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Attachment B <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: Relationship <br />Client MIS information attached. <br />II. In -Home Service Information <br />Authorization Date: Total approved Hours: <br />Authorized service from: To: <br />Rate: <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 />