R 2016-147-E Health - Family Centered Healthcare, PA to provide primary care for uninsured males in OC

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DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 ORANGE COUNTY—DEPARTMENT USE ONLY Department Party/Vendor Name: Family Centered Healthcare, PA Party/Vendor Contact Person: Amanda Dorthy Contact Phone: 919-245-3247 Party/Vendor Address: 400 Millstone Drive, Suite 100 City Hillsborough State: NC Zip: 27278 Department: Health Amount: $30.000 Purpose: Provide Primary Care for uninsured males of Orange Count Budget Code(s): 10414020-630000-71414 Vendor # 63536 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ® Renewal ❑ Amendment ❑ Effective Date 2/1/16 Approved by Board Yes❑Nor-1 Agenda Date: This agreement is approved as to to /eatufl"and content: Department Director's Signature bv4r Date: 1/28/2016 69EB99BFC-.F;B5 4 5E... Information Technolosies (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 sufficienc Iastandards, specifications,and requirements: gusa. (hVV ,�16 1/28/2016 Office of the Risk Management Office Date: Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: EDocuSigned by: Office of the Chief Financial Officer Date: 2/9/2016 Legal Services This agreement is approved as t eg9FT&4f Hd sufficiency: Office of the County Attorney , Date: 2/16/2016 �,1 y 4035C88304CA4A9... Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydkorangecount.nic.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: