Appointment of Authorized Representative. Each Originator hereby irrevocably designates and appoints Professional Services as its exclusive representative under this Agreement (the “Authorized Representative”) to deliver and receive all notices on behalf of such Originator and to receive on behalf of such Originator, and distribute, all payments and distributions of Originators in accordance with the respective interests of Originators and to take such other actions as are set forth in this Agreement. Each Originator hereby unconditionally releases the Buyer and its Affiliates with respect to any claims, obligations or duties that such Persons may otherwise have been deemed to possess absent the designation and appointment contained in this Section 9.13(b).
Appointment of Authorized Representative. Complete this section, only if someone else is representing the patient in this appeal ** You may represent yourself or you may ask another person, including your treating health care provider, to act as your personal representative. You may revoke this authorization at any time. I hereby authorize to pursue my appeal on my behalf. Signature of Enrollee (or legal representative – Please specify relationship or title) Date Representative’s Mailing Address: City: State: Zip Code: Representative’s Phone Number(s): Daytime: ( ) Evening: ( ) Member’s Name: Relationship to Patient: Member’s Insurance ID #: Claim/Reference #: Health Insurance Company’s Name: Insurance Company’s Mailing Address: City: State: Insurance Company’s Phone Number: ( ) Zip Code: Name of Insurance Company representative handling appeal: Is the member’s insurance plan provided by an employer? Yes • Name of employer: No • Employer’s Phone Number: ( ) • Is the employer’s insurance plan self-funded? Yes* No * If you are not certain, please check with your employer. Most self-funded plans are not eligible for external review. However, some self-funded plans may provide external review, but may have different procedures. New Hampshire Premium Assistance Program Is the patient’s health insurance provided through the Medicaid Premium Assistance Program, which is administered by the NH Department of Health and Human Services? Yes No If yes, please provide the Medicaid ID number & complete the following records release: Medicaid ID Number: I, , hereby authorize the New Hampshire Insurance Department to release my external review file to the New Hampshire Department of Health and Human Services (DHHS), if I request a Medicaid Fair Hearing following my independent external review. I understand that DHHS will use this information to make a Fair Hearing determination and that the information will be held confidential. Name of Primary Care Provider (PCP): PCP’s Mailing Address: City: State: Zip Code: PCP’s Phone Number: ( ) Name of Treating Health Care Provider: Provider’s clinical specialty: Treating Provider’s Mailing Address: City: State: Zip Code: Treating Provider’s Phone Number: ( )
Appointment of Authorized Representative. Within fourteen (14) days of execution of this IGA, each Member DDA agrees to appoint a representative who is authorized to make decisions for the Member DDA regarding all matters covered by this IGA (the “Authorized Representative”), and the identity of such person will be communicated to all other Member DDAs via email at the addresses identified in Section 8 below. Each Member DDA shall be entitled to replace such Authorized Representative at its discretion upon notice to the other Member DDAs; provided, however, that all decisions made by the Authorized Representative prior to his or her replacement shall be binding upon such Member DDA.
Appointment of Authorized Representative. Owner hereby appoints Karim El Kheiashy to be the Owner Representative. The Owner Representative shall have full authority to act on Owner’s behalf under this Agreement; provided, however, that the Owner Representative shall not be entitled to amend or terminate this Agreement without further written authorization from Owner; provided, further, that Owner may from time to time by notice to Contractor limit the authority of the Owner Representative to take certain actions on Owner’s behalf under this Agreement, which notices will be effective only prospectively from and after the date that the notices are deemed to have been given under Article 22. Owner may from time to time by notice to Contractor remove any person from his appointment as the Owner Representative and appoint another person in his place with effect from a future date to be specified in the notice. Owner shall at all times throughout the term of this Agreement ensure that some person continues to act as the Owner Representative.
Appointment of Authorized Representative. The individual presently serving as the Vice President – Financial Planning and Enterprise Systems of the Borrower, is hereby designated as an “Authorized Representative” of Borrower for purposes of (i) signing the certifications required under Sections 8(a) through 8(c) of the Loan Agreement; (ii) signing the compliance certificate required under Section 8(d) of the Loan Agreement; (iii) signing the Borrowing Base Certificate; (iv) initiating the making or repayment of Advances pursuant to Section 2 of the Loan Agreement; (v) submitting requests for wire transfer activity; (vi) signing account access requests to view loan accounts and request intercompany wire transfers; and (vii) signing authorization forms for ACH payments to vendors covering an amount not to exceed $500,000. All prior actions by the Borrower’s Vice President – Financial Planning and Enterprise Systems are hereby ratified, approved and confirmed. The Borrower may designate one or more additional employees as an Authorized Representative for the purposes enumerated in this First Amendment by furnishing the Lender with a written statement of such appointment which is executed by its Chief Executive Officer or Chief Financial Officer. Any appointment hereunder shall remain in place until Lender is notified in a writing executed by the Borrower’s Chief Executive Officer, Chief Financial Officer or counsel stating that it is no longer effective.
Appointment of Authorized Representative. Licensor may by written notice to Licensee appoint such person as Licensor deems appropriate for purposes of exercising the quality control rights described in Sections 4(b), (c) and (d) above.
