Submission Information. To increase efficiencies, Member shall be responsible for uploading all requested information to xxx.xxxxxxxxxxxx.xxx (the “Website”) Members’ Area before August 1, 2020. Information requested may include, but is not limited to: subdivision name; home address; builder information; home latitude and longitude location; home price; school district; directions to the home; home model name; builder website; exterior/interior images; description of the home; basic room information for the home. Member hereby grants to the Association a non-exclusive, irrevocable, transferable, perpetual right and license to publish, print, display, record and use (by photograph, film, video, audio or any other method or device) all materials, images, trademarks, logos and information uploaded to the Website.
Submission Information. To increase efficiencies, Member shall be responsible for uploading all requested information to xxx.xxxxxxxxxxxx.xxx (the “Website”) Members’ Area before February 19, 2021. Information requested may include but is not limited to subdivision name; subdivision latitude and longitude location; lot price range; school district; directions to subdivision; developer website; lot layout image; color photograph or rendering at subdivision. Member hereby grants to the Association a non-exclusive, irrevocable, transferable, perpetual right and license to publish, print, display, record and use (by photograph, film, video, audio or any other method or device) all materials, images, trademarks, logos and information uploaded to the Website.
Submission Information. Please be advised that the documentation process take time. Act now. Do not wait until the few weeks before the deadline to begin the documentation process. All documentation must be submitted to the Claims Administrator postmarked on or before the deadlines noted above. If you need a copy of the Agreement or the Exhibits, please contact the Claims Administrator. Claims Administrator Telephone: This notice summarizes the Agreement. In the event of contradiction between this notice and the Agreement, the Agreement shall govern. This notice has been approved by the Supreme Court of British Columbia.
Submission Information. The City of Copperas Cove will receive Proposals until June 13, 2023 @ 11:00AM. Deadline for questions or request for clarification must be submitted to Xxxxxxxxx Xxxxxx- Assistant Finance Director by email prior to June 01, 2023 @ noon, at xxxxxxxxxxx@xxxxxxxxxxxxxx.xxx . All responses to the questions will be posted to the City’s website in addendum form. Two electronic submissions on a CD or USB drive in a PDF format of the Request for Proposals shall be submitted in an envelope or box bearing the name and address of offeror and also be identified in the lower left corner with “Request for Proposals of Concession Agreement, RFP No. 2023-05-74” and be addressed as follows: City of Copperas Cove Xxxxxxxxx Xxxxxx PO Box 1449 000 X. Xxxx Xxxxxx, Xxxxx X Xxxxxxxx Xxxx, Xxxxx 00000
Submission Information. Each of the Participants agrees that, to the extent that the Participant has the capability to submit such information electronically at no additional cost to the Participant, the Participant shall submit to UUMC for inclusion in EGRET, at a minimum, the following data, collectively “Information,” from the sources identified below: Encounter information for each emergency department, outpatient clinic visit or hospital visit, including: patient demographic information, reason for visit, treating health care provider(s), date of visit, place of visit, diagnoses, and procedures; and Xxxxx xxxxx, pathology reports, radiology reports, discharge summaries, operative notes, inpatient medications, laboratory test results, cardiology studies, orders, allergies, history and physicals, nursing observations and assessments, outpatient prescriptions, and other diagnostic tests. Although financial information related to payment of patients’ claims whether governmental, commercial or self-pay may be part of the submission of Information, the Parties agree such financial information shall not be available for research projects unless such information is specifically approved by unanimous vote of the Executive Committee. UHOSPITAL shall submit the Information stored on its electronic medical record system (or its successor system) and UPP shall submit the Information stored on the practice billing system (or its successor system). Unless otherwise mutually agreed by the Participants, the Participants will not provide such data stored on other systems or in paper format. The EGRET Executive Oversight Committee has the authority to modify the definition of Information as necessary to meet the needs of the Participants. No Participant will be required to provide information or any other data it is holding pursuant to a promise of, or a legal obligation requiring, confidentiality. Participants may submit Information in addition to the minimum set of data required by this Section 2.02 and are encouraged to submit any and all information that may be relevant to the clinical care of a patient. Notwithstanding the foregoing, Participants shall not be required to submit alcohol and drug abuse patient records that are maintained in connection with the performance of any federally assisted alcohol and drug abuse program which are protected from disclosure by 42 C.F.R. Part 2, psychotherapy notes as defined by 45 C.F.R. § 164.501, or where otherwise prohibited by state or federal law...
Submission Information. Reason for Submission* - Check the New Enrollment radio button if this application is to enroll a new provider for ERA. Check the Change Enrollment radio button if this application is to make a change to an existing provider’s ERA information. Check the Cancel Enrollment radio button if this application is to cancel an existing provider’s ERA and change to the paper RA instead. Authorized Signature Written Signature of Person Submitting Enrollment* - This application should be signed by the provider or an authorized person. Printed Name of Person Submitting Enrollment – Enter the name of the person who signed the form to submit enrollment. Submission Date – Enter the current date. Missing ERA Procedures • The provider will contact the Conduent EDI Support Unit (0-000-000-0000, option 2 then 4) to submit a research request. • If possible, the electronic remittance advice will be reposted within 3 to 5 business days.
Submission Information. Indicate your reason for completing this form by checking the appropriate box: Reason for Submission o New Enrollment - Currently not receiving EFT from West Virginia Family Health o Change Enrollment - Currently receiving EFT, updated to financial routing information needed o Cancel Enrollment – Discontinue EFT, return to paper checks Included with Enrollment Submission – Must submit at least one of the below documents with the enrollment o Voided Check – A voided check is attached to provide confirmation of Identification/Account Numbers o Bank Letter – A letter on the providers financial institution letterhead that formally certifies the accounting owners routing and account numbers Authorized Signature Written Signature of Person Submitting Enrollment – A (usually cursive) rendering or a name unique to a particular person used as confirmation or authorization and identity Printed Name of Person Submitting Enrollment - The printed name of the particular person used as confirmation or authorization and identity (Must match Written Signature of Person Submitting Enrollment) Printed Title of Person Submitting Enrollment – The printed title of the person singing the form; may be used with electronic and paper based manual enrollment Submission Date – The date on which the enrollment was submitted Requested EFT Start/Change/Cancel Date – The date in which the requested action is to begin EFT Legal Notice Written Signature of Person responsible for EFT at Provider(s) office General Information Complete forms can be faxed to System Administration @ 000-000-0000 Please type or print legibly Use only black or blue ink. Online form can be accessed @ xxxx://xxx.xxxx.xxx/sites/default/files/electronicfundstransfer.pdf Before submitting this form, we encourage providers to contact their financial institution to confirm they can handle EFT transactions via PNC Bank with the required minimum CCD+ data elements needed for re-association of the payment and the ERA. For questions about the paper or electronic enrollment process, please contact Xxxxxx Xxxxx @ 412-255- 7242. Determine Status of EFT enrollment Please allow 4 weeks for the enrollment process. If after 4 weeks you do not start receiving EFT payments, you may contact Xxxxxx Xxxxx @ 000-000-0000.
Submission Information. Reason for Submission New Pre-enrollment, Change Pre-enrollment, Cancel Pre-enrollment Include with Submission Voided Check – A voided check is attached to provide confirmation of Identification/Account Numbers. Bank Letter – A letter on bank letterhead that formally certifies the account owners routing and account numbers. Written Signature of Person Submitting Pre-enrollment A (usually cursive) rendering of a name unique to a particular person used as confirmation of authorization and identity. Printed Name of Person Submitting Pre- enrollment The printed name of the person signing the form; may be used with electronic and paper-based manual pre-enrollment. Printed Title of Person Submitting Pre- enrollment The printed title of the person signing the form; may be used with electronic and paper-based manual enrolment. Submission Date The date on which the pre-enrollment is submitted. Requested EFT Start/Change/Cancel Date The date on which the requested action is to begin.
Submission Information. Reason for Submission * New Enrollment Change Enrollment Cancel Enrollment Include with Enrollment Submission * Voided Check - A voided check is attached to provide confirmation of identification/account numbers OR Bank Letter - A letter on bank letterhead that formally certifies the account owners routing and account numbers AUTHORIZATION Pursuant to A.R.S. Sec. 35-185, I authorize theArizona Department of Administration (ADOA, General Accounting Office (GAO) and the Arizona Health Care Cost Containment System (AHCCCSA) to process payments owed to me via Automated Clearing House (ACH) deposits. The State of Arizona and AHCCCSA shall deposit the ACH payments in the financial institution and account designated above. * I recognize that if I fail to provide complete and accurate information on this authorization form, the processing of the form may be delayed or made impossible, or my electronic payments may be erroneously made.
Submission Information. Upon delivery of this Application/Contract or shortly thereafter, Applicant and/or the Loan Correspondent shall provide Nationwide with any documentation and information requested by Nationwide that is reasonably necessary for Nationwide to evaluate the feasibility of the Mortgage Loan, including, but not limited to, such items as an appraisal, site plan (showing the location of Improvements, parking, means of ingress and egress and other easements), operating statements, leasing information, a current rent roll, leases, plans and specifications for the building(s), surveys, legal description of the Security Property, copies of restrictive covenants and easements affecting the Security Property, credit reports, bank references, information about pending litigation affecting the Security Property, the Borrower, Guarantors, or Responsible Individuals, and partnership agreements, trust agreements, articles of incorporation, or other organizational documents.
