Reimb to Corizon if yearly amount is greater than $500,000 but less than
$1,242,000 88,784.05
Total amount due from County 386,863.79
Less: Previous invoicing related to current contract year
[Total amunt due this invoice