Authorization of Payment. By making intial payment you authorize the COMPANY to charge your credit card or cash your check as payment for your membership in the Program, if the COMPANY accepts you into the Program. This is not an installment contract. Furthermore, you agree that if you are accepted into the Program you are responsible for full payment of fees for the entire Program (the “Commitment Period”), regardless of whether you actually attend or complete the Program, and regardless of whether you have selected a lump sum or monthly payment plan. By paying in full or making a down payment for this program you agree that, if, for any reason, you choose to remove or cancel yourself out of the program prior to the end date of the Commitment Period, you are obligated to pay or continue paying any outstanding balance(s). Failure to make payment will remove you from the program, but will not remove the payment obligation. To further clarify, no refunds will be issued and all scheduled payments must be paid on a timely basis whether you complete the Program or not.
Authorization of Payment. Notwithstanding part 4, if Customer has a credit card on file with Contractor, Contractor may schedule the Work prior to the charge of the Final Payment, and Customer agrees to allow Contractor to charge the Final Payment one day prior to the commencement of the Work. If Contractor is unable to process the credit card payment prior the commencement date of the Work, Contractor is its sole discretion can reschedule the date the Work is to begin.
Authorization of Payment. The payment of a Fair Share/Representation Fee is a condition of employment. Therefore, the District agrees that effective after ratification of this Agreement and upon notification by the Association, it will deduct the Fair Share/Representation Fee from the monthly earnings of non- Association members. The Board agrees to withhold said monies by deductions in the same manner as it does with the dues of Association members. Beginning with 2003, each individual contract of employment will contain the following authorization for payroll deduction of the Fair Share/Representation Fee. In signing this contract, the employee authorizes and directs the District to deduct from his/her monthly earnings such amounts as are required to pay the Association’s Fair Share/Representation Fee. The Fair Share/Representation Fee will be Unified Dues paid by regular Association members.
Authorization of Payment. I request payment of authorized benefits be made on my behalf for services rendered by ERCC and other related facilities. I hereby authorize Medicare or Medicaid to pay directly to the billing party or parties statements received from ERCC and to pay any physicians for services rendered to me. I authorize any and all nursing facilities, hospitals or physicians to furnish to ERCC, the Social Security Administration or their agents, the State DHHR and all fiscal intermediaries and insurance carriers all requested information from my medical record needed for payment of services rendered to me. I authorize ERCC to disclose any necessary part of my medical record to any person or entity which is or may be liable under contract to ERCC, to me, or my legal representative to pay all or a portion of the cost of care provided to me, including, but not limited to, hospital, or medical service companies, health care companies, insurance companies, or welfare funds.
Authorization of Payment. I hereby assign all medical benefits directly to Obstetrics & Gynecology of North Texas for the payment of any services rendered. I also authorize release of medical records necessary to process my health claims. I fully understand that in the event my insurance provider does not pay for services I received; I will be financially responsible for all balances.
Authorization of Payment. I hereby assign all benefits directly to Xxxxxxxx Physical Therapy and authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the services I receive; I will be financially responsible for payment. ___________
Authorization of Payment. I hereby authorize the provider of services to release information concerning my examination and/or treatment for insurance purposes and to receive direct payment for benefits payable to me for services rendered. CANCELLATIONS Cancellations must be made twenty-four hours in advance to avoid charge. Missed appointments will be charged at the regular fee. NSF CHECKS AND REJECTED CREDIT CARD CHARGES There will be a $35 charge for each NSF check. WRITTEN ACKNOWLEDGEMENT AND CONSENT TO COUNSELING I have reviewed this Counseling Agreement, including the summary of Privacy Policy. I understand that I have the right to request restrictions as to how my health information may be used or disclosed and that the organization is not required to agree to the restrictions I request. I accept this agreement and herewith consent to counseling. Client Name (Please Print) Client or Parent/Legal Guardian/Legal Representative Signature Printed Name Date
Authorization of Payment. Subject to the ENTITY’S satisfactory performance and compliance with the terms of this AGREEMENT, the CITY agrees to pay the ENTITY up to fifty percent (50%) of the Project. The Project is estimated to be $ and fifty percent of which is $ Payment will be made within forty-five (45) days of acceptance of the complete Post Event Report. Partial or incomplete reports will not be accepted. Only expenditures that meet Chapter 351 of the Tax Code and this AGREEMENT shall be reimbursed.
Authorization of Payment. I hereby assign all Medical benefits directly to Academy Foot & Ankle Specialists for the payment of any services rendered. I also authorized release of medical records necessary to process my health claims. I fully understand that in the event my insurance company does not pay for the services I received, I will be financially responsible for payment. We are dedicated to providing the best possible care and service to you and regard your complete understanding of our policies as an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or supervisor. Patient’s Name: Signature of Patient/Guardian: Date:
Authorization of Payment. Subject to the Chamber’s satisfactory performance and compliance with the terms of this Agreement, the City agrees to provide funding to the Chamber in equal quarterly payments from City Hotel Occupancy Tax funds as authorized by the City Council in the City Annual Operating Budget. Quarterly payments will be made after services have been provided and within thirty (30) days of receiving the required reports.
