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ORANGE COUNTY RESPITE CARE PROGRAM <br />PROVIDER AGREEMENT AGR=1 12-IT rOPA <br />(Sample) <br />This is to certify that Hom Health Agency of Chapel Hill, Inc. <br />( Name of Provider agency ) <br />hereinafter known as the Provider agenvy, located at <br />101 Ephesus Church Rd., Chapel Hill, N.C. 27514 <br />(address) <br />on this day of <br />agrees to participate as a provider in the Orange County Respite Care <br />Program for the period October 1, 1989 through June 30, 1990. <br />1. The Provider agency agrees to provide necessary respite service <br />to approved recipients at a $ per upon the <br />request of the Orange County Department on Aging's Care Management <br />Program, hereinafter known as the Lead Administrative Agency. <br />2. The Provider agency agrees to meet all service provision <br />standards such as training as required by the State of North <br />Carolina and provide documentation upon request. (Attachment A) <br />3. The Provider agency agrees to provide the respite service <br />within two weeks from the beginning service date specified in the - <br />Purchase of Service Authorization on each approved <br />recipient. (Attachment B) <br />4. The Provider agency agrees to provide a Respite worker <br />with above minimum training if the recipient's condition <br />is judged by the Lead Administrative Agency to require it. <br />S. The Provider agency agrees to ensure that such records as <br />necessary are kept to fully disclose the extent of the <br />service provided to recipients for four years and available <br />for inspection. <br />6. The Provider agency agrees to submit a monthly bill for <br />services rendered payable within 30 days from date of receipt. <br />7. The Provider agency agrees to adher to the Inter - agency Long <br />Term Care Management Procedures in the provision of Respite Care <br />Service. (Attachment C) <br />8. This agreement may be terminated by 'Orange County upon giving 30 <br />days prior written notice or by the Provider agency upon giving 30 <br />days prior written notice. However, Orange County may immediately <br />suspend a provider agency for violations of the rules or <br />regulations that govern the program or this agreement. <br />Lead Administrative Agency <br />By: Hy: <br />Signature of Authorized Agent <br />Title of Authorized Agent <br />Date: Date: <br />FN:RESPAGRE.DOC <br />Provider Agency <br />Signature of Agent <br />Title of Authorized Agent <br />