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.
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.
Consent to Receive Information in English You hereby expressly declare that you have full knowledge of the English language and have read, understood and fully accepted and agreed with the terms and conditions established in the Plan and Agreement.
Notice Information Notices will be sent: If to LESSOR: INTERNATIONAL LEASE FINANCE CORPORATION 1999 Avenue of the Stars, 00xx Xxxxx Xxx Xxxxxxx, Xxxxxxxxxx 00000, X.X.X. Attention: Legal Department Fax: 000-000-0000 Telephone: 000-000-0000 If to LESSEE: AMERICAN TRANS AIR, INC. 0000 Xxxx Xxxxxxxxxx Xxxxxx Indianapolis International Airport Xxxxxxxxxxxx, Xxxxxxx 00000 Xxxxxx Xxxxxx of America Attention: Xxx Xxxxx Executive Vice President and Chief Financial Officer Fax: 000-000-0000 Telephone: 000-000-0000 or to such other places and numbers as either party directs in writing to the other party.
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
Contractor Designation of Trade Secrets or Otherwise Confidential Information If the Contractor considers any portion of materials to be trade secret under section 688.002 or 812.081, F.S., or otherwise confidential under Florida or federal law, the Contractor must clearly designate that portion of the materials as trade secret or otherwise confidential when submitted to the Department. The Contractor will be responsible for responding to and resolving all claims for access to Contract-related materials it has designated trade secret or otherwise confidential.
Relationship to the Plan This grant of Performance Units is subject to all of the terms, conditions and provisions of the Plan and administrative interpretations thereunder, if any, that have been adopted by the Board. Except as otherwise defined in this Award Agreement, capitalized terms shall have the same meanings given to them under the Plan. To the extent that any provision of this Award Agreement conflicts with the express terms of the Plan, the terms of the Plan shall control and, if necessary, the applicable provisions of this Award Agreement shall be hereby deemed amended so as to carry out the purpose and intent of the Plan. References to the Participant also include the heirs or other legal representatives of the Participant.
Notice of Dispute The party wishing to commence the dispute resolution process must give written notice (Notice of Dispute) to the other parties of:
Information About Your Right to Dispute Errors In case of errors or questions about your Card Account, call 0-000-000-0000 or write to Cardholder Services, X.X. Xxx 000000, Xxxxxxxxxxxx, XX, 00000. if you think an error has occurred on your Card Account or if you need more information about a transaction listed on your electronic or written history or receipt. We must allow you to report an error until sixty (60) days after the earlier of the date you electronically access your Card Account, if the error could be viewed in your electronic history, or the date we sent the FIRST written history on which the error appeared. You may request a written history of your transactions at any time by calling 0-000-000-0000 or writing to X.X. Xxx 000000, Xxxxxxxxxxxx, XX, 00000. You will need to tell us:
