HomeMy WebLinkAboutR 2016-353-E Health - Piedmont Health Services, Inc. - Memorandum of Agreement WIC Program Services DocuSign Envelope ID: C4E78886-164A-49E2-8252-F6D46323E8CC
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: $8.000 Purpose: Reimbursement for WIC Hemoglobin Testing Budget Code(s): 10414005-443110-71403
Vendor#27898 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No❑ Contract Type: (Check one)
New❑ Renewal ® Amendment ❑ Effective Date 7/1/16 Approved by Board Yes❑No❑ Agenda Date:
D c Si ned b
This agreement is approved as to to mcaI Yo in Ad content:
(^'u"� 7/6/2016
Department Director's Signature .'z.DOFCS8545E... Date:
Information Technolo0es
(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 /4t i e w Aandards, specifications,and requirements:
QUSA. r,Orwc,�16 7/6/2016
Office of the Risk Management Officer ,FOCFS,�sgoo498___ Date:
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control
Act: DocuSigned by:
rl 7/13/2016
Office of the Chief Financial Officer 7D4ES9R1ACCIAOB__ Date:
Legal Services
This agreement is approved as t dftd sufficiency:
Office of the County Attorney L--'�� Date: 7/13/2016
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:
4