HomeMy WebLinkAboutR 2019-253 Health - Triangle Urology vasectomy services DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D
ORANGE COUNTY—DEPARTMENT USE ONLY
Department
Party/Vendor Name: Triangle Urology Associates, P.A. Party/Vendor Contact Person: Pat Grinstead Contact Phone: 919-
313-3662 Party/Vendor Address: 205 Frasier Street City Durham State: NC Zip: 27707 Department: Health Amount:
4 800 Purpose: Provide vasectomy services to OCHD referred males Budget Code(s): 10414020-630000-71400 Vendor#
63847 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)New ❑ Renewal
❑ Amendment ® Effective Date 4-24-19 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
projehas not been initiated prior t^^�^^ *^^ ^F*',^
ct P Oceusigned by:nedb� S�_Wo 4/29/2019
Department Director's Signature Date:
3C16F2D09E3445F.
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 sufficient '-oocusigned by:' ' ds, specifications,and requirements:
USa (,4V1rt,t,�6 4/29/2019
Office of the Risk Management Officer[, Date:
7F6CF917E800498.
Financial Services
This instrument has been pre-audited it ^pocusigned by "—the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer 4 Date: 5/1/2019
7NE5181ACC1409.
Legal Services
This agreement is approved as to'
g PP Docusigned by:
Office of the County Attorney IKAZ AkaYit, TM(h Date: 5/1/2019
079A40525C0F4FB.
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 Dec 2018