Claims Submission Certifications Sample Clauses

Claims Submission Certifications. I understand the information in this document or otherwise given by me to Certified Dermatologists will be used in submitting claims for payment for services rendered to me or the patient named below, and I certify that such information is correct. I authorize a copy of this document to be used in place of the original, and the use of “signature on file” on all claims submissions. I agree to notify Certified Dermatologists if any of the information I have provided in this document changes or is no longer accurate and understand that I am responsible for notifying Certified Dermatologists of the new or corrected information. I understand that I am responsible for notifying Certified Dermatologists of any pre-certifications or referrals required by my health plans or the health plans of the patient named below. In the event any account becomes delinquent and collection activity is required to collect payment, I agree to pay all reasonable attorney fees and collection agency costs and/or fees associated with the collection of any unpaid balance.
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Claims Submission Certifications. I understand the informaﳳon in this document or otherwise given by me to Cerﳳfied Dermatologists will be used in submiﹹng claims for payment for services rendered to me or the paﳳent named below, and I cerﳳfy that such informaﳳon is correct. I authorize a copy of this document to be used in place of the original, and the use of “signature on file” on all claims submissions. I agree to noﳳfy Cerﳳfied Dermatologists if any of the informaﳳon I have provided in this document changes or is no longer accurate and understand that I am responsible for noﳳfying Cerﳳfied Dermatologists of the new or corrected informaﳳon. I understand that I am responsible for noﳳfying Cerﳳfied Dermatologists of any pre‐cerﳳficaﳳons or referrals required by my health plans or the health plans of the paﳳent named below. In the event any account becomes delinquent and collecﳳon acﳳvity is required to collect payment, I agree to pay all reasonable aﹷorney fees and collecﳳon agency costs and/or fees associated with the collecﳳon of any unpaid balance.
Sample 1
Claims Submission Certifications. I understand the information in this document or otherwise given by me to UC Health will be used in submitting claims for payment for services rendered to me or the patient named below, and I certify that such information is correct. I authorize a copy of this document tobe used in place of the original, and the use of “signature on file” on all claims submissions. I agree to notify UC Health if any of the information I have provided in this document changes or is no longer accurate, and understand that I am responsible for notifying UC Health of the new or corrected information. I understand that I am responsible for notifying UC Health of any pre- certifications or referrals required by my health plans or the health plans of the patient named below. In the event any account becomes delinquent and collection activity is required to collect payment, I agree to pay all reasonable attorney fees and collection agency costs and/or fees associated with the collection of any unpaid balance.
Sample 1

Related to Claims Submission Certifications

  • TERMINATION CERTIFICATION Upon separation from employment with the Company, I agree to immediately sign and deliver to the Company the “Termination Certification” attached hereto as Exhibit C. I also agree to keep the Company advised of my home and business address for a period of three (3) years after termination of my employment with the Company, so that the Company can contact me regarding my continuing obligations provided by this Agreement.

  • Financial Information Certifications The Parties agree to cooperate with each other in such manner as is necessary to enable the principal executive officer or officers, principal financial officer or officers and controller or controllers of each of the Parties to make the certifications required of them under Sections 302, 404 and 906 of the Xxxxxxxx-Xxxxx Act of 2002.

  • NOTIFICATIONS AND SUBMISSION OF REPORTS Unless otherwise stated in writing after the Effective Date, all notifications and reports required under this IA shall be submitted to the following entities: Administrative and Civil Remedies Branch Office of Counsel to the Inspector General Office of Inspector General U.S. Department of Health and Human Services Xxxxx Building, Room 5527 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxxxxxxxx, XX 00000 Telephone: (000) 000-0000 Facsimile: (000) 000-0000 LFAC: Xxxxxxx X. Xxxxx, DPM 0000 Xxxxxxxxxxx Xx. X-000 Xxxxxxxxx, XX 00000 Telephone: (000) 000-0000 Email: xx.xxxxx@xxxxx.xxx Unless otherwise specified, all notifications and reports required by this IA may be made by electronic mail, overnight mail, hand delivery, or other means, provided that there is proof that such notification was received. Upon request by OIG, LFAC may be required to provide OIG with an additional copy of each notification or report required by this IA in OIG’s requested format (electronic or paper).

  • New Certifications If a participating Employer is newly certified by ONA at one of its owned nursing homes for its registered nurses, the existing standard non-monetary provisions in the central ONA/RN agreements will automatically apply to the nurses effective nine (9) months after the Employer receives notice to bargain from the Union or a Memorandum of Agreement or Interest Arbitration Award is received, whichever is earlier. These provisions include: Article 1 Article 2.03 Articles 2.05, 2.07-2.12 Articles 3-8 Articles 9.01(d) only, 9.03-9.13, 9.15, 9.16, 9.17 Article 10

  • COMPENSATION CERTIFICATION Labor Code Section 3700 in relevant part provides: Every employer except the State shall secure the payment of compensation in one or more of the following ways:  By being insured against liability to pay compensation by one or more insurers duly authorized to write compensation insurance in this State.  By securing from the Director of Industrial Relations a certificate of consent to self-insure, which may be given upon furnishing satisfactory proof to the Director of Industrial Relations of ability to self-insure and to pay any compensation that may become due to its employees. I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the Work of this Contract. Date: Name of Consultant: Signature: Print Name and Title: (In accordance with Article 5 – commencing at Section 1860, Chapter 1, part 7, Division 2 of the Labor Code, the above certificate must be signed and filed with the District prior to performing any Work under this Contract.) Consultant’s entire Proposal is not made part of this Agreement.

  • DEBARMENT AND SUSPENSION CERTIFICATION CONTRACTOR certifies that it and its principals:

  • DEBARMENT CERTIFICATIONS The parties are prohibited from making any award at any tier to any party that is debarred or suspended or otherwise excluded from or ineligible for participation in Federal Assistance Programs under Executive Order 12549, “Debarment and Suspension.” By executing this agreement, the Engineer certifies that it is not currently debarred, suspended, or otherwise excluded from or ineligible for participation in Federal Assistance Programs under Executive Order 12549. The parties to this contract shall require any party to a subcontract or purchase order awarded under this contract to certify its eligibility to receive Federal funds and, when requested by the State, to furnish a copy of the certification.

  • SUBCONTRACTOR REPRESENTATIONS AND CERTIFICATIONS Any Contractor representations or certifications set forth in this Contract shall apply to subcontractors (at any tier) and Contractor shall not utilize any subcontractors (at any tier) who cannot provide such representations or certifications, excepting the certification to be registered with Washington’s Statewide Payee Desk, unless Purchaser will pay such subcontractor directly.

  • Lobbying Certification This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S.C. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

  • SUBMISSION OF REPORTS All applicable study reports shall be submitted in preliminary form for approval by the State before a final report is issued. The State's comments on the Engineer's preliminary report must be addressed in the final report.