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OL%AINGE COUNTY RESPITE DAY CARE <br />PROVIDER AGREEMENT <br />This is to certify that Sharon's Way Adult Day Care <br />(Name of Agency) <br />herein after known as the Provider agencv, lc.cated at <br />4907 Garrett Road, Durham, N. C. 27701 <br />(AddresE) <br />=zz, <br />on this dad` of JUIV, 1990 <br />agrees to participate as a provider in the Orange County Elderly <br />Program for the period July 1, 1990 through June 30, 1491. <br />I. The Provider agency agrees to provide necessary Respite service <br />to approved recipients at 522.00 per 8 hour da'v 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 serv:lce <br />within two weeks from the beginning service date specified in the <br />Purchase of Service Authorization: on each approved recipient. <br />(Attachment E) <br />4. The provider agency agrees to ensure that such records as <br />necessary are kept to full\- disclose the e� :tent of the service <br />provided to recipients for four years and available for <br />inspection. <br />5. The Provider agency agrees tc submit a monthly_- bill for services <br />rendered payable within 30 davE from date of receipt. <br />6. The Provider agency agrees to adhere to the Inter - agencv Long_ Term <br />Care Management Procedures in the provision of the service. <br />(Attachment C) <br />i. This agreement may be terminated by Orange County upon. Giving <br />30 dabs prior vritten notice or by the Provider agencv uoon <br />giving 30 days prior written notice. However, Orange Countv <br />may immediately suspend a provider agency- for violatlonE of the <br />rules or regulations that govern the program or this agreement. <br />Lead Age c1 Provi ' A ency <br />By: By. <br />S nature of Auth zee: Agen_ Signa,ir-e of Age <br />� � mob• �XEGUi`i`(�. Y /��G�� <br />`Azle o� Aut oriz <br />e. en- _4.e _ yu- °;o -�zec <br />Date: <br />I _000 <br />FN:PROVIDER.DOC <br />