R 2017-504-E Health - Piedmont Health Services for reimbursement for WIC hemoglobin testing

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DocuSign Envelope ID:6559831A-34F6-4E7D-8F67-060E5EABC688 PHS/OCHD Memo of Agreement ORANGE COUNTY—DEPARTMENT USE ONLY Department Party/Vendor Name: Piedmont Health Services Party/Vendor Contact Person: Ashley Brewer Contact Phone: 336-570-3739 Party/Vendor Address: PO Box 17179 City Chapel Hill State:NC Zip: 27516 Department: Health Amount: $10.000 Purpose: Reimbursement for WIC Hemoglobin Testing Budget Code(s): 10414001-476020- 71403 Vendor# 27898 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 7/1/17 Approved by Board Yes No Agenda Date: This agreement is approved as to tec 9aY`II 'll lld ; co tent: era 9/8/2017 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 sufficien • i,i at"e,standards,specifications,and requirements: Riskk. Cartulfh 9/8/2017 Office of the Risk Management Office 7FDCF9176900498... Date: Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: DocuSigned by: '�°' 9/8/2017 Office of the Chief Financial Officer 704E5-1-81 Arr44.09 Date: Legal Services This agreement is approved as t ecfbsigffdahtl sufficiency: a tAIAL 441t, 1 SCb 9/8/2017 or Office of the County Attorney L.070A4n525C11E4EB._. 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: 5