R 2015-311-E DSS - OPT - Memorandum of Understanding to provide Medicaid transportation to eligible clients

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DocuSign Envelope ID:0806BD7C-9E5B-4DB8-9CC2-8583BB1 EA400 ORANGE COUNTY--DEPARTMENT USE ONLY Department Party/Vendor Name: Orange Public Transportation Party/Vendor Contact Person: Craig Benedict Contact Phone: (919)245-2592 Party/Vendor Address: 600 Hwy City Hillsborough State: NC Zip:27278 Department: DSS Amount: $12.75 per one way trip Purpose: Provide Medicaid transportation to eligible clients_ Budget Code(s): 10400020-760021 Vendor# (NIA if new vendor) Vendor is a BOCC consultant? Yes ❑No❑ Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 07/01/15 Approved by Board Yes® No❑ Agenda Date: This agreement is approved as to technical fo EloevsiiR py: NAArt.G� Sf01�, 6/29/2015 Department Director's Signature �,Ea��nea.B�=� Date: Information Technologies (Applicable only to hardware/so_ftware 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 insur g@agMw&y:speciVlit fcations, and requirements: QUs& r,6 6 6/29/2015 Office of the Risk Management Officer 7FnrFan6an04g8_ Date: Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Art: DocuSigned by: INAL tA+6VU Office of the Chief Financial Officer BfFEZC-rte Date: 6/29/2015 Legal Services This agreement is approved as to legal form and suf7u,,gned by: 6/29/2015 Office of the County Attorney l Date: Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd(a,oranQecountync.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: