HomeMy WebLinkAboutR 2015-561-E Health - Piedmont Health Services, Inc. WIC Program - MOA for reimbursement for WIC Hemoglobin testing DocuSign Envelope ID:0652E34F-D5F8-4884-8968-B1860CA82441
PHS/OCHD Memo of Agreement
ORANGE COUNTY—DEPARTMENT USE ONLY
Department
Party/Vendor Name: Piedmont Health Services Party/Vendor Contact Person: Ashley Brewer Contact Phone:
336-570-3739 Party/Vendor Address: PO Box 17179 City Chapel Hill State:NC Zip: 27516 Department: Health
Amount: $6,000 Purpose:Reimbursement for WIC Hemoglobin Testing Budget Code(s): 10414005-443110-71403
Vendor 4 27898 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No❑ Contract Type: (Check one)
New ❑ Renewal ® Amendment ❑ Effective Date 7/1/15 Approved by Board Yes❑No❑ Agenda Date:
This agreement is approved as to to "d content:
PM hG(� 10/7/2015
Department Director's Signature Date:
Information Technologies
(Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer Date:
Risk Management
This agreement is approved for sufficienc qoicamtWtandards,specifications,and requirements:
ausa, (hm,&b 10/19/2015
Office of the Risk Management Officer ZEDCF_q_Lzaa0DAga__ Date:
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control
Act: DocuSigned by:
Office of the Chief Financial Officer EM4E5181ACC1409_lj Date: 10/19/2015
Legal Services
This agreement is approved as to ab& mod sufficiency:
Office of the County Attorneys Date: 10/23/2015
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ DolloyLyorangecou go v
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board Date:
4