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• <br /> N.C. Department of Environment, Health, and Natural Resources Page 1 of 2 <br /> Division of General Services <br /> FY 1993-1994 <br /> CONTRACT ADDENDUM <br /> Children and Youth Section 93-5323-068 <br /> Office, Section, or Branch Contract Number <br /> Orange County Health Department Children's Special <br /> Scoliosis Clinic ADMINISTRATIVE SECTION Health Services <br /> Contractor Activity <br /> An estimated . _35 (total number) of clients will be served through this clinic. <br /> Refer to HSIS Report: HBS 124 II. <br /> 3. An estimated 25 (number) of new clients will be admitted to this clinic. <br /> Refer to HSIS Report: HBS 124 II. <br /> 3. An estimated 35 (number) of client visits will be made to this clinic. <br /> Refer to HSIS Report: HBS 124 III. • <br /> An estimated N/A (number) of eligible* clients will receive speech therapy. <br /> Refer to HSIS Report: HBS 124 IIIB. Applies only to Speech and Hearing Clinics. <br /> 5. List counties which are served by this clinic. <br /> 1. Orange 3. 5. <br /> 2. 4. 6. <br /> List all services funded through this contract, such as laboratory and diagnostic services, <br /> casting, therapy, etc. <br /> 1. x-rays 2. 3.. <br /> 4. 5. 6. <br /> 7. Attach a copy of the eligibility criteria used in this clinic. <br /> CSHS Criteria <br /> 3. Do you bill individuals above poverty for diagnostic services? Yes' J NoJT If yes, attach <br /> copy of fee schedule. <br /> 3. When do you complete a financial eligibility foim? <br /> ]1st visitflonce diagnosis is made Uwhen a cost service is needed[ they Please <br /> explain none completed <br /> 3. Do you bill private insurance? Yes[1 No 71 <br /> 1. Attach a list of subcontractors funded by this contract stating name, address and discipline, <br /> e.g. identify the physicians who staff the clinic, sources of x-rays, therapists, etc. <br /> N.C. Spine Center, Dr. Stephen Grubb, 101 Conner Dr. , Suite 200, Chapel Hill, NC 27514 <br /> 2. Who are the durable medical equipment suppliers? Applies to Orthopedic, Neuromuscular, and <br /> Myelodysplasia Clinics. <br /> Name: N/A Company: Phone: <br /> 3. Who is the clinic coordinator or contact person? 14. Name of person who completed the contra <br /> addendum: <br /> Name: Leigh McFalls Phone: (919) Name Leigh McFalls Phone: (919) <br /> 732-8181 d 732-8181 ext. .2400 <br /> 2lients not covered by Medicaid or other thi€4tpatfQ9 Reviewed y <br /> DEHNR 3300 (Revised 2/90) `� �� J�3 <br /> General Services Division (Review 1/95) Initials J Date <br />