REASON FOR SUBMISSION. INSTRUCTIONS: If you are signing a Medicaid application on behalf of the applicant, you must provide the authorization/legal document authorizing you to apply on the applicant’s behalf OR attest that the applicant is incompetent or incapacitated. Please check the appropriate boxes below. Attach the authorization (if applicable) to this form and sign and date below. I have authorization to apply for Medicaid on behalf of the applicant. (Check the box for the type of authorization you have and submit the authorization OR complete Section D below.) Guardianship Document Power of Attorney (POA) Document Other Written Authorization (Specify) I attest that the applicant is incompetent or incapacitated. S/he is unable to sign the application herself/himself and is unable to provide written consent for me to apply on his/her behalf. Signature of Person Completing This Form Date Signed SECTION D AUTHORIZATION TO APPLY FOR MEDICAID ON APPLICANT’S BEHALF INSTRUCTIONS: If the applicant would like to provide the below authorization allowing you to represent him/her in applying for and/or renewing Medicaid, the applicant or his/her legal representative or spouse must sign the authorization below.
REASON FOR SUBMISSION. Indicate your reason for completing this form by checking the appropriate box: New EFT authorization or change to your account information. If you are authorizing EFT payments to the home office of a chain organization of which you are a member, you must attach a letter authorizing the contractor to make payment due the provider of service to the account maintained by the home office of the chain organization. The letter must be signed by an authorized official of the provider of service and an authorized official of the chain home office.
REASON FOR SUBMISSION. Indicate your reason for completing this form by checking the appropriate box: New EFT enrollment, a change to your EFT enrollment account information, or cancellation of your EFT enrollment.
REASON FOR SUBMISSION. See Instructions on Page 2 Document Included: Voided Check Bank Letter New Enrollment Change Enrollment Cancel Enrollment PART II: ACCOUNT HOLDER INFORMATION- See Instructions on Page 2 Account Holder Legal Name: DBA Name: Street Address: City: State: Zip Code: Account Holder Tax Identification Number (9 digits EIN or SSN) EIN: SSN:
REASON FOR SUBMISSION. Indicate your reason for completing this form by checking the appropriate box: New EFT enrollment, change to your EFT enrollment account information, or cancellation of your EFT enrollment. If you are authorizing EFT payments to the home office of a chain organization of which you are a member, you must attach a letter authorizing the contractor to make payment due the provider of service to the account maintained by the home office of the chain organization. The letter must be signed by an authorized official of the provider of service and an authorized official of the chain home office.
REASON FOR SUBMISSION. Reason for Submission: ❑ New EFT Authorization ❑ Revision to Current Authorization (e.g. account or bank changes) Chain Home Office: Organization ❑ Check here if EFT payment is being made to the Home Office of Chain (Attach letter Authorizing EFT payment to Chain Home Office)
REASON FOR SUBMISSION. □ New Electronic Funds ☐ New EFT and Electronic Transfer (EFT) Enrollment Remittance Advice (ERA) Enrollment □ New ERA Enrollment Note: Any changes or cancellations to EFT Enrollment will be made through the Banking Services. Please visit their website at xxxxx://xxxxxxxxxxxxxx.xxxxxxxx.xxx/hcp/app for more information.
REASON FOR SUBMISSION. The Department of Health and Social Care (DHSC) have agreed a 5 year lease at Skipton House. This was agreed earlier this year, following an extended period of negotiation (previous lease ended December 2016). As a result we have requested a MOTO base on the standard Civil Estate Occupancy Agreement (and similar to our previous arrangement) to reflect the revised terms and extend our lease period at Skipton House. Term: 1 April 2018 – 20th December 2021 Space occupied: 631.42sqm (3.11% of total occupancy) Licence payment: £233,250/annum Other costs (rates, facilities management; utilities recharged at 3.11%) HRA responsible for decorations / lighting / cleaning in own demise HRA scheme of delegation require Board approval for all contracts greater than £250,000. Total annual costs associated with this MOTO are £475,000. There are no further extensions anticipated to these arrangements with the expectation that all current occupants will move to government hubs (Stratford or Canary Wharf) or other DHSC London buildings at the end of this term. We are actively participating in the DHSC London Strategy Group to ensure our future requirements are met as well as meeting Government Policy initiatives. Once approved, HRA Chair to sign MOTO. Lead Reviewer: Xxxxx Xxxxxxx Time required for item: 5 minutes Recommendation / Proposed Actions: To Approve Yes To Note For discussion Comments Name: Xxxxx Xxxxxxxx Job Title: Director of Finance, procurement and estates Date: 17th January 2019
REASON FOR SUBMISSION. □ New EFT Enrollment □ Change to current EFT Enrollment □ Cancel EFT Enrollment Payee Information Payee Name Provider NPI THC Provider ID Number Tax ID Number (□ SSN or □ EIN) EFT Contact Phone Number ( ) Financial Institution Information Institution Name Phone Number Address City State Zip Routing Number Account
REASON FOR SUBMISSION. New Enrollment - Change Enrollment - Cancel Enrollment Select the reason for submission of the EFT enrollment data. - If the provider is not currently enrolled in EFT, the reason for submission should be New Enrollment. - If the provider is currently enrolled in EFT and wishes to update their EFT information, the reason for submission should be Change Enrollment. - If the provider is currently enrolled in EFT and wishes to cancel that enrollment, the reason for submission should be Cancel Enrollment. Please note, however, that EFT is mandated by DSS. If the provider cancels their current enrollment, they must submit new EFT enrollment data. Include with Enrollment Submission Voided Check Bank Letter A voided check is attached to provide confirmation of Identification/Account Numbers A letter on bank letterhead that formally certifies the account owners routing and account numbers Attach a copy of a voided check or bank letter when enrolling or updating EFT information using this paper form.
