R 2017-399-E Health - Triangle Urology Associates, P.A. to provide vasectomy services to OCHD referred males

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DocuSign Envelope ID: 111672FC-E5A1-4E39-A023-8AC8C18839C7 ORANGE COUNTY-DEPARTMENT USE ONLY Department Party/Vendor Name: Triangle Urology Associates,P.A. Party/Vendor Contact Person: Pat Grinstead Contact Phone: 919-313-3662 Party/Vendor Address: 205 Frasier Street City Durham State: NC Zip: 27707 Department: Helath Amount: $8,000 Purpose: Provide vasectomy services to OCHD referred males. Budget Code(s): 10414020-630000- 71400 Vendor#63847 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 7-1-17 Approved by Board Yes No Agenda Date: This agreement is approved as to to tm�d'co11n��tent: 7:72. rlt,c-Att 8/17/2017 Department Director's Signature Date: 5E48F... Information Technologies (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 .7[ins�i m 'standards, specifications, and requirements: aMMS& CbVrn {b 8/17/2017 Office of the Risk Management Officer 7 Qe,4„= Date: Financial Services This instrument has been pre-audited i chittliffd P quired by the Local Government Budget and Fiscal Control Act: � Office of the Chief Financial Officer �� Date: 8/21/2017 �B4E5181ACC1100... Legal Services This agreement is approved as t n l=4i�t Nid sufficiency: al',U Aunt, 1 I Scb 8/21/2017 Office of the County Attorney Date: o7-07 Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd@orangecountync.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 2/17 5