Third Party Antitrust Violations. The Subrecipient hereby assigns to the State of Arizona any claim for overcharges resulting from antitrust violations to the extent that such violations concern materials or services supplied by third parties to Subrecipient toward fulfillment of this Agreement.
Third Party Antitrust Violations. The Contractor assigns to the State any claim for overcharges resulting from antitrust violations to the extent that those violations concern materials or services supplied by third parties to the Contractor, toward fulfillment of this Contract.
Third Party Antitrust Violations. The Contractor assigns to the School District/public entity any claim for overcharges resulting from antitrust violation the extent that those violations concern materials of services supplied by third parties to the contractor toward fulfillment of this Contract.
Third Party Antitrust Violations. The Qualified Vendor assigns to the State any claim for overcharges resulting from antitrust violations to the extent that those violations concern materials or services supplied by third parties to the Qualified Vendor toward fulfillment of this Agreement.
Third Party Antitrust Violations. The Developmental Home Provider assigns to the State any claim for overcharges resulting from antitrust violations to the extent that those violations concern material or services supplied by third parties to the Developmental Home Provider, toward fulfillment of this Agreement.
Third Party Antitrust Violations. The Cooperator assigns to the State any claim for overcharges resulting from antitrust violations to the extent that such violations concern materials or services supplied by third parties to the Cooperator toward fulfillment of this Agreement.
Third Party Antitrust Violations. JOC hereby assigns to City any claim for overcharges resulting from antitrust violations, to the extent that such violations concern materials or services supplied by third parties to JOC toward fulfillment of the requirements of an issued Job Order and this Agreement.
Third Party Antitrust Violations. 44.1 The Job Order Contractor assigns to the Owner any claim for overcharges, resulting from antitrust violations to the extent that such violations concern materials or services supplied by third parties to the Job Order Contractor toward fulfillment of this Contract.
Third Party Antitrust Violations. The Vendor assigns to the School District any claim for overcharges resulting from antitrust violation the extent that those violations concern materials of services supplied by third parties to the Vendor toward fulfillment of this Agreement. I certify that I am an Authorized Representative of the Vendor and have the authority to bind my company to this Agreement: Print - Vendor Name Print – Authorized Representative’s Name
Third Party Antitrust Violations. The Contractor assigns to AHCCCS any claim for overcharges resulting from antitrust violations to the extent that those violations concern materials or services supplied by third parties to the Contractor toward fulfillment of this contract. Attachment A-1 Transplant Invoice Coversheet CONTRACTOR FACILITY FACILITY ADDRESS CITY, STATE ZIP CONTRACTOR CONTACT NAME CONTACT INFORMATION SUPERVISOR CONTACT TRANSPLANT INVOICE COVERSHEET DO NOT SEPARATE BILL TO: AHCCCS 000 Xxxx Xxxxxxxxx Xxxxxx, Mail Drop 6600 Xxxxxxx, Xxxxxxx 00000 DATE BILLED AUTHORIZATION DATES COVERED CONTRACTOR ID MEMBER NAME MEMBER ID COMPONENT BILLED TOTAL BILLED BILLED CHARGES DETAILED NUMBER OF TOTAL BILLED CLAIMS BILLED CHARGES BY WITH PACKET FORM TYPE INPATIENT $ OUTPATIENT $ PROF FEES $ EXPECTED PAYMENT $ PLEASE REMIT PAYMENT TO: FACILITY NAME **Include only if different from billing facility FACILITY ADDRESS CITY, STATE ZIP CONTACT NAME Included in this component are hospital, physician, and professional services. Attachment A-2 Transplant Invoice Coversheet Instructions FACILITY TRANSPLANT FACILITY ADDRESS HOSPITAL BILLING FACILITY CONTRACTOR BILLING PERSON'S PHONE #, FAX# AND EMAIL ADDRESS FACILITY ADDRESS CITY, STATE ZIP SUPERVISOR CONTACT PHONE, FAX AND EMAIL ADDRESS NEEDED IN THE EVENT THAT BILLING CONTACT CANNOT BE REACHED CONTRACTOR CONTACT NAME CONTACT INFORMATION SUPERVISOR CONTACT TRANSPLANT INVOICE COVERSHEET DO NOT SEPARATE Total of ALL billed charges: IP UB's + OP UB's + 1500's Transplant Component being billed-IE: MUD, Prep and Trans, 1-30 etc. Recipient's AHCCCS ID# Name of Transplant recipient TOTAL BILLED COMPONENT BILLED MEMBER ID MEMBER NAME AHCCCS Contractor ID Begin and end dates when actual services were performed-verify services are within date authed date span Authorization # Given to facility from Med Mgmt Date mailed to AHCCCS CONTRACTOR ID DATES COVERED AUTHORIZATION DATE BILLED BILL TO: Enter either AHCCCS or Health Plan and address NUMBER OF CLAIMS BILLED WITH PACKET INPATIENT $ OUTPATIENT $ PROF FEES $ EXPECTED PAYMENT $ Payment expected for component from AHCCCS or Health Plan per Contractor Total charges for all 1500's(HCFA's) billed with packet Number of 1500's (HCFA) claims billed in packet Total charges for all Outpatient claims billed with packet Number of outpatient claims billed in packet Total charges for Inpatient claims billed with packet Number of Inpatient claims billed in packet TOTAL BILLED CHARGES BY FORM TYPE BILLED CHARGES DETAILED This i...
