Orange County NC Website
Browse       Search
ORANGE COUNTY RESPITE DAY CARE <br />PROVIDER AGREEMENT <br />This is to certify that Charles House Association <br />(Name of Agency) <br />herein after known as the Provider agency, located at <br />109 Hillcrest Street, Carrboro N. C. 27510 <br />(Address) <br />on this first day of _ July, 1990 <br />agrees to participate as a provider in the Orange County Elderly <br />Program for the period July 1, 1990 through June 30, 1991. <br />1. The Provider agency agrees to provide necessary Respite service <br />to approved recipients at $30.00 per 8 hour day upon the request <br />of the Orange County Department on Aging's Care Management <br />Program hereinafter known as the lead Administrative <br />Aency. <br />2. The Provider agency agrees to meet all service provision <br />standards for Respite such as training as required by the <br />State of North Carolina and provide documentation upon request. <br />(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 recipient. <br />(Attachment B) <br />4. The provider agency agrees to ensure that such records as <br />necessary are kept to fully disclose the extent of the service <br />Provided to recipients for four years and available for <br />inspection. <br />5. The Provider agency agrees to submit a monthly bill for services <br />rendered payable within 30 days from date of receipt. <br />6. The Provider agency agrees to adhere to the Inter - agency Long Term <br />Care Management Procedures in the provision of the service. <br />(Attachment C) <br />'. This agreement may be terminated by Orange County upon giving <br />30 days prior written notice or by the Provider agency upon <br />giving 30 days prior written notice. However, Orange Count= <br />may immediately suspend a provider agency for violations of the <br />rules or regulations that govern: the program or this agreement. <br />Lead s ra ive cy Provider Agency <br />By: By:__ �. <br />Sig at e of Authorized A e Signature 8f Agent <br />Title of Auth rize6 gent <br />Date <br />FN:PROVIDER.DOC <br />LL: 4ic(� <br />Title of Authorized Agent <br />Date: We /? C) <br />