Orange County NC Website
PHS/OCHD Memo of Agreement <br /> 5 <br /> <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br /> <br />Party/Vendor Name: Piedmont Health Services Party/Vendor Contact Person: Ashley Brewer Contact Phone: 336- <br />382-0242 Party/Vendor Address: 88 Villcom Cntr. Dr., Ste 110 City Chapel Hill State: NC Zip: 27514 Department: <br />Health Amount: $3,000 Purpose: Reimbursement for WIC Hemoglobin Testing and use of facilities Budget Code(s): <br />10414001-476020-71403 - This is a contract for Piedmont to pay us. Vendor # 27898 (N/A if new vendor) Vendor <br />is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective <br />Date 7-1-22 Approved by Board Yes No Agenda Date: --- For Section XIV. c. contracts only, Approved <br />by Board in Current FY Budget Yes No <br /> <br />This agreement is approved as to technical form and content and I as Department Director affirmatively state work on <br />this project has not been initiated prior to execution of the agreement: <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 de scribe the nature of the emergency condition that <br />was addressed: <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 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 />Clerk to the Board <br /> <br />Received for record retention: <br />All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@or angecountync.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: CA985EC6-D34F-4940-83FD-DFD88C4FA5EC <br />8/2/2022 <br />8/2/2022 <br />8/2/2022 <br />8/2/2022