Intake Form Sample Clauses

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Intake Form. CHR will provide or arrange to provide intake services on behalf of the Program, which intake services shall include the completion of an Intake Form for the applicable Patient by means of telephone, United States mail service, or facsimile communication, verification of insurance coverage and prior authorization, as necessary. “Intake Form” means the form to be used by CHR to gather information regarding, among other things, Patient demographics, referral information, primary and secondary insurance, and physician and medical information.
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Intake Form. (i.) Includes verification of income eligibility, with instructions provided on
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Intake Form. Upon receiving the retainers and contracts for both parents, each parent will beasked to complete an intake questionnaire prior to their individual intake interview. Please ensure this is submitted at least one day prior to the interview in order to allow enough time for review.
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Intake Form. (A) As consideration for the use of this non-exclusive license, Licensee agrees to provide the data requested on the College Affordability Academy Intake Form, as shown in Exhibit B, attached hereto and made a part hereof (“Intake Form”), and further agrees that the Licensor may use this data to engage in additional works of authorship and publication relating to debt management and financial aid. (B) Failure of Licensee to provide the data requested in the Intake Form within three (3) weeks of execution of this Agreement, shall, at Licensor’s option, entitle Licensor to terminate this Agreement. Licensor will provide written notice to Licensee of termination of this Agreement for failure to provide the requested data within thirty (30) days from the due date outlined above.
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Related to Intake Form

  • Contract Form Observe the Contract and confirm the form number on the Contract is on the List of Approved Contract Forms.

  • Alcohol Testing Alcohol testing will be conducted by using an evidential breath-testing device (EBT) approved by the National Highway Traffic Safety Administration. A screening test will be conducted first. This initial screening may be accomplished using a saliva test kit. If the result is an alcohol concentration level of less than 0.02 percent, the test is considered a negative test. If the alcohol concentration level is 0.02 percent or more, a second confirmation test using the EBT will be conducted. The procedures that will be utilized by the lab for collection and testing of the specimen are attached hereto as Appendix A.

  • Specialty Prescription Drugs (+ Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

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  • DRUG-FREE WORKPLACE FORM The Drug-Free Workplace Form is attached and shall be completed and submitted with your bid.