Fraud Notice definition

Fraud Notice. Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties. This includes Attending Physician portions of the claim form. Doctor’s Signature Date: (MM/DD/YYYY) Referring Physician’s name and address Doctor’s Phone : ( ) Fax : ( ) Hospital Name Hospital Phone ( ) Hospital’s Address (Street) (City) (State) (Zip Code)
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Fraud Notice. Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties. This includes Employer and Attending Physician portions of the claim form. Signed by Title Print name Date (MM/DD/YYYY) Telephone Number ( ) Fax Number ( ) E-mail Address (*Please print) Phone 0.000.000.0000 Fax 0.000.000.0000 Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my eligibility for insurance and eligibility for benefits under an existing policy/certificate including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application or claim forms, I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial Life) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record and insurance claim history but does not include psychotherapy notes. Non health information including earnings or employment history or any other facts deemed appropriate by Colonial Life to evaluate my application or claim forms may be disclosed by any entity, person or organization that has these records about me, including but not limited to my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial Life obtains pursuant to this authorization will be used for the purpose of evaluating and administering my claim for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial Life will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution or the duration of my claim, whic...
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Fraud Notice. Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalities. This includes the Physician Statement portion of the claim form. Print claimant’s name Claimant’s signature Date (MM/DD/YYYY) Print policy owner’s name Policy owner’s signature Date (MM/DD/YYYY) Claimant name: Claimant SSN:
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Examples of Fraud Notice in a sentence

  • OFFICE OF THE INSPECTOR GENERAL FRAUD NOTICE NOTE: FAILURE TO PROVIDE PROPERLY COMPLETED EXECUTED DOCUMENTS; INCLUDING SMALL BUSINESS ENTERPRISE (SBE) & DISABLED VETERAN BUSINESS ENTERPRISE (DVBE), ETHICS CERTIFICATIONS, RATE SCHEDULE, ETC., WITH EACH BID OR FAILURE TO PROPERLY EXECUTE GOOD FAITH EFFORTS MAY RESULT IN A DETERMINATION OF NON-RESPONSIVENESS.

  • FRAUD NOTICE: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

  • FRAUD NOTICE NOTICE TO APPLICANTS OF WASHINGTON: Any person who knowingly, and with the intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any material false information or conceals for the purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties and denial of insurance benefits.

  • If you are a resident of California, Florida, Kentucky, New Jersey, New York, Ohio, Oklahoma or Pennsylvania see the FRAUD NOTICE at geobluetravelinsurance.com/purchase/fraudAgreement.cfm for additional information.About the Global Citizens Association: The Global Citizens Association is a national organization dedicated to promoting the interests of international travelers.

  • FRAUD NOTICE, THAT THE ABOVE INFORMATION IS CORRECT AND THAT THE CLAIMS HAVE BEEN PAID IN ACCORDANCE WITH THE PLAN DOCUMENT.

  • Reasons for the offer: The net proceeds of the issue of the Notes will be used for the general corporate purposes of the Guarantor.

  • I CERTIFY FURTHER THAT I HAVE READ AND UNDERSTAND THE ATTACHED FRAUD NOTICE, THAT THE ABOVE INFORMATION IS CORRECT AND THAT THE CLAIMS HAVE BEEN PAID IN ACCORDANCE WITH THE PLAN DOCUMENT.

  • NOTICE IN DISTRICT OF COLUMBIA: FRAUD NOTICE: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person.

  • FRAUD NOTICE: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

  • FRAUD NOTICE – WHERE APPLICABLE UNDER THE LAW OF YOUR STATE NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY.


More Definitions of Fraud Notice

Fraud Notice. Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalities. This includes the Physician Statement portion of the claim form. Print claimant’s name Claimant’s signature Date (MM/DD/YYYY) Print policy owner’s name Policy owner’s signature Date (MM/DD/YYYY) If deceased, attach a death certificate and complete below. Beneficiary’s name Beneficiary’s signature Date (MM/DD/YYYY) Beneficiary’s SSN: Beneficiary’s DOB: / / Relationship to deceased: Beneficiary’s address: City: State: ZIP: Telephone: Witness’ name: Witness’ signature: Witness’ address: City: State: ZIP:
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Fraud Notice. Any person who, with the intent to defraud or knowing that he/ she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of the crime of insurance fraud as determined by a court of competent jurisdiction. The President and Secretary of the Company witness this Policy. President Secretary
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Fraud Notice. Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties. This includes Attending Physician portions of the claim form. Doctor’s Signature (completing this form): Tax ID or SSN : Phone Numbers: ( ) Date : (MM/DD/YYYY) Fax Number: ( ) Claimant Name Social Security Number SECTION 4 TO BE COMPLETED BY PHYSICIAN (Fill this section out for Disability claims Only) Patient’s name Patient’s DOB What primary condition prevents the patient from working? Symptoms: Objective Findings: Date first treated for this condition (MM/DD/YYYY) If pregnancy, what is EDC? (MM/DD/YYYY) Is condition due to accident? Yes No If yes, date and description of accident. Are any secondary conditions preventing the patient from working? Yes No If yes, what are these secondary conditions? When did symptoms first appear? (MM/DD/YYYY) Date of new patient consultation (MM/DD/YYYY) Date of patient’s last visit. (MM/DD/YYYY) List any test(s) performed and submit a copy of the results. List any surgeries performed with the date and procedure code.(CPT) (Attach a copy of the operative report) Restrictions (What the patient SHOULD NOT DO) Limitations (What the patient CANNOT DO) How soon do you expect significant improvement in the patient’s medical condition? 1-2 months 3-4 months 5-6 months more than 6 months Expected return to work (MM/DD/YYYY) Dates unable to work (full-time): From: (MM/DD/YYYY) To: (MM/DD/YYYY) Dates unable to work (part-time): From: (MM/DD/YYYY) To: (MM/DD/YYYY) Actual date released to return to work (MM/DD/YYYY)
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Fraud Notice. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. 529 Fund Agr App 1-17 XX XXXXX Tracking #: AMFA-130884786 State Tracking #: Company Tracking #: 529 FUNDING AGREEMENT State: District of Columbia Filing Company: Ameritas Life Insurance Corp. TOI/Sub-TOI: A08G Group Annuities - Unallocated/A08G.001 Funding Agreement Product Name: 529 Funding Agreement Project Name/Number: 529 Funding Agreement/529 Funding Agreement Supporting Document Schedules Satisfied - Item: Readability Certification Comments: Attached is a readability certification as required. Attachment(s): DC-Readability Certification.pdf Item Status: APPROVED Status Date: 01/27/2017 PDF Pipeline for SERFF Tracking Number AMFA-130884786 Generated 09/17/2020 07:31 PM DISTRICT OF COLUMBIA CERTIFICATE OF READABILITY INSURER: Ameritas Life Insurance Corp. hereby certifies that the filing achieves a Xxxxxx Reading Ease Test Score as stated below. Form Number Form Title Xxxxxx Score 529 Fund Agr 1-17 DC Funding Agreement 46 529 Fund Agr App 1-17 DC Application for Funding Agreement 46 when scored with agreement Signature: Xxxxxxx X. Xxxxx Title: Second Vice President and Associate General Counsel
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Fraud Notice. Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties. This includes Attending Physician portions of the claim form. Doctor’s Signature (completing this form): Tax ID or SSN : Phone Numbers: ( ) Date : (MM/DD/YYYY) Fax Number: ( ) *WELLNESS/HEALTH SCREENING If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 12 months, you’ll need to submit the type and date of the test performed as well as your doctor’s name and phone number. We also need to know if this is for you or another covered individual and their name and social security number. If you file by telephone or internet please retain a copy of the medical information and/or your receipt if needed for further verification..
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Related to Fraud Notice

  • FOIA notice means a decision notice, enforcement notice and/or an information notice;

  • CAFA Notice refers to the notice requirements imposed by 28 U.S.C. § 1715(b).

  • Demand Notice has the meaning set forth in Section 2(a)(i).

  • Repurchase Response Notice means a notice delivered by the Indenture Trustee at the direction of the Administrator to a Noteholder or Note Owner indicating that a Repurchase Request is unresolved.

  • Penalty Notice means a written no- tification from the Director informing a respondent that the Director has made a finding of violation and, absent a request for a hearing, will impose a civil monetary penalty.

  • Denial notice means a board notification denying an application for the issuance or renewal of a license as required by the Act.

  • Second Notice means notice to the Class in a form to be approved by the Court, which shall substantially be in accordance with the notice at Schedule “E”.

  • Required Notice Period means the number of days required notice set forth below applicable to the Aggregate Reduction indicated below: Aggregate Reduction Required Notice Period £$100,000,000 two Business Days >$100,000,000 to $250,000,000 five Business Days ³$250,000,000 ten Business Days

  • Exchange Notice has the meaning set forth in Section 2.1(a)(iii).

  • Long Form Notice means the form of notice that shall be posted on the Settlement Website created by the Settlement Administrator and shall be available to Settlement Class members by mail on request made to the Settlement Administrator in the form attached as Exhibit 2.

  • OJEU Notice means the contract notice published in the Official Journal of the European Union.

  • Determination Notice is defined in Section 6.1(b)(i) of the Agreement.

  • Nomination Notice means all information and documents that a Nominating Stockholder is required to submit to the Secretary of the Corporation pursuant to Section 1.13(f).

  • Change Notice is defined in Section 3.5(a) of this Agreement.

  • Warning Notice means a notice in writing by the Secretary of State to the Academy Trust requiring the Academy Trust to procure the admission of a sufficient number of pupils by such date as he deems appropriate in the circumstances and setting out the consequences of not procuring the admission of a sufficient number of pupils by the date specified in such Warning Notice. 91D) If at any time after signing this Agreement, the Parties agree that by virtue of low pupil numbers the Academy is not financially viable, then the Parties jointly may terminate this Agreement having agreed first the precise terms of termination.

  • Termination Warning Notice means a notice sent by the Secretary of State to the Academy Trust, stating his intention to terminate this Agreement.

  • Breach Notice has the meaning specified in Section 8.2(a);

  • Repudiation/Moratorium Extension Notice means a notice from the Calculation Agent to the Issuer (which the Calculation Agent has the right but not the obligation to deliver) that describes a Potential Repudiation/Moratorium that occurred on or prior to the Scheduled Maturity Date. A Repudiation/Moratorium Extension Notice must contain a description in reasonable detail of the facts relevant to the determination that a Potential Repudiation/Moratorium has occurred and indicate the date of the occurrence. The Potential Repudiation/Moratorium that is the subject of the Repudiation/Moratorium Extension Notice need not be continuing on the date the Repudiation/Moratorium Extension Notice is effective.

  • Offeror’s Notice means the notice described in Section 12.3.

  • CFIUS Notice means a joint voluntary notice with respect to the Contemplated Transactions prepared by Parent and the Company and submitted to CFIUS in accordance with the requirements of the DPA.

  • decision notice means a written notice of a decision by the Department regarding an individual's eligibility for benefits in a program.

  • Initial Notice shall have the meaning set forth in Section 7.1.

  • Publication Notice means the summary notice of proposed Settlement and hearing for publication substantially in the form attached as Exhibit 3 to Exhibit A.

  • Email Notice means the legal notice summarizing the proposed Settlement terms, as approved by Class Counsel, Facebook’s Counsel, and the Court, to be provided to Class Members (including Minor Subclass Members), under Section 3.3 of this Agreement via electronic mail or the Facebook domain of xxx.xxxxxxxx.xxx. The Email Notice must be substantially similar to the form attached hereto as Exhibit 3.

  • Suspension Notice As defined in Section 6(d) hereof.

  • Timely Notice means a stockholder’s notice to the Secretary of the Corporation which must be delivered to or mailed and received at the principal executive offices of the Corporation not less than ninety (90) days nor more than one hundred twenty (120) days prior to the first anniversary of the preceding year’s annual meeting of stockholders; provided, however, that in the event that the date of the annual meeting is more than thirty (30) days before, or more than sixty (60) days after, such anniversary date, notice by the stockholder to be timely must be so delivered not earlier than the one hundred twentieth (120th) day prior to such annual meeting and not later than the ninetieth (90th) day prior to such annual meeting or, if later, the tenth (10th) day following the day on which the date that such annual meeting was Publicly Disclosed (as defined above).