CLIENT INFORMATION FORM Sample Clauses

The CLIENT INFORMATION FORM clause requires the client to provide specific personal or business details necessary for the engagement. Typically, this includes information such as names, contact details, identification numbers, and relevant background data, which may be collected at the outset of a contractual relationship. By formalizing the collection of this information, the clause ensures that the service provider has accurate and complete data to fulfill their obligations, communicate effectively, and comply with legal or regulatory requirements.
CLIENT INFORMATION FORM. In order to accurately submit claims for services to your insurance company it is essential that you present a current insurance identification card and the client information form must be filled out completely and accurately. Any omission of necessary information will result in your being responsible for the charges for services you receive. In addition, you are solely responsible for notifying the office PRIOR to your scheduled appointment with any changes in your insurance coverage and/or will be responsible for immediate payment on any service that is denied or not covered by your insurance company including, but not limited to all deductibles, co-insurances, and co-payments. I have read and understand the above statement. Client Signature: Date: Parent Signature: Date:
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CLIENT INFORMATION FORM. In order to accurately submit claims for services to your insurance company it is essential that you present a current insurance identification card and the client information form must be filled out completely and accurately. Any omission of necessary information will result in your being responsible for the charges for services you receive. In addition, you are solely responsible for notifying the office PRIOR to your scheduled appointment with any changes in your insurance coverage and/or will be responsible for immediate payment on any service that is denied or not covered by your insurance company including, but not limited to all deductibles, co-insurances, and co-payments. I have read and understand the above statement. Client Signature: _______________________________________________________________________________ Date: _______________________________________ Parent Signature: _______________________________________________________________________________ Date: _______________________________________
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CLIENT INFORMATION FORM. The Community Team uses a common registration form and a common format for development of an Education and Employment Action Plan to use with each young person. This Plan identifies the steps required to meet goals, and the agencies/people who can assist at each stage. School Transition Managers and Jobs Pathway staff will undertake much of the assessment work. Community agencies use the form with their clients if employment and education goals were necessary. Employment placement agencies use it with a young person where it is appropriate. The information form may identify issues which the young person needs to address before an education/employment placement is secured, or which require ongoing support. Any referral for these purposes would be confidential and would meet the privacy principles outlined in the Spirit of Agreement.
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CLIENT INFORMATION FORM. This agreement, dated is made between VetMedics Inc. located at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇. ▇▇▇▇▇▇▇▇, ▇▇.▇▇▇▇▇, referred to as “VetMedics” and the Client.
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CLIENT INFORMATION FORM. Name : Surname: Mother’s Maiden Name : Citizenship No.: Address Telephone Information Contact/Correspondence Address Type: Home Office Address: Locality: County: City: Mobile Tel. (Akbank Password Telephone*): / Country: Fax No.: / Home Tel.: / E-mail Address: @ Educational Background: Uneducated Primary School Secondary School High School
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Related to CLIENT INFORMATION FORM

  • Client Information Protected Health Information in any form including without limitation, Electronic Protected Health Information or Unsecured Protected Health Information (herein “PHI”);

  • Patient Information Each Party agrees to abide by all laws, rules, regulations, and orders of all applicable supranational, national, federal, state, provincial, and local governmental entities concerning the confidentiality or protection of patient identifiable information and/or patients’ protected health information, as defined by any other applicable legislation in the course of their performance under this Agreement.

  • Payment Information The Authority shall issue a purchase order to the Contractor prior to commencement of the Service.

  • Alert Information As Alerts delivered via SMS, email and push notifications are not encrypted, we will never include your passcode or full account number. You acknowledge and agree that Alerts may not be encrypted and may include your name and some information about your accounts, and anyone with access to your Alerts will be able to view the contents of these messages.

  • IDENTIFYING INFORMATION AND PRIVACY NOTIFICATION (a) FEDERAL EMPLOYER IDENTIFICATION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER. As a condition to NYSERDA’s obligation to pay any invoices submitted by Contractor pursuant to this Agreement, Contractor shall provide to NYSERDA its Federal employer identification number or Federal social security number, or both such numbers when the Contractor has both such numbers. Where the Contractor does not have such number or numbers, the Contractor must give the reason or reasons why the payee does not have such number or numbers.