HomeMy WebLinkAboutR 2019-150 Health - NCCCN participation agreement ORANGE COUNTY-DEPARTMENT USE ONLY
Party/Vendor Name : NC Community Care Networks , Inc . Party/Vendor Contact Person : Cherie Ross Contact
Phone : 919 -745 -2388 Party/Vendor Address : 2300 Rexwoods Drive , Suite 390 City Ralei h State : NC Zip :
27607 Department : Health Amount : $ 315 , 020 Purpose : PCCM Participation Budget Code (s) : 10414005443110 -
71402 /71412 Vendor # (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No ® Contract
Type : (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 7 - 149 Approved by Board Yes [:] No
❑ Agenda Date :
This agreement is approved as to technical form and content and I as Department Director affirmatively state work
on this project has not been initiated prior to execution of the agreement :
Department Director ' s Signature v Date : 3 -
Agreements for emergency services or repair are not subject to the above affirmation . If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that
was addressed :
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 :
' r
Office of the Risk Management Officer Date : ► i i
Financial Services
i
This instrument has been pre- audited in the 114 er equ ' ed by the Local Government Budget and Fiscal Control
Act :
Office of the Chief Financial Officer Date : f
Legal Services
This agreement is approved as to legal form and sufficiency .
Office of the County Attorney j�1it Date : 06 / 16 / 1 `I
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 :
Revised 12/ 18