PLEASE READ THIS DOCUMENT CAREFULLY Sample Clauses

PLEASE READ THIS DOCUMENT CAREFULLY. This is a legally binding agreement (the “Registration Agreement”) between you (“you” or “your”) and Health Current (“we” or “us”) about your submission of documents to the AzHDR. If the instructions herein are not followed, your form(s) may be rejected. How to complete this Agreement: • Read the agreement and complete this form. • Fill in all blank spaces on this form. • Sign and date form. • Attach a copy of the witnessed or notarized advance directive(s). DO NOT SEND ORIGINALS TO THE AZHDR. • Mail to: AzHDR – Health Current 0000 X. 0xx Xx., Xxx. 000 Xxxxxxx, XX 00000 • Or fax to: 000-000-0000 • Or email to: xxxxxxxxx@xxxxx.xxx Processing time: up to three weeks. REQUIRED REGISTRANT INFORMATION Last Name: First Name: Middle Name: Address: Date of Birth: MM/DD/YYYY City: State: Zip: Phone: I choose to opt out of SMS text Email: I choose to opt out of email Mailing address if different from above: City: State: Zip: Check the applicable box (check only one box per submission): New registration. Replace an advance directive(s) presently in the AzHDR with the new one(s) attached. Replace all documents presently in the registry with the new one(s) attached. Replace only the following document type(s) presently in the registry with the new one(s) attached while leaving the others in place (check all that apply): Living will Health care power of attorney Mental health care power of attorney DNR Add an additional document to my currently stored directive(s). Inactivate my account: Check this box if you do not want your documents to be active in the registry. Change registrant demographic information previously submitted (update your information on this form). Please note: All documents submitted to Health Current must be copies. Please do not submit originals. Once your account has been activated and your documents have been uploaded to the AzHDR, Health Current will not retain paper copies of your advance directives. Additionally, any documents received by Health Current that are not advance directives or attachments thereto will not be accepted and will be shredded and securely destroyed. Arizona Healthcare Directives Registry Health Current | 0000 X. 0xx Xx., Xxx. 000 | Xxxxxxx, XX 00000 P: 000-000-0000 | F: 000-000-0000 | xxxxx@xxxxxxxxxxxxx.xxx | xxxxx.xxx Arizona Advance Directives Registration Agreement Terms & Conditions
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PLEASE READ THIS DOCUMENT CAREFULLY. I acknowledge that the Company will use this Agreement to govern my actions and responsibilities during my participation in the Puzzle Adventure Room (the “Activity”).
Sample 1
PLEASE READ THIS DOCUMENT CAREFULLY. University agrees to provide Student space in University-Operated Residence Halls. The term of this Agreement shall be for one academic year, including both the Fall and Spring semesters, and Summer semester, if applicable (the “Term”), unless this Agreement is cancelled in accordance with the section of this Agreement entitled “Termination.” Residing in University-Operated Residence Halls is considered a fundamental part of the Student’s education, therefore this Agreement is only a license to occupy and use the residential space assigned to the Student for limited purposes (the “Residential Space”) and is not a lease of the University’s property. This Agreement is personal and non-transferable, and it is not a commitment of admission to the University. The University reserves the right, at its sole discretion, to determine if any past behavior, conduct, or activity of any individual is such that the interest(s) of the University, the Student, and/or other students would best be served by terminating this Agreement. In addition, the Student acknowledges that convicted and/or registered sexual offenders are not allowed to reside in University-Operated Residence Halls. The Student must pay to the University a one hundred and thirty-five dollar ($135) Application Fee. The Student represents to the University that the Student is eighteen (18) years of age or older at the time this Agreement is executed and the University relies on that representation. If the Student is under the age of eighteen (18) years, then one of the Student’s parents or legal guardians must sign this Agreement and that person is hereby made a party to this Agreement, subject to all terms and conditions of this Agreement. The University’s “Residence Halls Service Agreement Terms and Conditions” shall be considered part of this Agreement although it may not be attached physically hereto. The Student’s occupancy is also governed by the “Living on Campus Housing Guide” and “Winston-Salem State University’s Student Handbook”, as currently written or as may be amended in the future. RESIDENCE HALLS SERVICES AGREEMENT Residence Halls Services Agreement Terms & Conditions
Sample 1

Related to PLEASE READ THIS DOCUMENT CAREFULLY

  • PLEASE READ CAREFULLY I, as applicant or duly authorized representative of the applicant, hereby affirm that the submitted information is true and correct to the best of my knowledge. As such, I have been authorized by the applicant to apply for this permit and have read, understand and agree to comply with all rules concerning the use of the Noblesville Parks and Recreation Auditorium at the Ivy Tech Community College Xxxxxxxx County Campus. The applicant agrees that while renting the park or park premise, the applicant will not exclude anyone from participation in, deny anyone benefits of, or otherwise subject anyone to discrimination because of that person’s race, color, sex, religion, creed, national origin or ancestry, age or handicap. Under this Auditorium Rental Agreement, the applicant assumes all responsibility for proper conduct in the park, including consumption of alcoholic beverages. I , on behalf of the permit applicant, shall agree to release, hold harmless, and forever indemnify the City of Noblesville and Ivy Tech Community College, its employees, officers, and agents from any and all claims or causes of action that may arise from the activities described herein. This includes claims for personal injury, property damage, and/or any other types of claim which may arise from these activities, whether such claims may be brought by the permit applicant or any of its agents, or by any third party. I have read this release and understand all of its terms. I agree with its terms and sign it voluntarily. Signature Date City of Noblesville Parks and Recreation Department 000 Xxxxxx Xxxx Noblesville, Indiana 46060 000-000-0000 000 Xxxxxx Xxxx Xxxxxxxxxxx, XX 00000 OFFICIAL EVENT PERMIT APPLICATION FOR AUDITORIUM City of Noblesville Parks and Recreation Department (NPRD) (Please Print or Type) - Auditorium operating hours are 8:00 a.m. - 10:00 p.m. - Permit applications must be submitted to the Department at least six weeks prior to event. - An application for Special Use shall not become a permit until it has been approved and signed by the Department. Application approval will not be finalized without submittal of an application, certificate of insurance and payment of all fees/charges/deposits. Type of Organization: (check all that apply) □City of Noblesville □Department-Affiliated □Private – City Resident □Xxxxxxxx County □Non-Profit □Private – Non-Resident □Other Tax ID# □Profit Making Please complete entire application: Non-Profit Fundraising Event □Other Tax ID# Date of Application: Date of Proposed Event: Contact Information:

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  • Our Right to Receive and Release Information About You We are committed to maintaining the confidentiality of your healthcare information. However, in order for us to make available quality, cost-effective healthcare coverage to you, we may release and receive information about your health, treatment, and condition to or from authorized providers and insurance companies, among others. We may give or get this information, as permitted by law, for certain purposes, including, but not limited to: • adjudicating health insurance claims; • administration of claim payments; • healthcare operations; • case management and utilization review; • coordination of healthcare coverage; and • health oversight activities. Our release of information about you is regulated by law. Please see the Rhode Island Confidentiality of HealthCare Communications and Information Act, R.I. Gen. Laws §§ 5-37.3-1 et seq. the Health Insurance Portability and Accountability Act of 1996, as amended by the Health Information Technology for Economic and Clinical Health Act, and implementing regulations, 45 C.F.R. §§ 160.101 et seq. (collectively “HIPAA”), the Xxxxx-Xxxxx-Xxxxxx Financial Modernization Act, 15 U.S.C. §§ 6801-6908, the Rhode Island Office of the Health Insurance Commissioner (OHIC) Regulation 100.

  • What Will Happen After We Receive Your Letter When we receive your letter, we must do two things:

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  • DEFECTIVE MANAGEMENT INFORMATION 5.1 The Supplier acknowledges that it is essential that the Authority receives timely and accurate Management Information pursuant to this Framework Agreement because Management Information is used by the Authority to inform strategic decision making and allows it to calculate the Management Charge.

  • SCOPE OF SERVICES/CASE HANDLING A. Upon execution by Xxxxxx, Attorneys are retained to provide legal services for the purpose of seeking damages and other relief in the Litigation. Client agrees that Xxxxxx may choose to associate additional law firm(s) and/or lawyer(s) to represent Client in connection with the investigation and prosecution of the rights Client has as a purchaser of publically traded securities of Xxxxxx, and Client understands that such representation shall be on the same terms as those described in this agreement.

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