HomeMy WebLinkAboutR 2013-128 Health - Wake Radiology Diagnostic Imagin for Scope of Services - Breast and Cervical Cancer Control Program $ N/A 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: Wake Radiology Diagnostic Imajzing,LLC Party/Vendor Contact Person: Chuck Wilcox Contact Phone:(919)
787-8221 x1227 Party/Vendor Address: 3949 Browning Place City Ralei State:NQ Zip:27609 Department: Public Health Amount:
N/A Purpose: See Exhibit A"Scope of Services"AND Exhibit B "North Carolina Breast and Cervical Cancer Control Program 2013-4
Fee Schedule,both of which are attached and hereby incorporated by reference. Budget Code(s): 10414020-630000 Vendor#27691
(N/A if new vendor) Vendor is a BOCC consultant? Yes❑Non Contract Type:(Check one)New❑ Renewal❑ Amendment
0 Effective Date May 1,2013 Approved by Board YesE]NoE] Agenda Date: Title of Contract. Wake Radiology BCCCP
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 YesF_1Nor_j Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
1
- 1411
Department Director's Signature: Date: OOL I-
IY'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 Required Bl*' 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: 1-3
Financial Services
This Contract is conditioned,&n appropriation by the Board of Commissioners Yes❑NoEd A budget amendment is necessary
before approval Yes❑NoFq. 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 and Fiscal Control Act:
Financial Services Director's Signature: umv, LL. 4111- Date:
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). Approval by Manager (Most other contracts$1,000 and above). Department Director approval only E](Under
$1,000). This contract has ben eviewek and approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date: r,-
County Manager
This contract has been reviewed and is approved by the County Manager YpK0 No❑.
This contract has been reviewed and is for si e by the havi YesnNo[�'
Manager's Signature: K`2, Date:
rk 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