Authorization to Release Information. By execution of this Agreement, the Resident, Resident Representative and Sponsor authorize the Facility to release to government agencies, insurance carriers or others who could be financially liable for any medical care provided to the Resident, all information needed to secure and substantiate payment for such medical care and to permit representatives thereof to examine and copy all records relating to such care.
Authorization to Release Information. I authorize the testing facility, to release any and all medical information obtained during this exam and testing procedure to the (Appointing Authority).
Authorization to Release Information. The undersigned Applicant, for itself and for its consultants, contractors, sub-consultants and/or subcontractors, hereby authorizes and consents to the District and PMO, acting on behalf of the District, in obtaining information from third parties, including, but not limited to any individual(s) or individual representative(s) of any firm(s), entity(ies) or organization(s) listed in the Application/Proposal, for the purpose of verifying the information provided by the Applicant or for any other purpose related to the evaluation of Applicant’s qualifications and/or the qualifications of its consultants, contractors, sub-consultants and/or subcontractors. Applicant recognizes that to ensure the effectiveness of the RFQ/RFTOP process, such individuals must be able to speak frankly and openly. Accordingly, Applicant, for itself and for its consultants, contractors, sub-consultants and/or subcontractors, hereby fully and unconditionally provides authority to such third parties and hereby also releases and discharges such third parties, and the firms, entities and organizations they represent, from any claim or liability relating to information provided by it/him/her/them to the District and/or PMO in connection with the processing, investigation and evaluation by District and the PMO of the Applicant’s Application/Proposal. Applicant hereby certifies that all of its consultants, contractors, sub-consultants and/or subcontractors have read this Authorization to Release Information and Applicant’s signature below represents its and its consultants, contractors, sub-consultants and/or subcontractors full agreement to the same. Name of Applicant Signature Title Date Attachment 8 to the RFQ Authorization to Release Information
Authorization to Release Information. All Applicants: Please read the following information and sign in the space(s) provided below.
Authorization to Release Information. By execution of this Agreement, the Resident, Designated Representative and/or Sponsor authorizes the Facility to release to government agencies, insurance carriers or others who could be financially liable for any medical care provided to the Resident, all information needed to secure and substantiate payment for such medical care and to permit representatives thereof to examine and make copies of all records relating to such care. The Facility is authorized to release Resident discharge planning summaries and medical information to any other health care institution or provider to which the Resident is transferred or from which the Resident is receiving care, and as otherwise required or permitted by law, throughout the Resident’s stay at the Facility and thereafter if required or permitted by law.
Authorization to Release Information. Initial I/We authorize Xxxxxxxxx X. Ramsey, LPC, CAADC, CCTP to file with my insurance carrier(s) for any benefits due under that policy for these services and authorize the release to that insurance carrier any information required for the completion of that claim. I/We authorize Xxxxxxxxx X. Ramsey, LPC, CAADC, CCTP to coordinate my treatment with the managed care company that authorizes the services provided and to provide them with the information they required to determine my eligibility for these services. ASSIGNMENT OF BENEFITS Initial I assign to Xxxxxxxxx X. Ramsey, LPC, CAADC, CCTP any benefits due me by any third party carrier for services rendered to the undersigned insured (or dependent), and do authorize and instruct such third parties to make payment of any benefits directly to Xxxxxxxxx X. Ramsey, LPC, CAADC, CCTP. I understand that the check for any benefits due and a copy of applicable benefits summary form will be mailed directly to Xxxxxxxxx X. Ramsey, LPC, CAADC, CCTP. I further agree that this assignment shall not be revoked without the consent of Xxxxxxxxx X. Ramsey.
Authorization to Release Information. Lessee hereby authorizes any person who may have funeral home, financing, financial, credit, valuation or other confidential or non-confidential information regarding Lessee or its business and affairs to release to Lessor such information as Lessor, in its sole discretion, deems necessary to respond to regulatory inquiries; for the performance of audits, quality control or other reviews or to market the Transaction Documents; or for any other legitimate purpose. Furthermore, upon Lessor’s request, Lessee shall sign a release authorizing the release to Lessor of any financial, credit, valuation, or other confidential or non-confidential information that Lessor, in its sole discretion, deems necessary to respond to regulatory inquires; to perform audits, quality control or other reviews, or to market the Transaction Documents; or for any other legitimate purpose.
Authorization to Release Information. Franchisee hereby authorizes (and agrees to execute any other documents deemed necessary to effect such authorization) all banks, financial institutions, businesses, suppliers, contractors, vendors and other persons or entities with whom Franchisee does business to disclose to Franchisor any financial information in their possession relating to Franchisee or the Franchised Business which Franchisor may request. Franchisee further authorizes Franchisor to disclose to prospective franchisees or other third parties data from Franchisee’s reports if Franchisor determines, in Franchisor’s sole discretion, that such disclosure is necessary or advisable.
Authorization to Release Information. The Fellow understands and agrees that should another institution, organization, or individual to which the Fellow has applied (e.g., state boards, specialty boards, medical staffs, health providers, etc.) request a reference from the Hospital, the Hospital may divulge any and all information it possesses concerning the Fellow, including information relating to any suspension or termination of this Agreement. The Fellow hereby authorizes the Hospital to release such information under these circumstances, either during the term of this Agreement or thereafter and to indemnify and hold harmless Hospital employees and agents from any liability arising from that disclosure.
Authorization to Release Information. The Resident/Fellow understands and agrees that should another institution, organization, or individual to which the Resident/Fellow has applied (e.g., state boards, specialty boards, medical staffs, health providers, etc.) request a reference from the Hospital, the Hospital may divulge any and all information it possesses concerning the Resident/Fellow, including information relating to any suspension or termination of this Agreement. The Resident/Fellow hereby authorizes the Hospital to release such information under these circumstances, either during the term of this Agreement or thereafter and to indemnify and hold harmless Hospital employees and agents from any liability arising from that disclosure.
