HomeMy WebLinkAboutR 2013-108 Health - Piedmont Health Services Inc Outside agency $10,000 �os�- 108
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: Piedmont Health Services,Inc., Party/Vendor Contact Person: Marni Holder Contact Phone: 933 8494
Party/Vendor Address:299 Lloyd Street City Carrboro State:NC Zip:27510 Department: HEALTH Amount: 000 se: The
fundin will be used to su ort the Piedmont Health Services Inc.communi health center mission of rovid' me yj di gent
residents of Orange Coup with access to a comprehensive,sliding-fee primgU care home including medical 6nd den are(ancillary
health support services are also provided but are not supported by this grant) Budget Code(s): 10414020-6300 endor#27898 (N/A
if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New® Renewal❑ Amendment ❑
Effective Date JULY 1,2012 Approved by Board Yes❑No❑ Agenda Date: Title of Contract:OUTSIDE AGENCY
PERFORMANCE AGREEMENT:PIEDMONT HEALTH SERVICES
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 Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
Department Director's Signature: Date: /
IT Director
(Applicable only to tar tware purchases or related services ntract has been reviewed and approved by the Information
7 Technology Director as to technical co d inform at' ology specifications:
IT Director's Signature: Date:
eisk;Man�emesnt
Include the following coverages: WCGL; [Auto; C fesional; ❑ Property; OR No Insurance Required ❑. Hold
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: Z�
Financial Services
This Contract is conditioned pon appropriation by the Board of Commissioners Yes❑No[ l 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 Budget nd Fiscal Control Act: /`
Financial Services Director's Signature: Date: `1 2S (3
County Attorney
Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approv by Manager (Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has b e evi d approved by the Attorney as to legal form and suffic' ncy:
Attorney's Signature Date: 4 so L?
County Manager
This contract has been reviewed and is approved by the Co ty Manager Y�
This contract has been reviewed and is for si a C ' Yes❑N
Manager's Signature:
Date:
Clerk to the Board
Approved by BOCC on the_day of ,20 . Submitted for Chair signature on the_day of ,20
Revised March 2012