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PHS/OCHD Memo of Agreement <br /> 5 <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br />Department <br /> <br />Party/Vendor Name: Piedmont Health Services Party/Vendor Contact Person: Ashley Brewer Contact Phone: <br />336-382-0242 Party/Vendor Address: 127 Kingston Drive City Chapel Hill State: NC Zip: 27514 Department: <br />Health Amount: $3,000 Purpose: Reimbursement for WIC Hemoglobin Testing Budget Code(s): 10414001- <br />476020-71403 Vendor # 27898 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract <br />Type: (Check one) New Renewal Amendment Effective Date 7/1/20 Approved by Board Yes No <br /> Agenda Date: <br /> <br />This agreement is approved as to technical form and content and I as Department Director affirmatively state work <br />on this project has not been initiated prior to execution of the agreement: <br /> <br /> <br />Department Director’s Signature ________________________________________ Date: ________ <br />Agreements for emergency services or repair are not subject to the above affirmation. If services related to this <br />agreement have already begun or been completed please briefly describe the nature of the emergency condition that <br />was addressed: We were waiting on the COI. This is a contract for Piedmont to pay us. <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 />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 />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 />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 required for Docusign contracts: <br /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br /> <br />DocuSign Envelope ID: 8B9EAFDE-602B-4270-B87F-8DFC5B17EB6E <br />10/6/2020 <br />10/7/2020 <br />10/8/2020 <br />10/8/2020