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ATTACHKENT 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 />Respite Care Fate: $ per <br />Tel.. <br />Relationship <br />Total approved Hours: <br />To: <br />The provider: <br />is <br />authorized to claim reimbursement as follows: <br />Code frQ uencv cost (monthly) <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: Dept. on Agin <br />9 <br />FN :RespFrmi <br />11/89 <br />Care Management Program 410 <br />Caldwell St. <br />Chapel Hill, N.C. '27516 <br />919- 968 --4478 <br />