Xxxxx’s Name. The name of the payee on each Item shall be only that of Company, and the Items may not include any additional payee(s), nor may the Items be endorsed by a third party.
Xxxxx’s Name. Full name of child DOB: Date of birth of child Service Coordinator: Name Date of Consultation: MM/DD/YYYY Start Time: Beginning time of consultation session End Time: End time of consultation session Location: This is the location where the meeting occurred. If face-to-face, enter the location as i.e. Home, Local Early Steps, Playpen Therapy; if occurred by phone, enter the location as Phone. Successes and Challenges to implementing strategies and achieving goals: Narrative of the discussion, by individual outcome. The team (family, caregivers, primary service provider and supporting providers) will continue or modify the following strategies to achieve goals: Narrative of the recommendation(s) resulting from the consultation, by individual outcome. PSP: Name and credentials of the current Primary Service Provider Consulting Team Members: List all members participating in the consultation and check Face-to-Face or Phone and obtain signatures of those present. Family Participation: The name(s) of the family member(s) and check Phone, Face-to-Face or Declined Invitation ALL THE ABOVE FIELDS SHOULD BE IDENTICAL FOR ALL PARTICIPANTS’ FORMS When each provider receives their copy of the completed form, they will complete the remaining fields before billing. Provider/Participant Name (Print): LEGIBLE name of provider/participant Signature: Provider/Participant signature Each participant should find their designation and sign, if face-to-face. Provider signature lines should include the code signifying if participation was Face-to-Face or Phone Consultation time must be authorized on the Individualized Family Support Plan (IFSP).Billing is based on the location of the Consultation session. Revised Jan 2015 EXHIBIT L – HOMELAND SECURITY STATEMENT Exhibit M AFFIDAVIT OF Early Steps Provider STATE OF FLORIDA COUNTY OF Before me, a notary public, personally appeared (print name) who, being duly sworn, says as follows: I Hereby attest that as (your position) for the Early Steps Provider (name of business entity/employer/provider) said early steps provider certifies the use of the US Department of Homeland security's E-Verify system to verify employment eligibility of (a) all new persons hired during the contract term to perform employment duties pursuant to this agreement and section 448.095, Florida statues and (b) the provider does not and will not employ, contract with, or subcontract with an unauthorized alien. Signature of Affiant Sworn and subscribed before me th...
Xxxxx’s Name. is a full-time student. (If the child/youth is a full-time student, proof of school attendance must be provided to DCS). We (I) certify that our (my) child (Xxxxx's Name) is currently not employed. (If the child/youth is employed, proof of the income {before taxes/expenses} must be provided to DCS). We (I) certify that our/my child (Child's Name) is not currently receiving a SSA or VA or SSI. (If the child/youth is receiving SSA, VA benefits, SSI or receives other monthly benefits, proof of the type and amount of the benefits must be provided to DCS). Type of Monthly Benefit: Monthly/Weekly Amount: $ We (I) certify that our (my) child (Child's Name) does not have any financial resources. (If the child/youth does have any financial resources, proof of each type and value of the resource must be provided to DCS). Type of Financial Resource: Value of Resource: $
Xxxxx’s Name. Mr. Mrs. Ms. …………………..…………………………………………………………………………………………………………………………………………….. Address …………………………………………………………………………………………………………………………………………………….. Country ……………………………………………………….Telephone Mob: ………………………………………………. Fixed Telephone: ……………………………………………………Email: …………………………………………………………………………… as of the date last written on the signature page of this Agreement. Owner and Guest maybe referred to individually as ‘’Party’’ and collectively as ‘’Parties’’. For good and valuable consideration, the sufficiency of which is acknowledged, the Parties agree as follows:
