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KITIACH, 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: 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 />Respite Care Rate: S Pei,_ _ <br />The provider- is <br />authorized to claim reimbursement as follows: <br />Code freauenCv cost (monthly) <br />Special Instructions: <br />Total Approved Cost: <br />Adee Turner. Care Manager <br />authori--ed signature <br />This authorization supplemen_s /replaces previous authorization <br />dated: <br />A monthly bill should be sent to: Dept. on Aginc <br />FN:R esoFrml <br />i❑o <br />Care Management Frogram 410 <br />Caldwell St. <br />Chapel Hill, N.C. 27516 <br />P 12--968 -4472 <br />