HomeMy WebLinkAboutR 2013-395 Health - UNC Family of Medicine Service Agreement $145,416 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.
Denartment
Party/Vendor Name: The University of North Carolina at Chapel Hill Panty/Vendor Contact Person: Warren P.Newton Contact Phone:
919-966-0210 Party/Vendor Address: 590 Manning Drive City Cha e� 1 Hill State:NC Zip:27599 Department: Public Health Amount:
$145,416 Purpose:Provider will render services in reference to medical director services, general consultation,and clinical services
Budget Code(s): 10414020-630000 Vendor#21243 (NiA 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: Unc Family of Medicine 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❑Non Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
Department Director's SignaturQ:�`� �W CA413 Date: 61--5-1-3
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 techljology specifications:
IT Director's Signature: Date:
t/ A4k Ma[ ement
Include the following coverages: CGL; [�utWC; Professional; ❑ Property; OR No Insurance Required ❑. Hold
Contract pending receipt of Certificate of Insurance [ With it,curporadon of insurance provisi ns as shown,this ontract is approved
by the Risk Manager: � �� �
Risk Manager's Signature: Date:
Financial Services
This Contract is conditionev
on appropriation by the Board of Commissioners Yes❑No 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 and Fiscal Control Act:
aa,4,u�, ��Financial Services Director's Signature: ,ol• ��/��. Date:
-I 130
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 b anager%(Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has been ev we roved by the Attorney as to legal form and sufficiency:
Attorney's Signature __________________ Date:10 9 L3
Cyt!nty,iltsi.�a ��r
This contract has been reviewed and is ppr ed the County iV1ai�,,gci Yes[[]No❑.
This contract has been reviewed an for si ur by -ha' es❑`�o❑.
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
Clerk's Signature: Date:
Revised March 2012