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DocuSign Envelope ID:90B9D659-59OB-40CA-85C6-4FA2FEE9lF35 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: ZirMed Inc Party/Vendor Contact Person: Ann Campbell Contact Phone: Party/Vendor <br /> Address: 501 N Broadway,3rd Floor City St. Louis State: Missouri Zip: 63102 Department: Tax Administration <br /> Amount: $9,400 Purpose: Provide electronic submission of patient claims and other ancillary EDI services for In- <br /> House Ambulance Billing and Collection. Budget Code(s): 10335020-630000 Vendor#N/A (N/A if new vendor) <br /> Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New® Renewal❑ Amendment ❑ <br /> Effective Date January 1,2016 Approved by Board Yes❑Nor-1 Agenda Date: <br /> This agreement is approved as to technical forth and cgn tTtt:Aned by: <br /> Department Director's Signature pWam, j5n,vuS6vu Date: 1/11/2016 <br /> 5EDD78428EB34BF... <br /> Information Technolosies <br /> (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is <br /> approved as to information technology content and specifications: <br /> Docu5igned by: <br /> Office of the Chief Information Officer <br /> 53lM W Date: 1/11/2016 <br /> C11BA91E73A64DF... <br /> Risk Management <br /> This agreement is approved for sufficiency of insurance standards,specifications,and requirements: <br /> Docu5igned""by: <br /> ''11i1 <br /> Office of the Risk Management Officer Pausa, (,6rvu,�16 Date: 1/12/2016 <br /> 7FDCF9176800498... <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: F�-CN ocuSigned by: <br /> Office of the Chief Financial Officer Date: 1/12/2016 <br /> 7D4E5181ACC1409... <br /> Legal Services <br /> This agreement is approved as to legal form and stied by: <br /> �bUIn, <br /> Office of the County Attorney �( Date: 1/12/2016 <br /> 165- <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydkorangecount.nic.gov <br /> The following signature block is for hard copies only and is not required for Docusign contracts: <br />