HomeMy WebLinkAbout2012-393 S Health - Patagonia Health Inc for Elecronic Medical Record $40,500 plus $3764 per month ORANGE COUNTY—CONTRACT CONTROL SHEET
Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk
This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager
determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for
BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should
be completed through the legal review process prior to being routed for signature.
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Department —�tz_-
Party/Vendor Name: Pata onia Health Inc Party/Vendor Contact Person: Ashok Mathur Contact Phone:919-622-6740 Party/Vendor
Address:202 Midenhall Way City Cary St e:NC Zip:27513 artment:Health Amount: $40,500/startup&$3,764/month Purpose:
Electronic Medical Record Budget Code(s): Ven W, if new vendor) Vendor is a BOCC consultant? Yes F-1 No[D
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Contract Type: (Check one)New[] Renewal Q Amendment F-1 Effective Date 10-24-2012 Approved by Board YesX NoF1
Agenda Date: Title of Contract:
If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No❑ If submitted for bid were
bids/P,FPs received Yes❑Non Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
Department Director's Signature: L Date: ic V 1�
IT i irector
(Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information
Technology Director as to technical content and information technology specifications:
IT Director's Signature: Date:
Risk Man3gement
Include the following coverages: ffyCGL; [Auto; Eg-VC; [i; Professional; M Property; OR No Insurance Required F-1. Hold
r'
Contract pending receipt of Certificate of Insurance With incorporation of Insurance provisions as shown,this contract is approved
by the Risk Manager:
Risk Manager's Signature: Date:
Financial Services
This Contract is conditioned upon appropriation by the Board of Commissioners Yes❑NoEg/ A budget amendment is necessary
before approval Yes❑No❑. If budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government Budge l and Fiscal Control ct*
Financial Services Director's Signature: Date: 3j)
County Attorney
Approval by Board F-1 (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approval by Manager A(Most other contracts$1,000 and above). Department Director approval only F-1 (Under
$1,000). This contract has evie d Vd approved by the Attorney as to legal form and sufficiency-
Attorney's Signature Date:
County Manner
This contract has been reviewed and is approved by the County Manager YesDINO❑.
This contract has been reviewed and is for signature by the Chair,YesmNoal*,
Manager's Signature: Date:
Clerk Yo the Board
Approved by BOCC on the day of 120 Submitted for Chair signature on the day of 20
Clerk's Signature: Date:
Revised March 2012