Intake Form Sample Clauses

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 Exhibit B: Steps to Verify Income Eligibility.
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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.
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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. Non-EBT devices may be used for initial screening tests. A screening test will be conducted first. If the result is an alcohol concentration level of less than 0.02, the test is considered a negative test. If the alcohol concentration level is 0.02 or more, a second confirmation test will be conducted. Levels of .04 or greater on the confirmation test will be considered positive.

  • SAMPLE (i) Unless agreed otherwise, wheeled or track lay- ing equipment shall not be operated in areas identified as needing special measures except on roads, landings, tractor roads, or skid trails approved under B5.1 or B6.422. Purchaser may be required to backblade skid trails and other ground disturbed by Purchaser’s Opera- tions within such areas in lieu of cross ditching required under B6.6. Additional special protection measures needed to protect such known areas are identified in C6.24.

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

  • Identity Verification In the case that the Subscriber provides telecommunication services to any Subscriber’s Customers pursuant to Section 8.1, the Subscriber is responsible for performing and shall perform personal identification of Subscriber’s Customer. SORACOM shall not bear any responsibility in relation to dealing with such matters.

  • Drug Testing (A) The state and the PBA agree to drug testing of employees in accordance with section 112.0455, F.S., the Drug-Free Workplace Act.

  • Destination CSU-Pueblo scholarship This articulation transfer agreement replaces all previous agreements between CCA and CSU-Pueblo in Bachelor of Science in Physics (Secondary Education Emphasis). This agreement will be reviewed annually and revised (if necessary) as mutually agreed.

  • DRUG/ALCOHOL TESTING 8.1 The parties agree that the maintenance of a drug/alcohol free work place is a goal of both the College and the Union. Employees are prohibited from possession, consumption and/or being under the influence of a controlled substance/alcohol while on the College’s premises or during time paid by the employer. Violations of this prohibition may result in a disciplinary action up to and including termination.

  • State Specific Contract Form Observe the state of the Seller on the Contract, if the Seller lists an address in Alaska, Arkansas, Delaware, North Carolina, Virginia, Maryland, Montana, Connecticut, Vermont, Louisiana or Mississippi, confirm the form number on the Contract is on the List of Approved Contract Forms, for the corresponding state.

  • Prescription Drugs The agreement may impose a variety of limits affecting the scope or duration of benefits that are not expressed numerically. An example of these types of treatments limit is preauthorization. Preauthorization is applied to behavioral health services in the same way as medical benefits. The only exception is except where clinically appropriate standards of care may permit a difference. Mental disorders are covered under Section A. Mental Health Services. Substance use disorders are covered under Section

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