HomeMy WebLinkAboutR 2019-415 Health - Family Centered Healthcare health services DocuSign Envelope ID:73A1D68B-6490-4299-A2E7-F696C988DD75
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: $3,000 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 7-1-2019
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:
Docusigned by:
tAInG� S&Wof 7/5/2019
Department Director's Signature[aC1sF2oosEsa45F. Date:
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 Docusigned by: rds, specifications,and requirements:
allSa. C6V'I�.&6 7/5/2019
Office of the Risk Management Officer 7FDCF0176800408. Date:
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control
Act: �o 1ACC1409.
cuSigned by:
Office of the Chief Financial Officer � C 7/5/2019
Date:
704E51S
Legal Services
This agreement is approved as t OocuSigned by:
§WAk �t, �S(b 7/8/2019
Office of the County Attorney 079A4D525C0F4FB. 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:
Revised 6/19
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