2021-399-E-Health-Triangle Urology Services PA-Provide vasectomy services to OCHD referred males

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Revised 6/21 9 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: Triangle Urology Associates, P.A. Party/Vendor Contact Person: Kimberly Lowery Contact Phone: 919-313-3662 Party/Vendor Address: 205 Frasier Street City Durham State: NC Zip: 27707 Department: Health Amount: $9,000 Purpose: Provide vasectomy services to OCHD referred males. Budget Code(s): 10414020-630000-71400 Vendor # 63847 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-21 Approved by Board Yes No Agenda Date: This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: Department Director’s Signature ________________________________________ Date: ________ Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: Information Technologies (Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts : Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: 609A8FBA-BBE6-486F-A19F-DE5ACA21D721 7/19/2021 7/19/2021 7/20/2021 7/20/2021