HomeMy WebLinkAboutR 2018-365 Health - Family Centered Healthcare medical servicesRevised 10/17
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ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Department
Party/Vendor Name: Family Centered Healthcare, PA Party/Vendor Contact Person: Anissa Vines Contact Phone:
919-245-3247 Party/Vendor Address: 400 Millstone Drive, Suite 100 City Hillsborough State: NC Zip: 27278
Department: Health Amount: $5,000 Purpose: Provide Primary Care for uninsured males of Orange County
Budget Code(s): 10414020-630000-71422 Vendor # 63536 (N/A if new vendor) Vendor is a BOCC consultant?
Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-2018
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 re quired for Docusign contracts:
Office of the Clerk to the Board __________________________________________Date:_________
DocuSign Envelope ID: B7DABF9A-D92E-48BA-BC0B-AFFC399D4D85
8/6/2018
8/6/2018
8/8/2018
8/8/2018