Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. For details on how to obtain prescription drug preauthorization for a prescription drug, see Prescription Drug Preauthorization in Section 3 for details. If preauthorization is not obtained, you will be required to pay for the prescription drug at the pharmacy. You can ask us to consider reimbursement after you receive the prescription drug by following the prescription drug preauthorization process. For a list of prescription drugs that require preauthorization, visit our website or call our Customer Service Department.
AGENT AUTHORIZATION FORM I/We, (Print Bidder name) , Do hereby authorize (print agent’s name), , to act as my/our agent to execute any petitions or other documents necessary to affect the CONTRACT approval PROCESS more specifically described as follows, (IFB NUMBER AND TITLE) , and to appear on my/our behalf before any administrative or legislative body in the county considering this CONTRACT and to act in all respects as our agent in matters pertaining TO THIS CONTRACT. Signature of Bidder Date STATE OF FLORIDA ) ) ss: COUNTY OF ) The foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]. ☐Personally Known; OR ☐Produced Identification. Type of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public My Commission Expires: (Printed, typed or stamped commissioned name of Notary Public) LEASED EMPLOYEE AFFIDAVIT I affirm that an employee leasing company provides my workers’ compensation coverage. I further understand that my contract with the employee leasing company limits my workers’ compensation coverage to enrolled worksite employees only. My leasing arrangement does not cover un-enrolled worksite employees, independent contractors, uninsured sub-contractors or casual labor exposure. I hereby certify that 100% of my workers are covered as worksite employees with the employee leasing company. I certify that I do not hire any casual or uninsured labor outside the employee leasing arrangement. I agree to notify the County in the event that I have any workers not covered by the employee leasing workers’ compensation policy. In the event that I have any workers not subject to the employee leasing arrangement, I agree to obtain a separate workers’ compensation policy to cover these workers. I further agree to provide the County with a certificate of insurance providing proof of workers’ compensation coverage prior to these workers entering any County jobsite. I further agree to notify the County if my employee leasing arrangement terminates with the employee leasing company and I understand that I am required to furnish proof of replacement workers’ compensation coverage prior to the termination of the employee leasing arrangement. I certify that I have workers’ compensation coverage for all of my workers through the employee leasing arrangement specified below: Name of Employee Leasing Company: Workers’ Compensation Carrier: A.M. Best Rating of Carrier: Inception Date of Leasing Arrangement: I further agree to notify the County in the event that I switch employee-leasing companies. I recognize that I have an obligation to supply an updated workers’ compensation certificate to the County that documents the change of carrier. Name of Contractor: Signature of Owner/Officer: Title: Date: INFORMATION FOR DETERMINING JOINT VENTURE ELIGIBILITY If the bidder is submitting as a joint venture, please be advised that this form MUST be completed and the REQUESTED written joint-venture agreement MUST be attached and submitted with this form. HOWEVER, IF THE BIDDER IS NOT A JOINT VENTURE, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLE
Consent to Medical Treatment 1. I authorize the School District and my child’s custodian to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment or hospital care which is deemed advisable by and is rendered under the general supervision of any licensed physician or surgeon, whether such treatment or diagnosis is rendered at the office of such physician or at a hospital.
How to Obtain Prescription Drug Preauthorization To obtain prescription drug preauthorization, the prescribing provider must submit a prescription drug preauthorization request form. These forms are available on our website or by calling the number listed for the “Pharmacist” on the back of your ID card. Prescription drugs that require preauthorization will only be approved when our clinical guidelines are met. These guidelines are based upon clinically appropriate criteria that ensure that the prescription drug is appropriate and cost- effective for the illness, injury or condition for which it has been prescribed. We will send you written notification of the prescription drug preauthorization determination within fourteen (14) calendar days of the receipt of the request. How to Request an Expedited Preauthorization Review You may request an expedited review if the circumstances are an emergency. Due to the urgent nature of an expedited review, your prescribing provider must either call or fax the completed form and indicate the urgent nature of the request. When an expedited preauthorization review is received, we will respond to you with a determination within seventy-two (72) hours or less. If we deny your request for preauthorization, you can submit a medical appeal. See Appeals in Section 5 for information on how to file a medical appeal. Formulary Exception Process When a prescription drug is not on our formulary, you can request that this plan cover the drug as an exception. To request a formulary exception, complete a Coverage Exception form (located on our website), contact our Customer Service Department, or have your prescribing provider submit a request for you. We will respond to you with a determination within seventy- two (72) hours following receipt of the request. For standard exception reviews, if the exception is approved, we will cover the prescription drug for the duration of the prescription, including refills. How to Request an Expedited Formulary Exception Review You may request an expedited review if a delay could significantly increase the risk to your health or your ability to regain maximum function, or you are undergoing a current course of treatment with a drug not on our formulary. Please indicate “urgent” on the Coverage Exception form or inform Customer Service of the urgent nature of your request. We will respond to you with a determination within twenty-four (24) hours following receipt of the request. For expedited exception reviews, if the exception is approved, we will cover the prescription drug for the duration of the exigency. For both standard and expedited exception reviews, if we grant your request for a formulary exception, the amount you pay will be the copayment at the highest formulary tier in your plan. Other applicable benefit requirements, such as step therapy, are not waived by this exception and must be reviewed separately. If we deny your request for a formulary exception, we will notify you with information on how to appeal our decision, including external appeal information.
Payment Authorization I authorize Xxxxx Management to collect payment of the application fee and application deposit in the amounts specified under paragraph 3 of the Disclosures.
Subsidy Requests and Reporting Requirements 1. The Grantee or Management Company shall complete a CRF Subsidy Request Report - Recap of Tenant Income Certification, which provides a unit-by-unit listing of all units in the Development for whom assistance is being requested and gives detailed information including the occupants’ eligibility, set-aside requirements, amount of household rent paid, utility allowance and amount of CRF Rental Subsidy requested.
Emergency Work Authorizations The State, at its sole discretion, may accept the Engineer's signature on a faxed copy of the work authorization as satisfying the requirements for executing the work authorization, provided that the signed original is received by the State within five business days from the date on the faxed copy.
AUTHORIZATION AND CONSENT The Government has given its authorization and consent for all use and manufacture of any invention described in and covered by a patent of the United States in the performance of this Agreement or any part hereof or any amendment hereto or any subcontract hereunder (including any lower-tier subcontract) which is expected to exceed $100,000.
Required Certifications A bidder who makes a false certification on the Bidder Certification of the Prequalification Classification and Work Capacity Form will be subject to forfeiture of his bid bond and/or disqualification from bidding on future work for a 90 day period, or both. The Contracting Officer will determine the imposition and the extent of such sanctions. A sworn statement shall be executed by the bidder or his agent on behalf of each person, firm, association, or corporation submitting a bid. The statement shall certify that the person, firm, association, or corporation has not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action to restrain free competitive bidding in connection with the proposal. The sworn statement shall be part of the bid or in the form of an affidavit and shall be sworn to before a person who is authorized by the laws of the State to administer oaths. The bids shall contain the identical sworn statement. For the purpose of this Section, affixing digital ID to the bid will be considered by the Department conditional evidence of signing before a person who is authorized by the laws of the Commonwealth to administer oaths. The original of the sworn statement shall be filed with the Department when the bid is submitted.
Authorization to Obtain Information You agree that we may obtain and review your credit report from a credit bureau or similar entity. You also agree that we may obtain information regarding your Payee Accounts in order to facilitate proper handling and crediting of your payments.
