R 2016-405-E Health - Piedmont Health Services, Inc. for support for medical and dental care

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DocuSign Envelope ID: 58ED7F55-231C-4FAC-AD50-6415BD24288B ORANGE COUNTY—DEPARTMENT USE ONLY Department Party/Vendor Name: Piedmont Health Services,Inc Party/Vendor Contact Person: Jen Cunningham Contact Phone: (919) 913-1097 Party/Vendor Address: PO Box 17179 City Chapel Hill State: NC Zip: 27516 Department: Health Amount: $11,000 Purpose: Support for medical and dental care Budget Code(s): 10414020-630000 Vendor# 27898 (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[]No❑ Agenda Date: 6/21/16 This agreement is approved as to to mPa4°�slid content: 4%_ � � 7/23/2016 Department Director's Signature Date: 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 I�l €iari wstandards, specifications,and requirements: gusa, r,Orwc,�16 7/26/2016 Office of the Risk Management Officer�F„GFg„FR„04QR Date: Financial Services DocuSi ned b This instrument has been pre-audited i the manger equired by the Local Government Budget and Fiscal Control Act: 7/26/2016 Office of the Chief Financial Officer Lita 4E51a1ACC140s... Date: Legal Services This agreement is approved as t egaDPT(ol ai�'d sufficiency: �q 1�- 7/27/2016 Office of the County Attorney 4035CE3304CA4A9 Date: 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: Piedmont Healtb Services,Inc. Orange County Performance Agreement Page 7 Rev. 712096