HomeMy WebLinkAbout2012-417 S EMS - EMS Management & Consultants for Update Business Associate Agreement in ref to HIPAA 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.
Department
Party/Vendor Name: EMS Management&Consultants Party/Vendor Contact Person: Samantha Travis Contact Phone: 336-766-1279
Party/Vendor Address: PO Box 863 City Lewisville State:NC Zip:27023 Department: Tax Administration Amount: 0.00 Purpose:
Update Business Associate Agreement in reference to HIPAA Budget Code(s):_ Vendor 9 59733 (N/A if new vendor) Vendor
is a BOCC consultant? Yes ❑NoE Contract Type: (Check one)New❑ Renewal ❑ Amendment Z Effective Date September 1,
2012 Approved by Board Yes❑NoZ 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/RFPs received YesE]NoD Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
Department Director's Si nature- � Date: 12,11011
IT Director
(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 Management
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Re uired 0 Hold
Contract pending receipt of Certificate of Insurance E]. With incorporation of Insurance provisions as shown, this contract is approved
by the Risk Manager:
Risk Manager's Signature: A^ Date: 2--
lei it—liz.
Financial Services
This Contract is conditioned Oon appropriation by the Board of Commissioners Yes❑Nod A budget amendment is necessary
before approval Yes[]No[V. If budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government Bud et and Fiscal I Act:
Financial Services Director's Signature: V014LL—1 Co 7, A— Date: /2-/1
County Attorney
Approval by Board ❑ (Contracts $90,00 00 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approyal by Manage(Most other contracts$1,000 and above). Department Director approval only El (Under
$1,000). This contract has e revi d d approved by the Attorney as to legal form and sufficle icy:
Attorney's Signature Date: 14 —
County Manage
This contract has been reviewed and is approved by the County Manager Y04-1,Nom.
This contract has been reviewed and is for sign sRNqff._
Manager's Signature: Date: rt
lerk to the Board
Approved by BOCC on the_day of 20 Submitted for Chair signature on the day of 20
Clerk's Signature:— Date:
Revised March 2012