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ATY'ACHKENr B <br />ORANGE COUNTY ELDERLY CHORE PROGRAM <br />administered by <br />Orange County Department on Aging <br />PURCHASE OF SERVICE AUTHORIZATION <br />I. Client Information <br />Name: Tel. <br />Address; <br />Caregiver Name: Relationship <br />Client MIS information attached. <br />II. Respite Service Information <br />Authorization Date: Total approved Hours: <br />Authorized service from: To: <br />Chore Service Rate: s 8.00 Der direct service hour <br />The provider: <br />is authorized to claim reimbursement as follows: <br />Code fre uenc cost (monthly) <br />Total Approved Cost: <br />Special Instructions: <br />Adee Turner. Care Manager <br />authorized signature <br />This authorization supplements /replaces previous <br />- authorization dated: <br />A monthly bill should be sent to: Dept. on Aging <br />Care Management Program <br />410 Caldwell St. <br />Chapel Hill, N.C. 2 <br />11/89 7516 <br />FN:CharFrm,T 919 -968 -4478 <br />