Treatment Authorization Sample Clauses

Treatment Authorization.  I request BHSI to plan and provide treatment to me (or my minor child) with my participation. I understand that I may withdraw this consent and terminate treatment at any time, for any reason.  I understand that the treatment relationship is considered terminated if I have not been seen at BHSI for more than one year.  I agree to have BHSI call, text, or email me to confirm appointments and/or to address billing issues.  I permit XXXX to leave a phone message about my appointment.
Sample 1Sample 2Sample 3
AutoNDA by SimpleDocs
Treatment Authorization. I request Xxx Xxx, MS, LP to plan and provide treatment to me (or my minor child) with my participation. I understand that I may withdraw this consent and terminate treatment at any time, for any reason. Client’s Signature Date (or parent/legal guardian if client is under 18 years old) 0000 Xxxxxx Xxxxxx North Stillwater, MN 55082 phone/fax 651·430·2212
Sample 1Sample 2
Treatment Authorization. The owner agrees that Carolinas Veterinary Medical Hospital, in its discretion, give first aid, medication, or other attention we deem it necessary for the health, and safety of your pet. Carolinas Veterinary Medical Hospital is authorized by the owner to provide veterinary care, including emergency care, at the owner's expense. If we believe that your pet needs care, time permitting, we will attempt to contact you before providing that care, but this document serves as our authorization to provide veterinary care for your pet in the event we are unable to reach the owner. The owner is responsible for the expenses of veterinary care, whether you have been reached in advance. Your signature on this authorization permits Carolinas Veterinary Medical Hospital to make reasonable care decisions regarding your pet; and the owner agrees to pay for all costs incurred for such treatment. In the unlikely event that a pet passes away while a guest of Carolinas Veterinary Medical Hospital we will contact you and discuss your options of aftercare.
Sample 1Sample 2
Treatment Authorization. Authorization for residential services will be approved by the Gateway Team. Appointments for continuing treatment in outpatient settings will be arranged prior to discharge from this treatment level.
Sample 1
Treatment Authorization. I request Stone Creek Psychiatry to plan and provide treatment to me (or my minor child) with my participation. I understand that I may withdraw this consent and terminate treatment at any time, for any reason. • I agree to have Stone Creek Psychiatry call me to confirm appointments. • I authorize Stone Creek Psychiatry to leave a phone message regarding my appointments.
Sample 1
Treatment Authorization. Authorization for Withdrawal Management Residential Services will be approved by the Gateway Team. Appointments for continuing treatment in residential settings will be arranged prior to discharge, with a plan for continued treatment at outpatient settings after the residential episode is completed.
Sample 1
Treatment Authorization. Resident authorizes the Facility to provide care and treatment consistent with the terms of this Agreement. Resident also authorizes the Facility to obtain all necessary clinical and/or financial information from the hospital or nursing facility from which Resident may be transferring.
Sample 1
AutoNDA by SimpleDocs
Treatment Authorization. I request BHSI to plan and provide treatment to me (or my minor child) with my participation. I understand that I may withdraw this consent and terminate treatment at any time, for any reason. I understand that the treatment relationship is considered terminated if I have not been seen at BHSI for more than one year. I agree to have BHSI call, text, or email me to confirm appointments and/or to address billing issues. I permit XXXX to leave a phone message about my appointment. Payment Responsibility: I have read, completed, and signed the Insurance Payment Order form authorizing BHSI to process my claims and receive payment from my third party payor. I agree to pay all co-payments or co-insurance required by my health plan. If the services I receive from BHSI are not covered by a third party payor, subject to the provisions of my third party payor contract, if any, I agree to pay for these services myself. I understand that an 8% finance charge will be applied to balances over 120 days old, and that BHSI utilizes a collections agency to collect delinquent balances. I agree to give BHSI 24-hour prior notice of any appointment cancellation. I understand that if I do not give this notice, I may be charged a fee. I am aware that insurance companies will not cover this cost.
Sample 1
Treatment Authorization. Contractor shall coordinate all services, excluding emergency psychiatric services, with County’s Clinical Division Directors. Contractor shall submit clinical documentation within seventy-two (72) hours of the date of service. Contractor shall use County’s forms for assessments, treatment planning, documenting progress, weekly summaries and discharges. Contractor shall request initial Mental Health Plan (MHP) payment authorization from the County for counseling, psychotherapy or other similar therapeutic interventions that meet the definition of mental health services and specialty mental health services as defined in Title 9, CCR, Section 1810.227 and Title 9, CCR, Section 1810.247, excluding services to treat emergency and urgent conditions as defined in Title 9, CCR, Sections 1810.216 and 1810.253 that will be provided on the same day that Day Treatment Intensive or Day Rehabilitation is being provided to the beneficiary. Contractor shall ensure that services provided outside of Day Treatment, on the same day of Day Treatment, document the actual time of the day the service was provided; and shall request County payment authorization for continuation of these services on the same cycle required for continuation of the concurrent day treatment intensive or day rehabilitation for the beneficiary.
Sample 1

Related to Treatment Authorization

  • Payment Authorization I authorize Xxxxx Management to collect payment of the application fee and application deposit in the amounts specified under paragraph 3 of the Disclosures.

  • AGENT AUTHORIZATION FORM I/We, (Print Bidder name) , Do hereby authorize (print agent’s name), , to act as my/our agent to execute any petitions or other documents necessary to affect the CONTRACT approval PROCESS more specifically described as follows, (IFB NUMBER AND TITLE) , and to appear on my/our behalf before any administrative or legislative body in the county considering this CONTRACT and to act in all respects as our agent in matters pertaining TO THIS CONTRACT. Signature of Bidder Date STATE OF FLORIDA ) ) ss: COUNTY OF ) The foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]. ☐Personally Known; OR ☐Produced Identification. Type of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public My Commission Expires: (Printed, typed or stamped commissioned name of Notary Public) LEASED EMPLOYEE AFFIDAVIT I affirm that an employee leasing company provides my workers’ compensation coverage. I further understand that my contract with the employee leasing company limits my workers’ compensation coverage to enrolled worksite employees only. My leasing arrangement does not cover un-enrolled worksite employees, independent contractors, uninsured sub-contractors or casual labor exposure. I hereby certify that 100% of my workers are covered as worksite employees with the employee leasing company. I certify that I do not hire any casual or uninsured labor outside the employee leasing arrangement. I agree to notify the County in the event that I have any workers not covered by the employee leasing workers’ compensation policy. In the event that I have any workers not subject to the employee leasing arrangement, I agree to obtain a separate workers’ compensation policy to cover these workers. I further agree to provide the County with a certificate of insurance providing proof of workers’ compensation coverage prior to these workers entering any County jobsite. I further agree to notify the County if my employee leasing arrangement terminates with the employee leasing company and I understand that I am required to furnish proof of replacement workers’ compensation coverage prior to the termination of the employee leasing arrangement. I certify that I have workers’ compensation coverage for all of my workers through the employee leasing arrangement specified below: Name of Employee Leasing Company: Workers’ Compensation Carrier: A.M. Best Rating of Carrier: Inception Date of Leasing Arrangement: I further agree to notify the County in the event that I switch employee-leasing companies. I recognize that I have an obligation to supply an updated workers’ compensation certificate to the County that documents the change of carrier. Name of Contractor: Signature of Owner/Officer: Title: Date: INFORMATION FOR DETERMINING JOINT VENTURE ELIGIBILITY If the bidder is submitting as a joint venture, please be advised that this form MUST be completed and the REQUESTED written joint-venture agreement MUST be attached and submitted with this form. HOWEVER, IF THE BIDDER IS NOT A JOINT VENTURE, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLE

  • Medical Authorization In the event of illness or injury while participating in the above referenced activity, I hereby consent to whatever x-ray, examination, anesthetic, medical, surgical, dental diagnosis or treatment, hospital care and emergency transportation from a licensed physician, surgeon, and/or dentist as deemed necessary for my safety and welfare.

  • AGREEMENT AUTHORITY 5.1 The Parties are authorized to meet together, discuss, reach agreement and take actions necessary to implement or effectuate agreements regarding sharing of vessels, chartering or exchange of space, rationalization and related coordination and cooperative activities pertaining to their operations and services, and related equipment, vessels and facilities in the Trade. It is initially contemplated that the Parties will jointly coordinate the operation and sharing of space on 151 container vessels in the Trade with nominal capacities ranging from 3,000-14,500 TEUs.

  • Prior Authorization A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.

  • Licenses and Similar Authorizations The Contractor, at no expense to the City, shall secure and maintain in full force and effect during the term of this Contract all required licenses, permits, and similar legal authorizations, and comply with all related requirements.

  • LEGAL AUTHORIZATION (a) The Sub-Recipient certifies that it has the legal authority to receive the funds under this Agreement and that its governing body has authorized the execution and acceptance of this Agreement. The Sub-Recipient also certifies that the undersigned person has the authority to legally execute and bind Sub-Recipient to the terms of this Agreement.

  • Client Authority If Client is an individual, Client represents that he or she is of the age of majority. If Client is a corporation, partnership or limited liability company, the person signing this Agreement for the Client represents that he or she has been authorized to do so by appropriate action. If this Agreement is entered into by a trustee or other fiduciary, the trustee or fiduciary represents that Advisor’s investment management strategies, allocation procedures, and investment advisory services are authorized under the applicable plan, trust, or law and that the person signing this Agreement has the authority to negotiate and enter into this Agreement. Client will inform Advisor of any event that might affect this authority or the propriety of this Agreement.

  • Management Authority Except as otherwise expressly provided herein or in the Act, responsibility for the management of the business and affairs of the Company shall be wholly vested in the Manager, which shall have all right, power and authority to manage, operate and control the business and affairs of the Company and to do or cause to be done any and all acts, at the expense of the Company, deemed by it to be necessary or convenient to the furtherance of the purpose of the Company described in this Agreement. Any action taken by the Manager which is not in violation of this Agreement, the Act and other applicable law shall constitute the act of, and serve to bind, the Company. Any and all actions taken or approved by the Manager pursuant to this Section 5.1 may, but need not, be evidenced by written resolutions. Without limiting the generality of the foregoing, the Manager may appoint, remove and replace officers of the Company at any time and from time to time, and the Manager may retain such Persons (including any Persons in which the Manager shall have an interest or of which the Manager is an Affiliate) as it shall determine to provide services to or on behalf of the Company for such compensation as the Manager deems appropriate. The Manager may designate individuals as authorized signatories to bind the Company and/or serve as “authorized persons,” within the meaning of the Act, to execute, deliver and file any amendments or restatements of the Certificate and all other certificates (and any amendments and/or restatements thereof) required or permitted by the Act to be filed in the office of the Secretary of State of Delaware. Without limiting the generality of the foregoing, the Secretary or any Vice President of DHC is hereby designated as an authorized person, within the meaning of the Act, to execute, deliver and file, or cause the execution, delivery and filing of, all certificates (and any amendments and/or restatements thereof) required or permitted by the Act to be filed in the office of the Secretary of State of Delaware.

  • Network Authorization For services that cannot be provided by a network provider, you can request a network authorization to seek services from a non-network provider. With an approved network authorization, the network benefit level will apply to the authorized covered healthcare service. If we approve a network authorization for you to receive services from a non- network provider, our reimbursement will be based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit. For more information, please see the How Non-Network Providers Are Paid section.

Time is Money Join Law Insider Premium to draft better contracts faster.