WHO WILL REVIEW THE INFORMATION DISCLOSED ON THE RELATIONSHIP DISCLOSURE FORM AND ANY UPDATES? The information disclosed on this form and any updates will be a public record as defined by Chapter 119, Florida Statutes, and may therefore be inspected by any interested person. Also, the information will be made available to the Mayor and the BCC members. This form and any updates will accompany the information for the applicant’s project or item. However, for development-related items, if an applicant discloses the existence of one or more of the relationships described above and the matter would normally receive final consideration by the Concurrency Review Committee or the Development Review Committee, the matter will be directed to the BCC for final consideration and action following committee review.
Scope of Communications to Be Provided in Electronic Form When you use a product or service to which this Disclosure applies, you agree that we may provide you with any Communications in electronic format, and that we may discontinue sending paper Communications to you, unless and until you withdraw your consent as described below. Your consent to receive electronic Communications includes, but is not limited to: • All legal and regulatory disclosures and communications associated with your Card Account and any related products or services • Your Cardholder Agreement and any notices about a change in terms of your Cardholder Agreement • Privacy policies and notices • Error resolution policies and notices • Responses to claims filed in connection with your Card Account • Notices regarding insufficient funds or negative balances
Updating Contact Information I understand and agree that I am responsible for keeping Lock Haven University records up to date with my current physical addresses, email addresses, and phone numbers by following the procedure at MyHaven Change of Address/ Phone Form. The linked procedure is incorporated herein by reference. Upon leaving Lock Haven University for any reason, it is my responsibility to provide Lock Haven University with updated contact information for purposes of continued communication regarding any amounts that remain due and owing to Lock Haven University. ENTIRE AGREEMENT This agreement supersedes all prior understandings, representations, negotiations and correspondence between the student and Lock Haven University constitutes the entire agreement between the parties with respect to the matters described, and shall not be modified or affected by any course of dealing or course of performance. This agreement may be modified by Lock Haven University if the modification is signed by me. Any modification is specifically limited to those policies and/or terms addressed in the modification. FINANCIAL AID I understand that aid described as “estimated” on my Financial Aid Award does not represent actual or guaranteed payment, but is an estimate of the aid I may receive if I meet all requirements stipulated by that aid program. I understand that my Financial Aid Award is contingent upon my continued enrollment and attendance in each class upon which my financial aid eligibility was calculated. If I drop any class before completion, I understand that my financial aid eligibility may decrease and some or all of the financial aid awarded to me may be revoked. If some or all of my financial aid is revoked because I dropped or failed to attend class, I agree to repay all revoked aid that was disbursed to my account and resulted in a credit balance that was refunded to me. I agree to allow financial aid I receive to pay any and all charges assessed to my account at Lock Haven University such as tuition, fees, campus housing and meal plans, student health insurance, parking permits, service fees, fines, bookstore charges, or any other amount, in accordance with the terms of the aid. Federal Aid: I understand that any federal Title IV financial aid that I receive, except for Federal Work Study wages, will first be applied to any outstanding balance on my account for tuition, fees, room and board. Title IV financial aid includes aid from the Pell Grant, Supplemental Educational Opportunity Grant (SEOG), Direct Loan, PLUS Loan, Xxxxxxx Loan, and TEACH Grant programs. I authorize Lock Haven University to apply my Title IV financial aid to other charges assessed to my student account such as student health insurance, parking permits, bookstore charges, service fees and fines, and any other education related charges. I may withdraw it at any time by notifying the Financial Aid Office in writing. Prizes, Awards, Scholarships, Grants: I understand that all prizes, awards, scholarships and grants awarded to me by Lock Haven University will be credited to my student account and applied toward any outstanding balance. I further understand that my receipt of a prize, award, scholarship or grant is considered a financial resource according to federal Title IV financial aid regulations, and may therefore reduce my eligibility for other federal and/or state financial aid (i.e., loans, grants, Federal Work Study) which, if already disbursed to my student account, may need to be reversed and returned to the aid source.
Changes to the Notice Information Either Party may change this information by giving five Business Days written notice prior to the effective date of the change.
Email Notice Any reference in this Agreement to “written notice” shall include notice by email, where there is reasonable certainty that such email notice originated either from a valid OANDA email address, or from the email address registered to your Account, as the case may be, and may be relied upon as valid and authentic written communication.
Notice Information Notice identifier/version: 4b0dc758f0da45e7b7bb8b9faca6d8be 01 Form type: Competition Notice type: Contract or concession notice – standard regime Notice dispatch date: 20240201Z 23:32:31Z Languages in which this notice is officially available: English
Method of Providing Communications to You in Electronic Form All Communications that we provide to you in electronic form will be provided either (1) via e-mail, (2) by access to a web site that we will designate in an e-mail notice we send to you at the time the information is available, (3) to the extent permissible by law, by access to a web site that we will generally designate in advance for such purpose, or (4) by requesting you download a PDF file containing the Communication.
Relationship Disclosure Form The purpose of this form is to document any relationships between a bidder to an Orange County solicitation and the Mayor or any other member of Orange County, Florida. This form shall be completed and submitted with the applicable bid to an Orange County solicitation. No contract award shall be made unless these forms have been completed and submitted with the bid. Any questions concerning these forms shall be addressed to the contracting agent identified in this solicitation. Also, a listing of the most frequently asked questions concerning these forms is attached to each for your information.
Service Information Service Visit Date Mode of service Face-to face, telephone, etc. Responsibility for payment Used to exclude federal govt., WCB, etc. Main and secondary diagnoses ICD10-CA codes Main and other interventions and attributes CCI procedure codes and attributes Type of Anesthetic Identifies the type used for interventions (general, spinal, local, etc.) Provider types NACRS code assigned to provider type (MD, Dentist, RN, etc.) Doctor name and identifier Physician specific information Admit via Ambulance Used if a Client is brought to the service delivery site by ambulance Institution from and institution to Used when a Client is transferred from or to another acute care facility Visit disposition Discharged, admitted, left without being seen, etc. Schedule “D” Appendix 2 Additional Elements Required for Data Management (XXX) Client Identifying Information Province Client‟s Home Province AB, BC, SK, MB, NL, PE, NS, NB, QC, ON, NT, YT, NU, US, OC (Other Country), NR (Unsp. Non-resident) Service Information Facility Code AHS provided code that indicates service being provided. Facility Fee Dollar value of service being provided Alberta Health Physician Fee Billing Code Alberta Health Physician Service Fee code that further defines facility code Regional standard format and submission method remains as is via excel file and email. NOTE: Submission method may be adjusted in accordance with security standards of AHS. Schedule “D” Appendix 3
Notice of Dispute The party wishing to commence the dispute resolution process must give written notice (Notice of Dispute) to the other parties of:
