HomeMy WebLinkAboutR 2016-200-E Tax - ZirMed Inc. - addt'l service for electronic submission of patient claims for in-house ambulance billing/collection DocuSign Envelope ID: D51D1329-1679-44BC-B77D-140BBBB1055F
ORANGE COUNTY—DEPARTMENT USE ONLY
Department
Party/Vendor Name: ZirMed Inc Party/Vendor Contact Person: Ann Campbell Contact Phone: Party/Vendor
Address: 501 N Broadway,3rd Floor City St. Louis State: Missouri Zip: 63102 Department: Tax Administration
Amount: $380 Purpose: Additional service for existing contract for electronic submission of patient claims for In-
House Ambulance Billing and Collection. Budget Code(s): 10335020-630000 Vendor#N/A (N/A if new vendor)
Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New® Renewal❑ Amendment ❑
Effective Date March 31,2016 Approved by Board Yes❑Nor-1 Agenda Date:
This agreement is approved as to techni&oal�E°�� content:
Department Director's Signature E5EDD78428EB34BF Wam, }5jVVUS6vu Date: 4/1/2016
.
Information Technolosies
(Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is
approved as to information technology content and specifications:
Docu5igned by:
Office of the Chief Information Office
r3 W Date: 4/1/2016
C11BA91E73A64DF...
Risk Management
This agreement is approved for sufficiency of insurance standards,specifications,and requirements:
Docu5ig/'ned""by:
''11i1
Office of the Risk Management Officer usa. (,6rvu,�16 Date: 4/3/2016
7FDCF9176800498...
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 Date: 4/6/2016
7D4E5181ACC1409...
Legal Services
This agreement is approved as to le g.W)ria end sufficiency:
6LVt' r6UfS
Office of C�jEAA3D33ED8A8465...
the County Attorne Date: 4/6/2016
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydkorangecount.nic.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board Date: