Orange County NC Website
Browse       Search
Revised 10/17 <br />9 <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br />Department <br /> <br />Party/Vendor Name: Family Centered Healthcare, PA Party/Vendor Contact Person: Anissa Vines Contact Phone: <br />919-245-3247 Party/Vendor Address: 400 Millstone Drive, Suite 100 City Hillsborough State: NC Zip: 27278 <br />Department: Health Amount: $5,000 Purpose: Provide Primary Care for uninsured males of Orange County <br />Budget Code(s): 10414020-630000-71422 Vendor # 63536 (N/A if new vendor) Vendor is a BOCC consultant? <br />Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-2018 <br />Approved by Board Yes No Agenda Date: <br /> <br />This agreement is approved as to technical form and content: <br /> <br />Department Director’s Signature ________________________________________ Date: ________ <br /> <br /> <br />Information Technologies <br /> <br />(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is <br />approved as to information technology content and specifications: <br /> <br />Office of the Chief Information Officer___________________________________ Date: ________ <br /> <br /> <br />Risk Management <br /> <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br /> <br />Office of the Risk Management Officer___________________________________ Date: _________ <br /> <br /> <br />Financial Services <br /> <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br />Act: <br /> <br />Office of the Chief Financial Officer ____________________________________ Date: _________ <br /> <br /> <br />Legal Services <br /> <br />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney __________________________________________Date: ________ <br /> <br /> <br />Clerk to the Board <br /> <br />Received for record retention: <br />All Docusign contracts must be copied to Sherri Ingersoll upon completion: singersoll@orangecountync.gov <br />The following signature block is for hard copies only and is not re quired for Docusign contracts: <br /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br /> <br /> <br /> <br />DocuSign Envelope ID: B7DABF9A-D92E-48BA-BC0B-AFFC399D4D85 <br />8/6/2018 <br />8/6/2018 <br />8/8/2018 <br />8/8/2018