HomeMy WebLinkAboutR 2016-405-E Health - Piedmont Health Services, Inc. for support for medical and dental care DocuSign Envelope ID: 58ED7F55-231C-4FAC-AD50-6415BD24288B
ORANGE COUNTY—DEPARTMENT USE ONLY
Department
Party/Vendor Name: Piedmont Health Services,Inc Party/Vendor Contact Person: Jen Cunningham Contact Phone: (919)
913-1097 Party/Vendor Address: PO Box 17179 City Chapel Hill State: NC Zip: 27516 Department: Health Amount:
$11,000 Purpose: Support for medical and dental care Budget Code(s): 10414020-630000 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: 6/21/16
This agreement is approved as to to mPa4°�slid content:
4%_ � � 7/23/2016
Department Director's Signature Date:
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:
Office of the Chief Information Officer Date:
Risk Management
This agreement is approved for sufficienc I�l €iari wstandards, specifications,and requirements:
gusa, r,Orwc,�16 7/26/2016
Office of the Risk Management Officer�F„GFg„FR„04QR Date:
Financial Services
DocuSi ned b
This instrument has been pre-audited i the manger equired by the Local Government Budget and Fiscal Control Act:
7/26/2016
Office of the Chief Financial Officer Lita
4E51a1ACC140s... Date:
Legal Services
This agreement is approved as t egaDPT(ol ai�'d sufficiency:
�q 1�- 7/27/2016
Office of the County Attorney 4035CE3304CA4A9 Date:
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:
Piedmont Healtb Services,Inc.
Orange County Performance Agreement
Page 7
Rev. 712096