Home Telephone Number. Employee's area code, home telephone number.
Home Telephone Number. No. Faksimili Rumah Home Facsimile Number No. Handphone
Home Telephone Number. I hereby request an unpaid leave of absence starting on Month Day Year through for the following reasons: Month Day Year Signature Date NOTE: When applying for an unpaid personal medical leave or unpaid job related medical leave, send the original request form and the originals of doctors’ notes directly to the Superintendent or designee. (Doctors’ notes must be hand signed by the doctors. Rubber stamped signatures are not acceptable.) Give a copy of this request form to your building principal. 0/00 Xxxxxxxx X XXXXXXXXX XXXX XXXXXX XXXXXXXX REQUEST FOR PROFESSIONAL LEAVE Date Submitted Name Date(s) Requested: Purpose for Request: Destination (City, State):
Home Telephone Number. I hereby request an unpaid leave of absence starting on Month Day Year through for the following reasons: Month Day Year Signature Date NOTE: When applying for an unpaid personal medical leave or unpaid job related medical leave, send the original request form and the originals of doctors’ notes directly to the Business Office. (Doctors’ notes must be hand signed by the doctors. Rubber stamped signatures are not acceptable.) Give a copy of this request form to your building principal.
Home Telephone Number. 3. Personal Cellular Telephone Number; and
Home Telephone Number. Section 4.5 No employee shall be recognized by the Employer as a Union representative until the Union has presented the Employer with written certification of that person’s selection.
Home Telephone Number j. Personal Cellular Telephone Number
Home Telephone Number. May I leave a voice message with appointment information? Yes No May I call you at this number? May I leave a voice message with treatment information? Yes No Yes No May I leave a voice message with billing information Yes No *Please be advised, in addition to the benefits, there are risks associated with the use of e-mail by patients and providers to discuss appointments and health-related matters, including privacy breaches, data integrity violations, repudiation, and others. Email Address: May I E-Mail you ? Yes No May I E-Mail appointment information? May I E-Mail treatment information? May I E-Mail billing information? Yes No Yes No Yes No Additional Instructions:
Home Telephone Number. May I call you at Yes this number? No May I call you at Yes this number? No May I leave a voice Yes message? No May I leave a voice Yes message? No May I leave a text Yes message? No May I leave appointment Yes information No *Please be advised, in addition to the benefits, there are risks associated with the use of e-mail by patients and providers to discuss appointments and health-related matters, including privacy breaches, data integrity violations, repudiation, and others. Email Address: May I email you Yes at this address? No May I leave appointment Yes information? No For Emergency Purposes Only In the event of an emergency you may contact: the person listed below: Name Relationship Phone My signature below attests that I have received, read, and understand the information explained in the INFORMED CONSENT SERVICE AGREEMENT and NOTICE OF PRIVACY PRACTICES / HIPPA documents. I hereby AGREE to all of its terms, conditions, practice policies and acknowledge the limits of confidentiality. Additionally, I hereby give my authorization and consent for treatment by XxxxxxXxxxxxx , LPC. X Signature of Client / Legal Representative Date Printed Name of Client / Legal Representative
