CONFIDENTIALITY OF RECORD. The Provider agrees to provide adequate precautions to protect the confidentiality of Consumer information in accordance with Welfare and Institutions Code section 4514, Health Insurance Portability and Accountability Act (HIPAA), and all other applicable state and federal statutes and regulations regarding confidentiality of consumer information. Provider Signature Information Full Printed Name Title Provider Signature Telephone Date Regional Center Approval of Enrollment Full Printed Name Title Approver’s Signature Telephone Date Return Provider Agreement to the Regional Center
CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to maintain adequate administrative, technical, and physical safeguards to protect the confidentiality and security of protected health information in accordance with State and Federal statutes and/or regulations, including 45 Code of Federal Regulations Parts 160 and 164. Any breach of security or unlawful disclosure of protected health information shall be reported to the Department within 24 hours of the Provider/Xxxxxx’x discovery of such breach or disclosure and may be grounds for termination of this Agreement.
CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of Medi- Cal beneficiary record and claims submission methods in accordance with statute or regulations Title 17, CCR, Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B. PROVIDER SIGNATURE INFORMATION Full printed name Title Provider signature (original signature required; DO NOT use black ink) Date BILLING SERVICE SIGNATURE INFORMATION (complete only if “Xxxxxx Information” is completed on page 1 of 5) Full printed name Title Owner or Corporate Officer signature (original signature required; DO NOT use black ink) Date Return Application/Agreement to: California MMIS Fiscal Intermediary CMC Unit P.O. Box 15508 Sacramento, CA 95852-1508 Privacy Statement (Civil Code Section 1798 et seq.)
CONFIDENTIALITY OF RECORD. Provider shall establish and maintain procedures and controls that are acceptable to VSUW for the purpose of assuring that no information contained in its records or obtained from the State of Arizona under this Agreement shall be used by or disclosed by it, its agents, officers, or employees, except as required, to efficiently perform duties under the Agreement. Provider also agrees that any information pertaining to individual persons shall not be divulged other than to employees or officers of Provider as needed for performance of duties under this Agreement, unless otherwise agreed to in writing.
CONFIDENTIALITY OF RECORD. All records and information given by Resident to Management shall remain confidential and shall not be disclosed except insofar as the Management is authorized by California Health & Safety Code section 34217, the Privacy Act of 1974: Amendment to an existing system of records; Enterprise Income Verification HUD/PIH-5 or any other Federal, State or Local Law to make disclosures to third parties or government agencies or as requested by Resident or the Resident's authorized representative.
CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of Medi-Cal beneficiary record and claims submission methods in accordance with statute or regulations Title 17, CCR, Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B. Provider Signature Information Full printed name Title Provider signature (original signature required; DO NOT use black ink) Date Billing Service Signature Information (complete only if “Xxxxxx Information” is completed on page 1 of 4) Full printed name Title Owner or Corporate Officer signature (original signature required; DO NOT use black ink) Date Return Application/Agreement to: ACS CMC Unit X.X. Xxx 00000 Xxxxxxxxxx, XX 00000-0000 Privacy Statement (Civil Code Section 1798 et seq.) The information requested on this form is required by the Department of Health Care Services for purposes of identification and document processing. Furnishing the information requested on this form is mandatory. Failure to provide the mandatory information may result in your request being delayed or not be processed.
CONFIDENTIALITY OF RECORD. The Provider agrees to provide adequate precautions to protect the confidentiality of Consumer information in accordance with Welfare and Institutions Code section 4514, Health Insurance Portability and Accountability Act (HIPAA), and all other applicable state and federal statutes and regulations regarding confidentiality of consumer information. Provider Signature Information Full Printed Name Title Provider Signature Telephone Date Regional Center Approval of Enrollment Full Printed Name Title Approver’s Signature Telephone Date Return Provider Agreement to the Regional Center Form W-9 (Rev. December 2011) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Name (as shown on your income tax return) Print or type See Specific Instructions on page 2. Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification: Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶ Exempt payee Other (see instructions) ▶ Address (number, street, and apt. or suite no.) Requester’s name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Employer identification number – Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of member record and claims submission methods in accordance with statute or regulations. Provider Signature Information Full Printed Name Title Provider Signature (original signature required; DO NOT use black ink) Date Billing Service Signature Information (complete only if “Xxxxxx Information” is completed on Page 1 of 4) Full Printed Name Title Owner or Corporate Office Signature (original signature required; DO NOT use black ink) Date Return Application/Agreement to: Central California Alliance for Health ATTN: PS Web & EDI Specialist 0000 Xxxxx Xxxxx Xxxx, Xxxxx 000 Xxxxxx Xxxxxx, XX 00000-0000 Or FAX application to 000-000-0000 For further information, contact the EDI Support Line: 000-000-0000 x0000 or 000-000-0000
CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of member record and claims submission methods in accordance with statute or regulations. Provider Signature Information Full Printed Name Title Provider Signature (original signature required; DO NOT use black ink) Date Billing Service Signature Information (complete only if “Xxxxxx Information” is completed on Page 1 of 4) Full Printed Name Title Owner or Corporate Office Signature (original signature required; DO NOT use black ink) Date Return Application/Agreement to: Central California Alliance for Health ATTN: Business Analysis Unit 0000 Xxxxx Xxxxx Xxxx Xxxxxx Xxxxxx, XX 00000-0000
CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of Medi-Cal beneficiary record and claims submission methods in accordance with statute or regulations Title 17, CCR, Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B. Provider Signature Information Full printed name Title Provider signature (original signature required; DO NOT use black ink) Date Billing Service Signature Information (complete only if “Xxxxxx Information” is completed on page 1 of 5) Full printed name Title Owner or Corporate Officer signature (original signature required; DO NOT use black ink) Date Return Application/Agreement to: California MMIS Fiscal Intermediary CMC Unit X.X. Xxx 00000 Xxxxxxxxxx, XX 00000-0000 Privacy Statement (Civil Code Section 1798 et seq.) The information requested on this form is required by the Department of Health Care Services for purposes of identification and document processing. Furnishing the information requested on this form is mandatory. Failure to provide the mandatory information may result in your request being delayed or not be processed.
