HomeMy WebLinkAboutR 2017-400-E Health - Piedmont Health Services, Inc. - Outside Agency Performance Agreement DocuSign Envelope ID:E8163127-982F-4CDF-AAFE-9EAE17837984
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: 127 Kingston Drive City Chapel Hill State: NC Zip: 27514 Department: Health
Amount: $16,500 Purpose: Support for medical and dental care Budget Code(s): 10495050-719021 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: 6/20/17
This agreement is approved as to to :O rd ifit atent:
8/17/2017
Department Director's Signature 5145A2CD945C40F... 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 sufficient '7Oxi 'antains'taandards,specifications, and requirements:
aMtSA. rblet/ut 6 8/17/2017
Office of the Risk Management Officer 7 Qe, „= Date:
Financial Services
This instrument has been pre-audited i e9'PfaNei iluired by the Local Government Budget and Fiscal Control Act:
A" o°"D 8/21/2017
Office of the Chief Financial Officer 71)4F5181ACC14o9 Date:
Legal Services
This agreement is approved as t e R1'f( �a 11'd Buff ciency:
L " - m' -Sfa 8/21/2017
Office of the County Attorney o79A4�525COF4FB... Date:
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd @orangecountync.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 Health Services,Inc.
Orange County Performance Agreement
Page 7
Rep. 7/2017