Enrollment Form. All Plan applicants shall be required to fill out and sign an eligibility/enrollment form provided by the Department of Human Resources.
Enrollment Form. The written or electronic form that each Eligible Employee must complete before he or she may participate in the Plan. To be effective, the Enrollment Form must include all of the information described in Section 3.01.
Enrollment Form. By submitting the Enrollment Form, you certify that all of the information you provide in the Enrollment Form is true and correct, and you authorize us and our agents to verify the information in the Enrollment Form and seek or obtain information about you and your financial condition and history by use of consumer reports and other sources both now and in the future. Your Enrollment Form is subject to our review and approval.
Enrollment Form. A form provided by WHP to gather specific information about a Subscriber and his Dependents. Where appropriate, the form is to be signed by the Subscriber to show the Subscriber’s agreement to accept and comply with the terms of this Agreement.
Enrollment Form the electronic or paper agreement entered into between the Primary Member participating in the Plan accepted by the Plan Administrator.
Enrollment Form. Each Full-Time Employee, Limited-Term Employee and each Part-Time Employee who, pursuant to Section 3.03, 3.04 or Section 3.05 above, is required to become a Member, shall complete an enrollment form prescribed by the University and shall file such form with the University.”
Enrollment Form. Upon request, Service Provider shall provide the Department with a Retail Voucher Program enrollment form. The enrollment form shall set forth the pricing, the time period the vouchers shall be available for redemption and other relevant Program details.
Enrollment Form. The information provided is true to the best of the Parents' knowledge. The School will be notified of any changes immediately. The signatures on the enrollment form are binding from the initial year until the Student is withdrawn or terminated from School.
Enrollment Form. The document signed by both parties from time to time that incorporates by reference this Agreement and when completed, sets forth the specific products and Service ordered from and provided by GPN, and which sets forth all applicable fees, certain restrictions and any other terms that GPN and you agree upon.
Enrollment Form. This Agreement notifies (fill in contractor name here) of the provider’s consent to participate in Electronic Data Interchange (EDI). EDI may include claims and claims attachments, remittances, eligibility/benefits, claim status, and any other electronic information for Centers for Medicare and Medicaid Services (CMS) federal program data (including but not limited to Title XVIII of the Social Security Act (Medicare), and/or Section 1011 of the Medicare Modernization Act) covered under Health Insurance Portability and Accountability Act (HIPAA) Transactions and Code Sets or Section 1011 of the Medicare Modernization Act (MMA) legislation.
