TO BE COMPLETED BY PROVIDER Sample Clauses

TO BE COMPLETED BY PROVIDER. I declare and affirm under the penalties of perjury that this Agreement has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I further declare and affirm under the penalties of perjury that any claim to be submitted pursuant to this Agreement will be examined by me, and to the best of my knowledge and belief, will be in all things true and correct. PROVIDER NAME: BY: Authorized Signature NAME/TITLE: APPLICATION ID: If application was submitted online FEDERAL TAX I.D. NUMBER: TAX I.D. NAME: DATE: TO BE COMPLETED BY MEDICAL SERVICES APPROVED BY: Xxxxxx Xxxxxxxx, Program Administrator DATE: PROVIDER NUMBER: ************************************************************************************************************************ MAIL SIGNED AGREEMENT AND OTHER APPLICABLE DOCUMENTATION TO: DEPARTMENT OF SOCIAL SERVICES FINANCE/EBT 000 XXXXXXXXX XXXXX XXXXXX, XX 00000-0000
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TO BE COMPLETED BY PROVIDER. I declare and affirm under the penalties of perjury that this Agreement has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I further declare and affirm under the penalties of perjury that any claim to be submitted pursuant to this Agreement will be examined by me, and to the best of my knowledge and belief, will be in all things true and correct. PROVIDER NAME: (Legal Name of Individual Provider for Individual Enrollments or Legal Name of Organization for Other Enrollment Types) BY: Authorized Signature (Must be Provider for Individual Enrollments) NAME: DATE: APPLICATION ID: (Printed Name of Signatory) (Complete only if new application submitted) SERVICING NPI: BILLING NPI: _ (Only applies if Agreement for individual enrollment type) BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ (Multiple Billing NPI fields are only acceptable when Agreement is for individual enrollment type) ENROLLMENT TYPE: FAOIP (Check one type, found on enrollment record) GROUP R. INDI S. INDI Tribal/IHS ************************************************************************************************************************ TO BE COMPLETED BY MEDICAL SERVICES APPROVED BY: REFERENCE NUMBER: DATE: NEW REVALIDATION RISK LEVEL
TO BE COMPLETED BY PROVIDER. I declare and affirm under the penalties of perjury that this Addendum has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I further declare and affirm under the penalties of perjury that any claim to be submitted pursuant to this Addendum will be examined by me, and to the best of my knowledge and belief, will be in all things true and correct. Provider NPI: Provider Name: Legal Name of Individual Provider By: Name/Title: Authorized Signature of Provider Printed Name of Signatory Date: TO BE COMPLETED BY MEDICAL SERVICES Approved By: Reference Number: Date: New Revalidation

Related to TO BE COMPLETED BY PROVIDER

  • Waiver of Right to Trial by Jury EACH PARTY TO THIS AGREEMENT HEREBY EXPRESSLY WAIVES ANY RIGHT TO TRIAL BY JURY OF ANY CLAIM, DEMAND, ACTION OR CAUSE OF ACTION ARISING UNDER ANY LOAN DOCUMENT OR IN ANY WAY CONNECTED WITH OR RELATED OR INCIDENTAL TO THE DEALINGS OF THE PARTIES HERETO OR ANY OF THEM WITH RESPECT TO ANY LOAN DOCUMENT, OR THE TRANSACTIONS RELATED THERETO, IN EACH CASE WHETHER NOW EXISTING OR HEREAFTER ARISING, AND WHETHER FOUNDED IN CONTRACT OR TORT OR OTHERWISE; AND EACH PARTY HEREBY AGREES AND CONSENTS THAT ANY SUCH CLAIM, DEMAND, ACTION OR CAUSE OF ACTION SHALL BE DECIDED BY COURT TRIAL WITHOUT A JURY, AND THAT ANY PARTY TO THIS AGREEMENT MAY FILE AN ORIGINAL COUNTERPART OR A COPY OF THIS SECTION WITH ANY COURT AS WRITTEN EVIDENCE OF THE CONSENT OF THE SIGNATORIES HERETO TO THE WAIVER OF THEIR RIGHT TO TRIAL BY JURY.

  • Right to Work For purposes of federal immigration law, you will be required to provide to the Company documentary evidence of your identity and eligibility for employment in the United States. Such documentation must be provided to us within three (3) business days of your Start Date, or our employment relationship with you may be terminated.

  • RESPONDING TO REQUESTS FOR INFORMATION To the extent authorized by the Participating Consumer(s) and to the extent such individual permission is required by law, the Competitive Supplier shall, during normal business hours (as set forth above), respond promptly and without charge therefore to reasonable requests of the Town for information or explanation regarding the matters covered by this ESA and the supply of electricity to Participating Consumers. Competitive Supplier agrees to designate a service representative or representatives (the “Service Contacts”) who shall be available for these purposes, and shall identify the office address and telephone number of such representative(s). Whenever necessary to comply with this Article 5.3, the Service Contacts shall call upon other employees or agents of the Competitive Supplier to obtain such information or explanation as may be reasonably requested. Nothing in this Article 5.3 shall be interpreted as limiting the obligation of the Competitive Supplier to respond to complaints or inquiries from Participating Consumers, or to comply with any regulation of the Department or AG regarding customer service.

  • Access to and Use of Content Customer has the right to access and use applicable Content subject to the terms of applicable Order Forms, this Agreement and the Documentation.

  • City’s Right to Terminate for Convenience City may, at its sole option and for its convenience, terminate all or any portion of this Contract by giving thirty (30) days’ written notice of such termination to Contractor. The termination of the Contract shall be effective upon receipt of the notice by Contractor. After termination of all or any portion of the Contract, Contractor shall: (1) immediately discontinue all affected performance (unless the notice directs otherwise); and (2) complete any and all additional work necessary for the orderly filing of documents and closing of Contractor's affected performance under the Contract. After filing of documents and completion of performance, Contractor shall deliver to City all data, drawings, specifications, reports, estimates, summaries, and such other information and materials created or received by Contractor in performing this Contract, whether completed or in process. By accepting payment for completion, filing, and delivering documents as called for in this section, Contractor discharges City of all of City’s payment obligations and liabilities under this Contract with regard to the affected performance.

  • Right to Join Employees shall have the right to form and join labor or employee organizations, and shall have the right not to form and join such organizations. Employees in an appropriate unit shall have the right by secret ballot to designate an exclusive representative for the purpose of negotiating grievance procedures and the terms and conditions of employment for employees of such unit with the School Board.

  • EMPLOYEE JURY SERVICE (check one or more boxes) Contractors with original or amended contracts in excess of $100,000 must have and adhere to a written policy that provides its employees living in San Mateo County up to five days regular pay for actual jury service in the County. Contractor complies with the County’s Employee Jury Service Ordinance. Contractor does not comply with the County’s Employee Jury Service Ordinance. Contractor is exempt from this requirement because: the contract is for $100,000 or less. Contractor is a party to a collective bargaining agreement that began on (date) and expires on (date), and intends to comply when the collective bargaining agreement expires. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that I am authorized to bind this entity contractually. Signature Name

  • Compliance with Contractor Employee Jury Service Ordinance Contractor shall comply with the County Ordinance with respect to provision of jury duty pay to employees and have and adhere to a written policy that provides that its employees shall receive from the Contractor, on an annual basis, no less than five days of regular pay for actual jury service in San Mateo County. The policy may provide that employees deposit any fees received for such jury service with the Contractor or that the Contractor deduct from the employees’ regular pay the fees received for jury service.

  • Waiver of Right to Jury Trial TO THE EXTENT PERMITTED UNDER APPLICABLE LAW, THE PARTIES HEREBY KNOWINGLY, VOLUNTARILY AND INTENTIONALLY WAIVE ANY RIGHT THAT THEY MAY HAVE TO A TRIAL BY JURY IN ANY LITIGATION ARISING IN ANY WAY IN CONNECTION WITH ANY OF THE TRANSACTION DOCUMENTS, OR ANY OTHER STATEMENTS OR ACTIONS OF THE COMPANY OR THE PURCHASERS. THE PARTIES ACKNOWLEDGE THAT THEY HAVE BEEN REPRESENTED IN THE SIGNING OF THIS AGREEMENT AND IN THE MAKING OF THIS WAIVER BY INDEPENDENT LEGAL COUNSEL SELECTED OF THEIR OWN FREE WILL. THE PARTIES FURTHER ACKNOWLEDGE THAT (I) THEY HAVE READ AND UNDERSTAND THE MEANING AND RAMIFICATIONS OF THIS WAIVER, (II) THIS WAIVER HAS BEEN REVIEWED BY THE PARTIES AND THEIR COUNSEL AND IS A MATERIAL INDUCEMENT FOR ENTRY INTO THIS AGREEMENT AND (III) THIS WAIVER SHALL BE EFFECTIVE AS TO EACH OF SUCH TRANSACTION DOCUMENTS AS IF FULLY INCORPORATED THEREIN.

  • Waiver of Trial by Jury Each party hereby irrevocably and unconditionally waives the right to a trial by jury in any action, suit, counterclaim or other proceeding (whether based on contract, tort or otherwise) arising out of, connected with or relating to this Agreement, the transactions contemplated hereby, or the actions of the Investor in the negotiation, administration, performance or enforcement hereof.

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