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Board of County Commissioners
Purchasing Department
S_Tieechaitoialy nated =<
State of Florida
February 5, 2013 CONTRACT RENEWAL FORM
ADPI/Intermedix
Attn: Brian Fields
1105 Schrock Road
Suite 610
Columbus, OH 43229
RE: Contract #C99-0257-PS (EMS Rescue Billing Services)
Dear Mr. Fields:
The Okaloosa County Department of Public Safety wishes to renew the subject contract, #C99-0257-PS
for an additional term. The contract renewal period will be May 19, 2013, to May 18, 2014. The
annual budgeted amount for this contract is $429,500.00.
If you are in agreement, please sign below and return this form along with a current
Certificate of Insurance listing Okaloosa County as co-insured (if applicable) to: Okaloosa
County Public Safety, 90 College Boulevard East, Niceville, FL 32578.
COUNTY REPRESENTATIVES AUTHORIZED COMPANY REPRESENTATIVE
Director: Dino J- Vi llani Publi Sa fly Contractor: ADPI/Intermedix
Director Santry XL
County Official:
Approved By: Approved By {) } 1,
Dye. SHANG
Title: Title: _ Peea peer
Date: Date: z vA ¥ VE
County Department Instructions:
1) Obtain signatures from Department Director, authorized Company Representative and then
Purchasing Director <$25K, County Administrator <$50K or BCC Chairman >$50K, as
necessary. Make sure the company provides a current Certificate of Insurance. (If applicable)
2) Keep a copy of this form for your records.
3) Send original to; Jack Allen, Purchasing Services Manager.
If you have any questions please contact Jack Allen at 850-689-5960, Fax-850-689-5998, e-mail:
jallen@co.okaloosa.fl.us