Orange County NC Website
Browse       Search
ATTACH-Mr. B <br />ORANGE COUNTY RESPITE CARE PROGRAM <br />administered by <br />Orange County Department on Aging <br />PURCHASE OF SERVICE AUTHORIZATION <br />I. Client Information <br />Name: <br />Address: <br />Caregiver Name: <br />Client MIS information attached. <br />II. Respite Service Information <br />Authorization Date: <br />Authorized service from: <br />Tel. <br />elationship <br />Total approved Hours: <br />Respite Care Rate: <br />-per <br />To: <br />The Provider: <br />authorized to claim reimbursement as follows: <br />Cade fre uencv cost (monthl ) <br />Special Instructions: <br />Total Approved Cost: <br />Adee Turner, Care Manager <br />authorized signature <br />This authorization supplements /replaces previous authorization <br />dated: <br />A monthly bill should be sent to: <br />FN :RespFrmi <br />11 /$9 <br />Dept. on Aging <br />Care Management Program 410 <br />Caldwell St. <br />Chapel Hill, N.C. 27516 <br />919 -968 -4478 <br />is <br />