R 2017-400-E Health - Piedmont Health Services, Inc. - Outside Agency Performance Agreement

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DocuSign Envelope ID:E8163127-982F-4CDF-AAFE-9EAE17837984 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: 127 Kingston Drive City Chapel Hill State: NC Zip: 27514 Department: Health Amount: $16,500 Purpose: Support for medical and dental care Budget Code(s): 10495050-719021 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: 6/20/17 This agreement is approved as to to :O rd ifit atent: 8/17/2017 Department Director's Signature 5145A2CD945C40F... Date: 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 sufficient '7Oxi 'antains'taandards,specifications, and requirements: aMtSA. rblet/ut 6 8/17/2017 Office of the Risk Management Officer 7 Qe, „= Date: Financial Services This instrument has been pre-audited i e9'PfaNei iluired by the Local Government Budget and Fiscal Control Act: A" o°"D 8/21/2017 Office of the Chief Financial Officer 71)4F5181ACC14o9 Date: Legal Services This agreement is approved as t e R1'f( �a 11'd Buff ciency: L " - m' -Sfa 8/21/2017 Office of the County Attorney o79A4�525COF4FB... Date: 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: Piedmont Health Services,Inc. Orange County Performance Agreement Page 7 Rep. 7/2017