Attestations. Except when CE’s data privacy officer exempts BA in writing, the BA shall complete the following forms, attached and incorporated by reference as though fully set forth herein, SFDPH Attestations for Privacy (Attachment 1) and Data Security (Attachment 2) within sixty (60) calendar days from the execution of the Agreement. If CE makes substantial changes to any of these forms during the term of the Agreement, the BA will be required to complete CE's updated forms within sixty (60) calendar days from the date that CE provides BA with written notice of such changes. BA shall retain such records for a period of seven years after the Agreement terminates and shall make all such records available to CE within 15 calendar days of a written request by CE.
Attestations. By signing this Participation Agreement, you, the Issuer, attest that you will follow the terms for participation in Washington Healthplanfinder as described in the Guidance for Participation and the accompanying Enrollment Payment and Process Guide. By signing this Participation Agreement, you, the Issuer, acknowledge that your participation in and plans offered through Washington Healthplanfinder are subject to federal and state law, and you agree to comply with applicable law which will include accepting payments on behalf of individuals as required under 45 CFR § 156.1240 and in accordance with the sponsorship policy established under RCW 43.71.030 and the Exchange Premium Sponsorship Program. This Participation Agreement is an amendment to the Guidance for Participation and incorporates, by reference, the terms and requirements for participation in Washington Healthplanfinder. Issuer Name: Click or tap here to enter text. Date: Click or tap here to enter text.
Attestations. C-1.4.1.4.4 Policies and procedures that comply with s. 394.9082(5)(q), F.S.
Attestations. By signing this Participation Agreement, you, the Issuer, acknowledge that the Guidance for Participation is incorporated and attest that you will follow the terms for participation in Washington Healthplanfinder as described in the Guidance for Participation, including guidance documents published by the Exchange and incorporated by reference therein. By signing this Participation Agreement, you, the Issuer, acknowledge that your participation in and plans offered through Washington Healthplanfinder are subject to federal and state law, and you agree to comply with applicable law which includes accepting payments on behalf of individuals (1) as required under 45 CFR § 156.1240, (2) in accordance with the sponsorship policy established under RCW 43.71.030 and the Exchange Premium Sponsorship Program, and (3) as provided pursuant to RCW 43.71.110 and in accordance with the Exchange State Premium Assistance Policy. Issuer Name: Click or tap here to enter text. Date: Click or tap here to enter text.
Attestations. I have read and understand the meaning of confidentiality and the information that I must keep private while a student Intern at the clinical sites of Methodist Sports Medicine as well as the surgery centers and hospitals. I understand that I am obliged to protect and maintain the confidentiality of this information at all times.
Attestations. I have read and understand the meaning of confidentiality and the information that I must keep private while a professional observer at the clinical sites of Methodist Sports Medicine as well as the surgery centers and hospitals. I understand that I am obliged to protect and maintain the confidentiality of this information at all times. I understand that my visit will potentially expose me to communicable and infectious disease, injury from needles and other sharp articles, slips and falls and other unforeseen incidents. I understand that if I am injured or exposed to communicable disease, or suspected of being injured or exposed to communicable disease, I will be offered treatment according to MSM policy for such exposures and injuries. I will be held responsible for the medical expenses related to all treatment that is provided to me in such instances. I am immune to normal childhood diseases including: Rubella (German measles) Rubeola (red measles) Varicella (chicken pox) either by: Natural means (diagnosed, documented, and signed by licensed healthcare provider), immunity by laboratory results (positive titre) Vaccination (signed by licensed nurse or healthcare provider). Influenza vaccine (for current flu season September-March) PPD – TB test within 1 year Hepatitis B These immunities are documented and will be presented on date of observation. Please contact the observation manager if you have a religious exemption for immunizations. I am free of significant eye, skin, respiratory, gastrointestinal, or other communicable infections. This includes fever, cough, cold, cold sores, hepatitis A, lice, scabies, diarrhea or recent exposure to communicable infections such as chicken pox (varicella), pertussis (whooping cough), or tuberculosis (TB). I am free of any skin rashes, including any reaction to recent chicken pox vaccination. I will comply with hand hygiene procedures by using soap and water/hand sanitizers before and after entering any patient room or treatment area, eating, and after using the restroom. I understand that if I become sick (including but not limited to fever, cough, diarrhea, vomiting, cold or flu), I will remove myself from the assignment, seek medical care as appropriate and will not return with any communicable disease. I will not use or disclose Protected Health Information (PHI), as described in the Health Insurance Portability & Accountability Act (“HIPAA”). I will hold all patient information in strict confidence. I understan...
Attestations. The undersigned attest to the following:
Attestations. I certify that I have read this pre-application and reviewed the attachments and attest that the material provided in this pre-application is an accurate reflection of our organization’s policies and operations. I further certify that, to the best of my knowledge, our organization is in compliance with all relevant local, state and federal laws and regulations.
Attestations. The Provider agrees to annual confirmation that must be attested online at xxx.xxxxxxxxxxxx.xxx indicating that no events have occurred which would change the status of the Provider’s account, including: liability insurance coverage, and additional enrollment requirements, if applicable.
Attestations. Event Contractor agrees to execute such documents as the County may reasonably require, to include a Public Entity Crime Statement, an Ethics Statement, and a Drug-Free Workplace Statement.
