R 2016-113 Aging - NC Department of Insurance, Division of SHIIP for Medicare improvements

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ORANGE COUNTY-DEPARTMENT USE ONLY Department Party/Vendor Name: NC Department of Insurance,Division of SHIIP Party/Vendor Contact Person: Van Braxton Contact Phone:919-807-6900 Party/Vendor Address: 11 S Boylan Ave City Raleigh State: NC Zip: 27603 Department: Aging Amount: $1,933 Purpose: Medicare Improvements for Patients and Providers Act Budget Code(s): 10432005-444128 Vendor# 173 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 10/01/2015 Approved by Board Yes❑Non Agenda Date: This agreement is approved as to technical form and content: Department Director's Signature ".4 Date: Information TechnoloLies (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: Office of the Risk Management Officer- Date: Financial Services This instrument has been pre-audited in the 4rqu* d b y the Local Government Budget and Fiscal Control L Act: Office of the Chief Financial Officer Date: I Legal Services This agreement is approved as to legal f d suffi e cy: Office of the County Attorney Date: LL tj�, Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd@orangecountvnc.gov The following signature block is for hard copie �o d is t required for Docusign contracts: Office of the Clerk to the Board Date: Z� /