Certification of Authority to Sign the Agreement. The persons signing this Agreement on behalf of the parties hereto certify by said signatures that they are duly authorized to sign this Agreement on behalf of said parties and that this Agreement has been authorized by said parties pursuant to formal resolution(s) of the appropriate governing bodies.
Certification of Authority to Sign the Agreement. The person signing this Agreement on behalf of the FMS Provider hereby certifies, by signing, to the best of his or her knowledge and belief that: Deleted: I
Certification of Authority to Sign the Agreement. The persons signing this Agreement on behalf of the parties hereto certify by said signatures that they are duly authorized to sign this Agreement on behalf of said parties and that this Agreement has been authorized by said parties. In Witness whereof, the authorized representatives of the parties hereto have fully executed this Agreement on the day and the year first above written. WITNESSED BY: PAYOR: GOGEBIC COUNTY COMMUNITY MENTAL HEALTH AUTHORITY BY: Witness Date Xxxxx Xxxxxxx, CEO Date PROVIDER: BY:
Certification of Authority to Sign the Agreement. The person signing this Agreement on behalf of the FI Provider hereby certifies, by signing, to the best of his or her knowledge and belief that:
Certification of Authority to Sign the Agreement. The persons signing this Agreement on behalf of the Parties hereto certify by said signatures that they are duly authorized to sign this Agreement on behalf of said Parties and that this Agreement has been authorized by said Parties. This Agreement shall be deemed executed, valid, enforceable and binding upon the Parties once signed in handwriting or by any electronic means and may be delivered by facsimile or electronic transmission. *******SIGNATURE PAGE FOLLOWS******** CERTIFICATION AND AUTHORITY TO SIGN CONTRACT - The persons signing this contract on behalf of CMHSP and PROVIDER certify by their signatures that this contract has been authorized by said Parties and they are duly authorized to sign this contract on behalf of said Parties. FOR THE PROVIDER: Provider Name: [PROVIDER NAME] Provider Address: [PROVIDER ADDRESS] Provider City, State, Zip Code: [CITY, STATE, ZIP] Tax ID# : [TAX ID #] NAME/TITLE (please print) DATE SIGNATURE FOR THE CMHSP: Allegan County Community Mental Health Services 0000 000xx Xxxxxx Xxxxxxx, XX 00000 FOR THE CMHSP: Community Mental Health of Ottawa County 00000 Xxxxx Xxxxxx Holland, MI 49424 Xxxx Xxxxx, Executive Director Xxxxx Xxxxx, Executive Director NAME/TITLE (Please print) DATE NAME/TITLE (please print) DATE SIGNATURE SIGNATURE FOR THE CMHSP: HealthWest 000 X Xxxxx Xxxxxx Xxxxxxxx, XX 00000 FOR THE CMHSP: Kent County CMH Authority dba Network180 0000 Xxxxx Xxxx Xxxxx XX Xxxxx 000 Xxxxx Xxxxxx, XX 00000 Xxxxx Xxxx, Executive Director Xxxx Xxxx, Executive Director NAME/TITLE (Please print) DATE NAME/TITLE (please print) DATE SIGNATURE SIGNATURE FOR THE CMHSP: West Michigan Community Mental Health System 000 Xxxxx Xxxxxx Ludington, MI 49431 Xxxx X. Xxxxxxxx, Ph. D., CEO NAME/TITLE (Please print) DATE SIGNATURE COMPENSATION SCHEDULE (FACILITY) Allegan County Community Mental Health, Community Mental Health of Ottawa County, HealthWest, Kent County Mental Health Authority d/b/a Network 180 and West Michigan Community Mental Health System and [INPATIENT PROVIDER] For medically necessary covered services rendered to Covered Persons by Provider, in accordance with the terms of the Agreement, Provider shall accept as payment in full the lesser of contracted rate or billed charges as follows:
