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ORANGE COUNTY RESPITE HOME CARE <br />PROVIDER AGREEMENT <br />This is to certify that Home Health Agency of-Chapel Hill, Inc <br />(Name of Agency) <br />herein after known as the Provider agency, located at <br />101 Ephesus Church Road, Chapel Hill, N. C. <br />(Address) <br />on this day of July, 1990 <br />agrees to participate as a provider in the Orange County Elderly <br />Program for the period July 1, 1990 through June 30, 1991. <br />1. The Provider agency agrees to provide necessary Respite service <br />to approved recipients at $9.00 per hour 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 service <br />within two weeks from the beginning service date specified in the <br />Purchase of Service Authorization on each approved recipient. <br />(Attachment B) <br />4. The provider agency agrees to ensure that such records as <br />necessary are kept to fully disclose the extent of the service <br />provided to recipients for four years and available for <br />inspection. <br />5. The Provider agency agrees to submit a monthly bill for services, <br />rendered payable within 30 days from date of receipt. <br />6. The Provider agency agrees to adhere to the Inter - agency Long Term <br />Care Management Procedures in the provision of the service. <br />(Attachment C) <br />�. This agreement may be terminated by Orange County upon giving <br />30 days prior written notice or by the Provider agency upon <br />giving 30 days prior written notice. However, Orange Countv <br />may immediately suspend a provider agency for violations of the <br />rules or regulations that govern the program or this agreement. <br />Lead Inare istratic= A envy Prov'd r A ency <br />By: By: <br />Sig of Authorized g nt Signature of Agent <br />"itie of AuthoIzed Agent v� Title <br />C U2 <br />Of' Authorized ?;gent <br />Date: <br />FN:PROVIDER.DOC <br />Date: <br />