HomeMy WebLinkAboutR 2013-296 Health - Cynthia Gamble Professional Dental Services-patient Acare at OCHD Clinics $11,200 �y
ORANGE COUNT'--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: Cynthia Gamble Party/Vendor Contact Person: Cynthia Gamble Contact Pho -380-1042 Party/Vendor
Address: 114 Oakmist Dr City C� State:NC Zip:27513 Department: Public Health Amount 11 2 urpose:Provider will render
professional dental services patient care at the OCHD clinics Budget Code(s): 10410120-63000 r#59544 (N/A if new vendor)
Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New® Renewal❑ Amendment ❑ Effective Date July 1,
2013 Approved by Board Yes[]No[] Agenda Date: Title of Contract: Dental Service Agreement
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:
irector
(Applicable only to hardware/software purchases or e :4.vic.:s)7 his contract has been reviewed and approved the Information
Technology Director as to technical content a nformation techn wy specifications:
IT Director's Signature: Date:
Risk Ma a ement
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; 10 Professional; ❑ 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: '�'�'�" '✓` Jr�' Date:
Financial Services
This Contract is conditioned 4on appropriation by the Board of Commissioners Yes❑Noo� A budget amendment is necessary
before approval Yes❑Non. 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 scal Contro Act: �
Financial Services Director's Signature: J Date:
Cowity Attorney
Approval by Board ❑ (Contracts $90,000 or more for goods o► 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 ❑(Under
$1,000). This contract has been iew an pproved by the Attorney as to legal form and suffic'ency:
Attorney's Signature Date:
County ManatYesNoEl.
This contract has been reviewed and is approved by the County Manager Y
This contract has been reviewed and is for signature by the Chair Yes❑No
Manager's Signature:
Date:
Clektothe Board
Approved by BOCC on the_day of ,20 . Submitted for Chair signature on the_day of 120
Clerk's Signature: __ Date:
Revised March 2012