Orange County NC Website
Browse       Search
ATTACHMENT 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 Rate; $ per <br />Tel.. <br />Relationship <br />Total approved Hours: <br />To: <br />The provider: <br />authorized to claim reimbursement as follows: <br />Code fre uencv cast (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: Dept. on Aging <br />FN:RespFrml <br />11/89 <br />Care Management Program 410 <br />Caldwell St. <br />Chapel Hill, N.C. 27516 <br />919 -968 -4478 <br />is <br />