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Home My WebLink About850685.tiff AR2D3473❑ EMERGENCY ORDINANCE NO. 82-E IN THE MATTER OF REPEALING ORDINANCE NO. 82-D AND RE-ENACTING %tic) THE SETTING OF FEES FOR SERVICES PROVIDED BY THE WELD COUNTY HEALTH DEPARTMENT. • O U • BE IT ORDAINED BY THE BOARD OF COUNTY COMMISSIONERS OF WELD o W COUNTY, COLORADO: 0Z oz "} W WHEREAS , the Board of County Commissioners of Weld County, o Colorado has authority under state statute and the Weld County U Home Rule Charter to establish certain fees for services N a provided by the various departments of Weld County Government, and •• w N a WHEREAS, the Board of County Commissioners of Weld County coo desires, through this Ordinance, to set fees and charges for services provided by the Weld County Health Department. Ls" z O H \ N "'' m NOW, THEREFORE, BE IT ORDAINED by the Board of County • Commissioners of Weld County, Colorado, that Ordinance No. 82-D M w is hereby repealed and that the fee schedule set forth in 1` w Exhibits "A" through "C" , copies of which are attached hereto m z and incorporated herein by reference, shall be the fees charged ,y by the Weld County Health Department for the described services. g Uai a BE IT FURTHER ORDAINED by the Board of County Commissioners of Weld County, Colorado, that this Ordinance shall supersede CT r- all prior Ordinances and Resolutions concerning fees for the r• o services enumerated in this Ordinance. w w BE IT FURTHER ORDAINED by the Board of County Commissioners of Weld County, Colorado, that an emergency exists in that the effective date of said fee schedule shall be January 1 , 1986 , and such fees shall remain in full force and effect until this Board ordains to change such fees and, therefore, this Ordinance is declared to be an Emergency Ordinance under the provisions of Section 3-14 of the Weld County Home Rule Charter. 850685 ., i.. /1 L r ,% 7 ' / ! - ji Page 2 RE: ORDINANCE NO. 82-E u The above and foregoing Ordinance No. 82-E was, on motion duly made and seconded, adopted by the following vote on the 4th N O day of December, A.D. , 1985 . Fa `i if- • BOARD OF COUNTY COMMISSIONERS o a ATTEST: ' ' Maui "•`-AC; ""f' ti`7.-I'a°v WELD COUNTY, COLORADO 03 (k r:4 Weld C014 la,�Crk and Recorder moo, tn- and ,C eDk to tUi Board J line son,,�� - Chairman AN N a BY: ene R. Br tner, Pro-Tem . ,a D utty. Coukt? Cl k EXCUSED APPROVED AS TO FORM: C.W. KirLn co G.rd: . .: . V cfli County Attorney �� / a r aau' i op M n M▪ z a Read and Approved: December 4 , 1985 Published: December 12 , 1985 , in the Johnstown Breeze U z Effective: January 1 , 1986 .4' In rnr O N d o w w EXHIBIT "A" NU. iNG CLINICS FEE SCHEDULE - 1986 , ADJUSTED TOTAL GROSS INCOME AND FAMILY SIZE CODES Annual Monthly Weekly Number in Family Income Income Income 1 2 3 4 5 6 7 8 Below $5,250 Below $437 Below $100 1 1 1 1 1 1 1 1 $5,250-$7,049 $437-$586 $100-$134 2 1 1 1 1 1 1 1 U $7,050-$7,875 $587-$656 $135-$151 2 2 1 1 1 1 1 1 r-Io , $7,876-$10,575 $657-$881 $152-$203 3 2 2 1 1 1 1 1 cn o o $10,576-$12,449 $882-$1,037 $204-$238 4 3 2 2 1 1 1 1 Ca o w $12,450-$13,275 $1,037-$1,106 $239-$255 4 3 2 2 2 1 1 1 og w $13,276-$14,250 $1,106-$1,187 $255-$274 4 3 3 2 2 1 1 1 w $14,251-$15,975 $1,187-$1,331 $274-$307 4 4 3 2 2 2 1 1 U N pW'I $15,976-$17,049 $1,3.32-$1,420 $308-$327 4 4 3 3 2 2 2 1 N $17,050-$17,700 $1,420-$1,475 $327-$340 4 4 3 3 2 2 2 2 $17,701-$18,675 $1,475-$1,556 $340-$359 4 4 4 3 2 2 2 2 Ln coo $18,676-$21,375 $1,557-$1,781 $360-$411 4 4 4 3 3 2 2 2 Lnz H $21,376-$24,900 $1,782-$2,075 $412-$478 4 4 4 4 3 3 2 2 N E+ a $24,901-$28,500 $2,075-$2,375 $478-$548 4 4 4 4 4 3 3 2 M w $28,501-$32,100 $2,375-$2,675 $548-$617 4 4 . 4 4 4 4 3 3 $32,101-$34,100 $2,675-$2,841 $617-$655 4 4 4 4 4 4 4 3 en z N a over $34,100 over 2,841 over$655 4 4 4 4 4 4 4 4 U CY. Use codes 1 to 4 with Sliding Fee Scale prices to determine amount patients .4• 1/40 pay for services and supplies. • CAN ON r-I o CODES: 1 - Below 100% poverty as defined by 1985. guidelines. w 2 - Between 101% and 150% poverty as defined by 1985 guidelines. 3 - Between 151% and 200% poverty as defined by 1935 guidelines. 4 - Above 200% poverty as defined by 1985 guidelines. FP/GYN Use 1-4 CRC. . ..Use 1-4 MAT Use 1-4 WOC. . . .Use 1-4 V. D Use 1-4 Revised 6/85 2 GUIDELINES FOR DETERMINING FEES To use the Adjusted Gross Income and family size codes you must first determine the family income either annually, monthly, or weekly and find where their income falls under the appropriate column. ANNUAL INCOME MONTHLY INCOME WEEKLY INCOME Below $5,250 Below $437 Below $100 o $5,250-$7,049 $437-$586 $100-$134 0U $7,050-$7,875 $587-$656 $135-$151 o $7,876-$10,575 $657-$881 $152-$203 o a $10,576-$12,449 $882-$1,037 $204-$238 oa 0 S $12,450-$13,275 $1,037-$1,106 $239-$255 oa v-rW $13,276-$14,250 $1,106-$1,187 $255-$274 o N a $14,251-$15,975 $1,187-$1,331 $274,$307 ” tzt $15,976-$17,049 $1,322-$1,420 $308-$327 $17,050-$17,700 $1,420-$1,475 $327-$340 L $17,701-$18,675 $1,475-$1,556 $340-$359 O H $18,676-$21,375 $1,557-$1,781 $360-$411 Ow $21,376-$24,900 $1,782-$2,075 $412-$478 w $24,901-$28,500 $2,075-$2,375 $478-$548 M r-- 124 z $28,501-$32,100 $2,375-$2,675 $548-$617 N z $32,101-$34,100 $2,675-$2,841 $617-$655 0 a over $34,100 over $2,841 over $655 ON After you have determined the income you need to determine the number In the ~ c' family under the "Number in Family" column. arlw Number in Family 1 2 3 4 5 6 7 8 You then need to follow the number in family column until you meet their income and the number of 1 through 8 is the sliding fee scale code number for each patient. See example on next page. 3 NURSING CLINICS Adjusted Total Gross Income And Family Size Codes NUMBER IN FAMILY _ANNUAL INCOME MONTHLY INCOME WEEKLY INCOME 1 2 3 4 5 6 7 8 Below $5,250 Below $437 Below $100 1 1 1 1 1 1 1 1 $5,250-$7,049 $437-$586 $100-$134 2 1 1 1 1 1 1 1 $7,050-$7,875 $587-$656 $135-$151 2 2 1 1 1 1 1 1 $7,876-$10,575 1 $657-$881 $152-$203-- - 3 2 2 1 1 1 1 1 .4. 0 ro O $10,576-$12,449 $882-$1,037 $204-$238 4 3 2 2 1 1 1 1 "' o $12,450-$13,275 $1,037-$1,106 $239-$255 4 3 2 2 2 1 1 1 0 w $13,276-$14,250 $1,106-$1,187 $255-$274 4 3 3 2 2 1 1 1 O3 o a $14,251-$15,975 $1,187-$1,331 $274-$307 4 4 3 2 2 2 1 1 u1w a $15,976-$17,049 $1,331-$1,420 $308-$327 4 4 3 3 2 2 2 1 0 ci N w $17,050—$17,700 $1,420—$1,475 $327—$340 4 4 3 3 2 2 2 2 N $17,701-$18,675 $1,475-$1,556 $340-$359 4 4 4 3 2 2 2 2 € a $18,676-$21,375 $1,557-$1,781 $360-$411 4 4 4 3 3 2 2 2 w In o a $21,376-$24,900 $1,782-$2,075 $412-$478 4 4 4 4 3 3 2 2 Ls) ff $24,901-$28,500 $2,075-$2,375 $478-$548 4 4 4 4 4 3 3 2 -. w H a $28,501-$32,100 $2,375-$2,675 $548-$617 4 4 4 4 4 4 3 3 w $32,101-$34,100 $2,675-$2,841 $617-$655 4 4 4 4 4 4 4 3 op w over $34,100 over $2,841 over $655 4 4 4 4 4 4 4 4 c o z Table continues with more income levels. Ng r An example would be a family making $683.00 a month with 5 family members. This w family would be a Code one, which means: a i cw o r- Use codes 1 to 4 with Sliding Fee Scale prices to determine amount patients pay for 'i ° services and supplies. Q 11 CODES: 1 - Below 100% as defined by 1985 guidelines. 2 - Betweem 101% and 150% poverty as defined by 1985 guidelines. 3 - Between 151% and 200% poverty as defined by1985 guidelines 4 - Above 200% poverty as defined by 1985 guidelines. FP/GYN Use 1 - 4 CHC.. . .Use 1 - 4 MAT Use 1 - 4 WOC. . ..Use 1 - 4 V.D Use 1 - 4 Example Page Revised 6/85 4 FAMILY PLANNING PROGRAM PATIENT CHARGES SLIDING FEE SCALE ITEM CODE CODE CODE CODE 1 2 3 4 (0-100%) (101-150%) (151-200%) (200%+) VISITS Initial medical -0- 20.00 40.00 60.00 d o Annual medical -0- 15.00 25.00 35.00 HI u Diaphragm fitting -0- 10.00 20.00 30.00 0 (initial , w/teaching-supplies) 10 o IUD insertion-supplies -0- 15.00 25.00 35.00 o IUD removal -0- 5.00 10.00 15.00 a Medical revisit -0- 5.00 15.00 20.00 c w (when there is a problem) o a Contraceptive revisit -0- 5.00 10.00 15.00 in- w Repeat Pap smear -0- 5.00 10.00 15.00 A Brief visit -0- 3.00 7.00 11.00 o Pregnancy test only -0- 2.00 5.00 7.00 w Rubella titer -0- 2.00 3.00 5.00 N Z (drawn and sent) 00 Counseling: 0-15 minutes -0- 5.00 11.00 17.00 x 16-30 minutes -0- 10.00 22.00 34.00 a 31-45 minutes -0- 15.00 33.00 51.00 LO A 46-60 minutes -0- 20.00 44.00 68.00 a H GC cultures -0- 1.00 3.00 5.00 A -.. w HI co CONTRACEPTIVES a o w Condoms-each -0- .15 .20 .25 r w Diaphragms -0- 6.00 7.00 8.00 C; z Jelly/Cream -0- 3.00 3.50 4.00 o z Applicators -0- .30 .40 .50 o Foam -0- 1.50 2.50 3.50 z Encare Ovals -0- 1.50 2.50 3.50 z IUD's (see above) -0- 15.00 25.00 35.00 Oral Contraceptives-cycle -0- 4.00 5.00 6.00 'V 0'% • r- 0o r SUPPLIES co w Ampicillin, each 500mg -0- .10 .15 .20 Sulfa Cream -0- 3.00 4.00 5.00 Benemid, each -0- .10 .15 .20 Flagly, each -0- .30 .40 .50 Koro-sulf -0- 2.00 3.00 4.00 Kwell Shampoo -0- 2.00 3.00 4.00 Monistat -0- 5.50 6.50 7.50 Mycostatin -0- 2.00 3.00 4.00 Podophyllum -0- 1.00 2.00 3.00 Tetracycline, each 250mg -0- .03 .05 . 10 5 WELL OLDSTER CLINIC PATIENT CHARGES ES SLIDING FEE SCALE Household Size Codes Item 1 2 3 4 O Visits: U o Physical Exam 1.00 1,00 - 1.00 1.00 N O Routine with Lab tests 2.00 2.00 2.00 2.00 U Repeat 1.00 1.00 1.00 1.00 Ca O Services: o Pap 5.00 5.00 5.00 5.00 a Hearing 1.00 1.00 1.00 1.00 u Flu shots 2.00 2.00 2.00 2.00 Na .. QS d' a Ln coU uz H CHILD HEALTH CONFERENCE PATIENT CHARGES SLIDING rr;� SCAIE oa • w Household Size Codes Mz Item 1 2 3 4 oz o a Visits: w x Physical Exam 0 .5.00 7.50 10.00 Repeat visit 0 2.00 3.00 4.00 V' o rn CO c N Services/Tests: • o P4 w Hearing 0 2.50 5.00 7.50 Injections 0 1.00 1.00 1.00 9/84 tair VENEREAL DISEASE PATIENT CHARGES SLIDING FEE SCALE ITEM HOUSEHOLD SIZE CODES 1 2 3 4 VISITS: • o Initial Exam ( Including tests) 0 5.00 7.50 10.00 o Repeat Exam 0 2.00 3.00 4.00 o G.C. 0 1.00 3.00 5.00 Wet prep/whiff/gram 0 1.00 3.00 5.00 a stain 0 3 Syphillis Serology 0 1.00 3.00 5.00 o • A SUPPLIES: Sulfa Cream 0 3.00 4.00 5.00 N a Monistat 0 5.50 6.50 7.50 N Kwell 0 2.00 3.00 4.00 Flagyl ea. 0 .30 .40 .50 Podophyllum 0 1.00 2.00 3.00 Ln T ao H MATERNITY N PATIENT CHARGES SLIDING FEE SCALE o1 mw • w PAYMENT SCALE mz N Code 1-- No Charge 3 LUX Code 2-- $150.00 Code 3-- $300.00 rnC° o `er H Code 4-- $450.00 o Kq W The client will be charged in installments according to the number of visits she is expected to have. 7 MATERNITY PAYMENT SCHEDULE CODE CODE CODE CODE ITEM 1 2 4 Client starting care 4-14 weeks gestation: Ten payments of -0- 515.00 530.00 545 .00 Clients starting care 15-20 weeks gestation: Eight payments of -0- $18. 75 537 . 50 556.25 o ,--. O Clients starting care 21-28 weeks gestation: Six payments of -0- 525.00 550.00 575.00 o U q Clients starting care 29-34 weeks 0 w gestation: Four payments of -0- 537 .50 $75.00 5112 . 50 O3 0 x Clients starting care 35-40 weeks u} W gestation: Two payments of -0- 575.00 $150.00 5225.00 v Code 1 clients are not charged. N * Discount for early prenatal care - client is not charged for last installment. .. w • ac coa aoU ▪ z H Nr CD ai O M n.41 o• z N 4 O U P4 a cr 01 CO O C- H O PO W 8 • WALK-IN-CLINIC PATIENT CHARGES SET FEE SCALE ITEM Fee ao Immunization $1.00 0 o Blood Pressure Check $1.00 Travel Injections $7.50 o 0 o• x Flu Immunizations $2.00 w z Head Lice Check $1.00 O PPD $1.00 N1:4 N W d' x to co U � z O H N E H (A NO CHARGE CLINICS 0 ro W � W en o 4 Neurology 0 C.) IX Orthodontia a r, Genetics rnco or T.B. C aaw 9 EXHIBIT "B" WELD COUNTY HEALTH DEPARTMENT HEALTH PROTECTION SERVICES -to o U ADMINISTRATION OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM REGULATIONS ri'+ OU SERVICE FEE Ca o •�-17 Individual Sewage Disposal System Permit $150.00 og o g Individual Sewage Disposal Repair/Alteration Permit 35.00 yr W • Holding Tank/Vault Permit 35.00 U N a Systems Contractor License 50.00 Renewal of Systems Contractor License (Annually) 25.00 r+▪ x • Systems Cleaners License 50.00 Lo ao U OH Renewal of System Cleaners License (Annually) 25.00 O H E Site Evaluation 75.00 rim • Loan Approval Inspection without Water Sample 40.00 or M Loan Approval Inspection with Water Sample 50.00 oZ oz N 4 ADMINISTRATION OF BOARD AND CARE HOME LICENSES U (x FEE a m m A. 1-3 Persons $ 25.00 oN .-1 B. 4-6 Persons 50.00 C. 7-9 Persons 75.00 D. 10-12 Persons 100.00 E. More than 12 Persons . . . 150.00 ENVIRONMENTAL HEALTH SPECIALIST FIELD TIME . . . $28.50/hour -1- EXHIBIT "C" ADMINISTRATION OF LABORATORY FEES c0 .-ft) 2 Laboratory Medical Sample Fee 040 � U Gonorrhea Culture $ 3.20 AGonorrhea Smear 3.90 0 3 Syphilis Serology 1.55 o rz Syphilis Darkfield 39. 10 cm- I4 Trichomonas/Clue Cell 7.80 O Blood Group 1.80 O Colorectal Screen 2.20 N Wx Urine Culture 7. 70 N Blood Glucose 4.40 Fecal Culture 111.65 Streptococcal 1. 10 Miscellaneous Screen 33.00 co I-1 co Food tnz a H Swab Rinse 4.00 cn Hamburger Test 20. 10 Suspect Food 30.25 O G,,, Water (Potable) Mz a Z Bacteria 5. 15 0 U a Laboratory Chemistry Sample W a Waste 'n Detergents 23.30 o-1 co o N Oil & Grease (Chem) 24.45 o Suspended Solids 8.75 m Settleable Solids 3.20 BOD 8.35 Chlorine 4.40 Temperature .65 Nitrite 14.95 Potassium 3.70 Ionic Balance 1. 15 Oil & Grease (Visual) 3.60 GC Samples Natural Gas 29.60 Benzene Series 38.80 —2— Water Quality Chemical Assessment FEE cO o U Step 1 M O TDS $ 9. 10 ri U Ph 5.50 q Nitrate 4.85 pi o W Fluoride 5.60 o S Oil & Grease (Visual) 3.60 o rz $ 28.75 yr al n g Step 2 U Total Hardness 3.95 43 N ai Calcium 5.60 N Chloride 5.60 v Sodium 3.70 a Iron 9.50 a Turbidity 1.00 w U $ 29.45 Ln2 OH Step 3 N E Magnesium .75 ~ a Sulfate 11.45 o N Total ALK 3.95 mw Specific Conductance 3.95 • G' Manganese 9.50 m z Copper 3.70 N rt4 Zinc 3.70 O Potassium 3.70 �U g Ionic Balance 1. 15 a Lead 4.45 d, Lo Mercury 3.70 CT CO Ammonia 4.35 o o H $ 54.45 mw Waste Water Sample Turbidity 1.00 Phen. Alkalinity 3.95 Manganese 9.50 Detergent 23.30 Oil & Grease (Chemical) 24.45 Suspended Solids 8.75 BOD 8.35 Chlorine 4.40 Temperature .65 Nitrite 14.95 COD 10.15 $109.50 -3- Energy Impact Sample FEE Flouride $ 5.60 Lead 4.45 Nitrate 4.85 d, 0 Potassium 3.70 "' U Total Hardness 3.95 0 c o Calcium 5.60 ,-I U Magnesium .80 a Sodium 3.70 o W Chloride 5.60 o S Sulfate 11.45 • a Total Alkalinity 3.95 a}W Total Dissolved Solids 9. 10 a a Specific Conductance 4.00 0 Iron 9.50 U WW Copper 3.70 N WN Zinc 3.70 a? Ammonia 4.35 ti a PH 5.50 W Ionic Balance 1. 15 in 4 co 0 $ 94.80 o H Municipal Contract \W NH ri a Turbidity 1.00 W Arsenic 5.80 C W Barium 5.80 • Ga Cadmium 5.80 co Z Chromium 5.80 N Z Flouride 5.60 o Lead 4.45 U X Mercury 3.70 Wj Nitrate 4.85 Selenium 5.80 d' CO 01 CO Silver 5.80 o N $ 59.35 .-+ o aaX Pollution Investigation - Bacterial Fecal Coliform 14.75 Fecal Streptococci 14.75 Confirmation Culture 8. 15 $ 37.65 Pollution/Dumping Compliance Sample Full Series Analysis 108.20 -4- EMERGENCY ORDINANCE NO. A2-R IN THE N►5h9R OF REPEALING ORDINANCE-MO. 92-D AND BE-ENACTING AFFIDAVIT OF PUBLICATION THE SETTING M-BEEF FOR SERVICES PROVIDED BY THE HELD COUNTY HEALTH DEPARTMENT. EE -rr. ORDAINED SY THE BOARD OF COUNTY COMMISSIONERS OP WELD THE JOHNSTOWN H N S TO W N BREEZE COUNTY, CGLOEADOI STATE OF COLORADO I NNEHEAS, the Board of County Coeateeionere of Weld CCounty ounty. ' 1 SS COUNTY OF WELD 1 Colorado has authority under state VI and the Weld a unty How Rule snarler to establish Lyin fees for , co I Clyde Briggs, du solemnly swear Ihai I provided by the various depaflments of Weld County Government,• am publisher of The Johnstown If reete and ,WHEREAS, the Board of County.Commissioners of weld County that the same is a weekly newspaper desires, through this Ordinance, to set fees and charges for services provided by the Weld County Health Department. printed, in whole or in part, and published the County of Weld, State of Colorado, NOW, THEREFORE,Weld BE IT ORDAINED Cld by ,the Board of County and has a general circulation therein; that ois Commissioners r e Neld County, Colorado,.far that Ordinance 82-D said newspaper has been published is hereby repealed and that the .tee schedule set forth in continuously and uninterruptedly in said end inns or Mroher N, copies ce Which are he feed hereto and ineorpa[atedhergin by reference, shall be the fees charged County of Weld for a period of more than by the Weld County eealtb Department for the described services. fifty-two consecutive weeks prior to tin: BE.IT FURTHER ORDAINED by the Hoard of County Commissioners first publication of the annexed legal 11otn., of Weld County, Colorado, that this Ordinance- shall supersede fo or advertisement; that said newspaper bas all Ordinances end Resolution, concerning [tea for the services enumerated in this ordinance. been admitted CO the United States 111(lull as second-class matter under the provisions i�t BE IT FURTHER C ORDAINED by the Beard no C exists fan ithat nthe the Act of March 3, Ifi79, or : l\ of Weld County, Colorado, t�echedul at an emergency ��• ybe danvery 1, 1986, effective date he said tee - amendments thereof, and that said and sues fees Snell rawin in full fortcheretore�f this Ordinance I Board erns a to change such less aid, newspaper is a weekly newspaper duly ' se declared to be an Emergency Ordinance under the previsions of ,Section 3-14 of the Weld County Row Rule Charter. qualified for publishing legal notices and The above and foregoing,Ordinance No. B2-C was motion advertisements within the meaning of the duly made and seconded, adopted by the following voce n on the ash laws of the State of Colorado. day of December,, A.D., 1985. 'T1.1� q BDAPD OP COUNTY COMMISSIONERS That the annexed legal notice or advertise- .II Is.'.P L`^w` ''tc Mskc..: `WELD C`W,yNTY r. COLORAoo _ anent was published in the regular and endd lernty Clerk end Recorder f'�etyfYina J h so airman' entire issue of every number of said weekly and'Clerk to the Beard G\aJYrp(y/pV \/I r ,.✓ newspaper for the period of / consec•u- .BYI Td-2Fo.- c `aa/`t.✓ en if, , her, Pro-Tm live insertions; and that the first Dfpucr Forney Clerk EXCUSED �. - - • publication of said notice was in the issti ,'L APPROVED AS TO FORM. said newspaper dated /21/2- A.11. .55 p ,< and that the last publication of said notice .'r � —• La=1 ' was in the issue of said newspaper dated auntya Attorney�� a. .0 " A �� , A.U. 19 i In witness whereof I have he eunto set my hand this / day of O.'4— . Reed and Approved: Deember 4, 19115 A.D. 19".35 :Publisheds December 12, 1985, in the Johnstown Brwae ' -Effective: January 1, 1986 NOSING GROSSEOILETOTAL INCOME AXD FANILF 572E COOS I'UhIISIICI Monthly Mak1Y my-r in doll Amnia' Di AM-air 55,9515 z04 $437-54J] 16101i 3100 z' i i_ i i i i i Subscribed and sworn to before toe, a $5,250-sf.a9 H37-5599 $7,°50-1'.875 $u]46w su9-i�11'1'.:- i 2 2 1.'i. i 1 i Notary Public in and for the County of 17.876410.575 scsfai - 110, WeI Stale of Colorado! us .../.j d:IY of •510.676-$12.449 588241.037' -stone 38.. 1 3..2 2 •1' 1 1 1 ..4/ A.D. 1961-5 $12.270-$14.275 - 61.037.51.186 $255.1274 0 3 2 2 2 1 1 1 _ i1J.276-S11,25D fl.la•f1.187 $255-5271 9 3 3 2 2 1 1 1 $11.251'$15.975 $1.187-51.311 • $2A-$w7 0 1 3 2 2 Y 1 1 N'utai\ I'abhe $15,976.317.09 $1,332-$1.420 5305-1327 4/ 4 3 3 2 2 2 1 $17.060-$17.700 $1.420-$1,0]5 $327•$340 4 4 3 3 2 2 2 2 $17,701-318.675 11.475-51.556 $004359 0 1 4 3 2 2 2 2 My expires .,, 4, 7y7?, $18.676-521.375 $1,557-$1,781 $3504411 4 4 4 3 3 2'2 2 _COltl llllsslull cxl. _.n . 52IWJ16-521.9a $1.782-12.071 fa12-f419 0 4 4 4 3 2 2 .. -. $24.90.528.500 f2,D15-$2.1]5 P78-3508 4.4...0.!VO 3 3 2 i4 — Dec. 14, 11,11I1 IL1l:Qffi1L11:Cfti1EC alt FAtI@t CIPICEl 1 sII6176f1ir- E. Lee: Ilo meSn1O Sim Grass Iwss [um 1 1 3 4 • visits: flrysical Exam 1.00 1.00 1-09 1.00 • Pouting with fab tests 2.00 2.00 1.00 1.00 00 1.00 f590at sptvllt9: . pap `5.00 5.0U 5,00 5.00 Waring 1.00 1-00 1.00 1.00 Flu shpt. 2.00 2.00 2.00 2.00 • CM11➢HEALTH Rt0'siITCC wean CRAM= SLIDING PTE SCALE IbueSWld Size Cozies item( 1 2 3 4 Visits: - - Physical Case 0 5.00 7.50 10.00 i_.D lkpeat visit 0 .2.00. 3.00 4.00 sesvi®s/lmest • lleorinq 0 2.50 5.00 7.50 Injections 0 1.00 1.00 1.00 9/84 • VENEREAL ISEASE SLIDING EEE CALF Iced • ITEM HOUSEHOLD SIZE CODES • 1 2 3 4 • vise. VISITS: Initial Exam (Including tests) 0 5.00 7.50 10.00 Yea Repeat Exam 0 2.00 3.00 4.00 0 - 1.00 3.00 5.00 • Vas L.C.Met Drep/uNi/f/gram 0 1.00 3.00 5.00 Stain Syphi 0 1.00 3.00 5.00 • Syphlll is Serology ' SUPPLIES: Sulfa Cream 0 3.00 4.00 5.00 - Montstat - 0 5.50 6.50 7.50 tweli 0 2.00 Flagyl ea. 0 .30 - .40 .50 Podophyllum 0 '1.00 2.00 3.00 cc MATERNITY PATIENT CHARGE; • SLIDING ja SCALE Use PAYMENTSCALE e Code 1-- No Charge - Code 2-- $150.00 Code 3-- $300.00 Code 4-- 5450.00 The client wfll De charged in Installments accordieR to the number of visits she • is expected to have. - _ :AIINIIIIY PAYNIIIISLIlEOtlLL CODE COOL t0?i 31103 ITEM. : 1 2 1 - Client starting care-4-14 weeks gestation. Ten payments of -0- Si$.Oo ;IO.[SO $P..ufn Clients starting.care 15-20 weeks gestation: Eight payments of -0- 519.)5 $31.50 SSfi.15 Clients starting care 21-2A weeks gestation: Sin payments of -0- • 525.00 550.00 525.00 Clients starting care 29-34 weeks gestation: Four payments of -0- 53).50 525.00 5111,50 Clients starting care 35-40 weeks - gestation. Two payments of -0- .525.00 5150.00 $225.00 Code I clients are not charged. Y Discount for early prenatal care - client is not charge° for last installment. yALN-IN• -CLINIC PATIENT CHARGES SE1 FEE SCALE ITEM - Fee • • Imunilation WOO Stood Pressure Check WOO Travel Injections 31.50 Flu lemnitations $2.0 ,IoM Lice teak 33.0 • FPO $0.00 MO NAME CLINICS• Neurology - Orthodontia - Genetics _ T.B. CXM15IT "V MD COMM(Elan OYASllm11' HALU fOn011ag snips ASKIIIIInyitgs oI tap4gn SW=DISPOSAL MUM ISOVIATlonls ns Individual Saone OteFeael testae Permit . . . . . - - . 1130.01 wlaMel Sewage Itne0a1 4ryte/umratam Iantt 33.0 Wan Teel/Teele Penh - 35.0 - Dynan Oescfsnly Wane . .. . . 30.0 BmaenB,If Spas 4stnens Was (hmelly) 23.0 bole.Bllern Mesa . . . . . . . . . . . . . . . 10.0 L.'a. 2t 0'106 do 1 o-luirat.il 14' '-Dress*, Doc. 12, 111110 band s o d Inman CMS@ Yew (sapy) . . 13.00 1 . .. . Attu.gffi* ttI0 SIC' - `'1 // PFi19Etrt OIA*.. Slam!valuating. . . . . . . . . . . .'. {_• , . 15.00 sLTo7TGi}E:SfAi Lau anr«al lrgett5M L ae van-swta . 40.00 Igaedadd • lSia Niue' ., Sample. . Its f 1 2 3 1' • Pass 41a�aN1«aniga!' �wnt !.. . .. .� . . ... 90.Y Stilts; - al10ItllA.11Ql or'bYeE alo car Ea SWIM. Physical tun 1.00 1.00 1.00 1.00 Poutir with lab tests. 2.00 2.00 2.00 2.00 • payout 1.00 1.00 i.CU 600 A. 1-3 Pansy 1 23:00 loMota: • I. 4-6 Penns Iscea 30.15r Pap 5.00 5.00 5.00 5.00 C. 7-I Naces 75.00 Nearing 1.00 1.00 1.00 1.00 • .. Flu shotsshots2.00 2.00 2.00 2.00 D. to-1S Nana* . . 100.00.: • I.Hers this 11 Nnfss -'155.00 - SNYISommsnsL lizALtn sPSCIALisi 91500 TIME . . . $20.50/hrr " - WWIWI"C" CHILD HEALTH CCHFEKeSE .. PAT110ft CHARMS 5L1DING FEE pout IbusSalld Size Code. 1UN 1 2 3 t _ aWINISIIIMlON QI WOYiORT Iles vials+ II Physical Ex= 0 5.00 •7.50 10.00 Laboratory Nadia,'Sample . ag. R{nat visit 0 2.00 3.00 4.00 • OinrrW 1 3.11 ssrviastN.t Canti a sou - 3.10 Syphilis baeolor 1.55 Neann9 •0 2.50 5.00 7.50 syphilis backfield 15.50 injections 0 1.00 1.00 1.00 ttiaharaaa/Clce Coil y.15 Claw Cramp I.:. . . . . . .. . ... 1.01' Colorectal Oilcan Sari 2.10 Orin Oilcan LM Blood Cleans - 1.45 1/50 Petal Cultureceeae 111.15 50n......el 1.15 VENEREAL DISEASE Nlaoelbners Sarno 11.111 -4MUT[@REFS SLIDING FEfLE food ERNSwab lino 4.15 HOUSEHOLD SIZE CODES - -Neuberger That - 10.10 1 2 3 4 Suspect rood . . . . . 30.15 - alter (Potable) VISITS: Dilator's - - - 5.15 Initial Exam (Including tests) g 5.00 ).50 10.00 laboratory ChemistryBayL Repeat Exam 2.00 3.00 9.00 - G.C. 0 1.00 3.00 5.00 Waste Net prep/ih1 if/gran 0 1.00 3.00 5.00 Eate•Sura Stain 0 011 a onus (atm) - 14.45 Sahiilis Serology 0 1.00 3.00•... 5.00 Suspendsd Solids . . .. 0.75 Nttl.ble Solids . . . .. . . . . . . . 3.30 bon . . . . . . 5.35 SOPPLIE5: - Chlori . . . 4.53 Sulfa Cream 0 3.00 4.00 5.00 • • • • • .\ .05 Itaistat 0 5.50 5.50 7.50 Nitrite 14.95 Iwel1 0 2.00 3.00 4.00 Pot ulu Lr0 Flagyl ea. . 0 .30 .00 : .50 'Ionic Balance • • 1.15 PodophYlluo 0 1.00 - 2.00' 3.00 - 011 a Craua (V isual) p .. . . . 1.14 OC 6arlu l MATERNITY • Natural C. . . . . . . . . . 11.., PATIENT CHARGES - mines saris .. . . ... . . . . . . . . . . . 30.15 SLIDING FEE SCALE Rater Quality Chemical Aaaeaanat lia PAYMENT SCALE steed Code 1-- No Charge k to 1- V.10 Pe 3.50 Code 3-- 5150.00 Nitrate " 4.55 Fluoride • 5.40 Code 3-- 1300.00. .. Oil C Crane (Visual) 1 2�3•-T155. Code 4-- 1450.00 BALI Tke client will.be charge In installments toweling to 1$member of visits I - Feat Yeau . . ' ' 7,99. Is expeCted to have. - r ate. .� u • 4- fY 50e.- _ 2sloi dt BAtLH1,Ilt - Sgdfua .l'. n n •Yl:.n PAYXEof Sc11EDun Seca 9.30;1 • .Turgidity • . . . . . , t B6' I:00E 1001 I. ..0010 79.9 5 aaga Client starling care 9-19 sects- ,p].. gestation. Ten nay eats of -p- S15 of aiti on SI' tan. Self - kl.{j Total ALL . - 3.99. Clients starting care 15-20 weeks Specific Teaduetnn . . . . . . .. n - gestation: Eight payments of -0- $08.7 537.5. 516.;5 Me - 9.50 Clientt starting cite 21-28 weeks - - r lineYIO 9ot.selua. . . . . . 3.70 gestation' Six payments of - -0- 325:00 - 550.181 - 525.00 lout..3.11.4 5.70 gestation' R- LU Clients starting care 29-1/ weeks Lead6A gestation: Four payments of -0- 53-7.50 575.00 5112.5. fly ,7.3 Clients starting/care 35-40-weeks g gestation: Two'panentg of - -0- 525.00 5150.00 5225.00 Code 1 clients are not charged.. Wain Wetr kept. ' Discount for early prenatal care - client is not .1 an gel Yor last installment. Turbidity . . . . . . 1.00- Obn. Alkalinity ].95 D.t.anese • P.50 0.teagne • 23.30 BALK-IX-CL INC - 011 I Greco id .saltel) ]A.6 PATIENT CHARGES Sump' Solids.. S.)0 fFT FEE SCALE .. ' • • '300 • • 6.10 Teepereture ... . . . A. 69 ITEM • ' ee F coed. . . . . . MD . . . . . . . . . . lu s9(B Immunization ' 51.009116130 h ood Presser.Check -- 11.00 Team 1.ect.!mile pgg Travel Injection 52.50, pne.ru g LSS /W Iwnlxatlone 33.00 B!nu 4.19 Dead lice Check Potassium : . . . . '3,'r . $1.00 Taut lard.... - 3.95 Celsius F.. . . ... •1.se 31.00 • Hyaena . . ... .... . . ... . . .. . .. . . ... . .. BD Sodium . . . . . . . . . . . . .. . 4.» Chlorin . . . . . . . . . . . . . . . . . ... _ -,...3.40 - Sulfate . . . . . . . . . . . . . . . 11.46 Tent A1Ylinq-.., •I 3.115 • Tani Dlwlved Scalds II.R Specific leWeeate. i ' 4.00 • Item.. . . . I _ 0.30 Copper . . . 500 - tine .,..).A' NO CHARGE allig, AwsL . . . . . . . 4.3S lit 5.30 ionic• Delano 1l,,pp Neurotogy ••stein Coetntt Orthodontia .. - Turbidity I,a. Genetics Annie 3.r nib= :. . . . . . . . . . . . . . .. . . . $.55 T.B. raNln - !.M I Okmmlua .. . . . . . ._t 5.M multi"gm Lad . . . . . ..' . . . . 7. . . . r:. . 4106 . . . . . . . . . . . . . . . . ... . . . . . ... . . . .4.4$, linear} d9.70 .43 Stur m Solent= 1 5.W Silty VIM COOMT MIAMI U1111ln Fellation Iaveotintlea-lecuru{ HAM p5DTMI I, AD10ttIYT[mm M ImmtylOpLL esi nee OIPpagLL PTlTM D9cp1AT{01y heel Califon . . . . 11.15 Fetal .ties a uoei . . . . . . . . . . . . . . . . . Idle • Wrtp in cefireetW lter.. . . __Alta Iebtlnl-Sewage Dtepe ai been Peree 7 -3T 8 $130.00 - Nlbela/4r1mm Catalano' SospL hdi ldaal Dense Oiepaal Doper/Alenatlmm Ferslt . . . . . . 35.00 - /all Y1W Waft DeeD/yalD Peale : .1. . ]5.00 ApneaWlyile .. . . . . . . . . . . . : . . . • . ..�,..: 610.20ApneaD.ersette Wens •. •.• WOO Dwl of ernes am Lanese (Aenoell+). . . . . . .. . . . - 23.40 .. *sum Clews ape 50:00 .•_1'[Y k. Ic.: t :'r,'3.x�a: :.w -, put, ray.1 :motet - 5 t.r • L:SE.Slo x2. ..1.. Hello