R 2016-352-E Health - Family Centered Healthcare, PA - primary care for uninsured males of Orange County

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DocuSign Envelope ID:977F9724-OD69-4F35-BE42-796A38945969 ORANGE COUNTY-DEPARTMENT USE ONLY Department Party/Vendor Name: Family Centered Healthcare, PA Party/Vendor Contact Person: Amanda Dorthv 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): 10414020-630000-71422 Vendor # 63536 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 7/1/16 Approved by Board Yes❑Nor-1 Agenda Date: This agreement is approved as to to ea1u£ta"lind content: Department Director's Signature �1_ Date: 7/6/2016 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 sufficient I' qtr ''l"" �'�tandards, specifications,and requirements: QUSA rbrwc 116 7/6/2016 Office of the Risk Management Officer ,F �Fg„549� Date: Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: DocuSigned by: Office of the Chief Financial Officer rl� �an=arm. Date: 7/13/2016 ea€sa. .. Legal Services This agreement is approved as tq4egaicComcmd sufficiency: Office of the County Attorney ��q 1-.1 Date: 7/13/2016 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: Revised 6/16 8