HomeMy WebLinkAboutR 2018-336 Health - Advanced Dental Associates referral agreementRevised 10/17
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ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Department
Party/Vendor Name: Advanced Dental Associates, Inc. Party/Vendor Contact Person: Mindy Gill Contact Phone:
919-545-0985 Party/Vendor Address: 11312 US 15-501 North, Suite 107-139 City Chapel Hill State: NC Zip:
27517 Department: Health Amount: $2,000 Purpose: Referral of licensed dental hygienists and dentists Budget
Code(s): 10410120-630000 Vendor # 64922 (N/A if new vendor) Vendor is a BOCC consultant? Yes No
Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-18 Approved by Board
Yes No Agenda Date:
This agreement is approved as to technical form and content:
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 sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control
Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Sherri Ingersoll upon completion: singersoll@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:_________
DocuSign Envelope ID: 9F2C2FF6-C184-4821-B124-5C284105DD0A
7/25/2018
8/1/2018
8/1/2018
8/1/2018