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I <br />r <br />-ORANGE COUNTY IN -HOME 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: <br />Client MIS information attached. <br />II. In -Home Service Information <br />Authorization Date: <br />Authorized service from: <br />Rate: <br />Attachment B <br />Relationship, <br />Total approved Hours: <br />To: <br />The provider: <br />is authorized to claim reimbursement as follows: <br />Code frequency cost (monthly) <br />Total Cost: <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. 27516 <br />FN:RespFrm2 919 -968 -4478 <br />05/91 <br />s <br />