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DocuSign Envelope ID: D51D1329-1679-44BC-B77D-140BBBB1055F <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: $380 Purpose: Additional service for existing contract for electronic submission of patient claims 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 March 31,2016 Approved by Board Yes❑Nor-1 Agenda Date: <br /> This agreement is approved as to techni&oal�E°�� content: <br /> Department Director's Signature E5EDD78428EB34BF Wam, }5jVVUS6vu Date: 4/1/2016 <br /> . <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 Office <br /> r3 W Date: 4/1/2016 <br /> C11BA91E73A64DF... <br /> Risk Management <br /> This agreement is approved for sufficiency of insurance standards,specifications,and requirements: <br /> Docu5ig/'ned""by: <br /> ''11i1 <br /> Office of the Risk Management Officer usa. (,6rvu,�16 Date: 4/3/2016 <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: DocuSigned by: <br /> Office of the Chief Financial Officer Date: 4/6/2016 <br /> 7D4E5181ACC1409... <br /> Legal Services <br /> This agreement is approved as to le g.W)ria end sufficiency: <br /> 6LVt' r6UfS <br /> Office of C�jEAA3D33ED8A8465... <br /> the County Attorne Date: 4/6/2016 <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 /> Office of the Clerk to the Board Date: <br />