INSTRUCTIONS FOR COMPLETING FORM A AND B Form A and Form B should be completed for Contracts for consulting services in accordance with Section XI.18.C of the Office of the State Comptroller’s Guide to Financial Operations (xxxx://xxx.xxx.xxxxx.xx.xx/agencies/guide/MyWebHelp/), “Consultant Disclosure Legislation,” and the following:
BILLING FORM The SUDRF shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form (or subsequent editions) for inpatient services, and the CMS 1500 Claim Form for outpatient services. The SUDRF shall identify SUDRF care on the billing form in the remarks block by stating “SUDRF care”.
Report of the Settlement Agreement to the Office of the Attorney General Of California
Waist to Shoulder Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): APPENDIX B – ABILITIES FORM Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No
AGREEMENT TO FOLLOW DIRECTIONS I agree to follow the rules for the Activities provided to me and to follow directions given to me by the leaders of the Activities.
Order to Submit to Testing A member's refusal or failure, when ordered, to submit within the time limits provided hereinafter to a test permitted by this Article shall subject the member to discipline. By taking a test under this Article, however, a member shall not be construed as waiving any objection or rights that he or she may possess. Within seventy-two (72) hours of the time the member is ordered to submit to reasonable suspicion testing, the City shall provide the member with a written notice setting forth the information and observations which form the basis of the order to test.
Modifications and Updates to the Wire Center List and Subsequent Transition Periods 2.1.4.12.1 In the event BellSouth identifies additional wire centers that meet the criteria set forth in Section 2.1.4.5, but that were not included in the Initial Wire Center List, BellSouth shall include such additional wire centers in a carrier notification letter (CNL). Each such list of additional wire centers shall be considered a “Subsequent Wire Center List”.
Shipping must be Freight On Board Destination to the delivery location designated on the Customer purchase order The Contractor will retain title and control of all goods until delivery is completed and the Customer has accepted the delivery. All risk of transportation and all related charges are the responsibility of the Contractor. The Customer will notify the Contractor and H-GAC promptly of any damaged goods and will assist the Contractor in arranging for inspection. The Contractor must file all claims for visible or concealed damage. Unless otherwise stated in the Agreement, deliveries must consist only of new and unused merchandise.
Allocation and use of scarce resources Any procedures for the allocation and use of scarce resources, including frequencies, numbers and rights of way, will be carried out in an objective, timely, transparent and non-discriminatory manner. The current state of allocated frequency bands will be made publicly available, but detailed identification of frequencies allocated for specific government uses is not required.
Time Limits to Present Initial Grievance An employee who wishes to present a grievance at Step 2 of the grievance procedure, in the manner prescribed in Article 9.4, must do so not later than thirty (30) days after the date:
