Intake Form Sample Clauses

Intake Form. CHR will provide or arrange to provide intake services on behalf of the Program, which intake services shall include the completion of an Intake Form for the applicable Patient by means of telephone, United States mail service, or facsimile communication, verification of insurance coverage and prior authorization, as necessary. “Intake Form” means the form to be used by CHR to gather information regarding, among other things, Patient demographics, referral information, primary and secondary insurance, and physician and medical information.
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Intake Form. Upon receiving the retainers and contracts for both parents, each parent will beasked to complete an intake questionnaire prior to their individual intake interview. Please ensure this is submitted at least one day prior to the interview in order to allow enough time for review.
Sample 1
Intake Form. (A) As consideration for the use of this non-exclusive license, Licensee agrees to provide the data requested on the College Affordability Academy Intake Form, as shown in Exhibit B, attached hereto and made a part hereof (“Intake Form”), and further agrees that the Licensor may use this data to engage in additional works of authorship and publication relating to debt management and financial aid. (B) Failure of Licensee to provide the data requested in the Intake Form within three (3) weeks of execution of this Agreement, shall, at Licensor’s option, entitle Licensor to terminate this Agreement. Licensor will provide written notice to Licensee of termination of this Agreement for failure to provide the requested data within thirty (30) days from the due date outlined above.
Sample 1
Intake Form. (i.) Includes verification of income eligibility, with instructions provided on
Sample 1

Related to Intake Form

  • Contract Form Observe the Contract and confirm the form number on the Contract is on the List of Approved Contract Forms.

  • Alcohol Testing Alcohol testing will be conducted by using an evidential breath testing device (EBT) approved by the National Highway Traffic Safety Administration. Non-EBT devices may be used for initial screening tests. A screening test will be conducted first. If the result is an alcohol concentration level of less than 0.02, the test is considered a negative test. If the alcohol concentration level is 0.02 or more, a second confirmation test will be conducted. Levels of .04 or greater on the confirmation test will be considered positive.

  • SAMPLE (If applicable and the project has specifications, insert the specifications into this section.)

  • Identity Verification In the case that the Subscriber provides telecommunication services to any Subscriber’s Customers pursuant to Section 8.1, the Subscriber is responsible for performing and shall perform personal identification of Subscriber’s Customer. SORACOM shall not bear any responsibility in relation to dealing with such matters.

  • Drug Testing (A) The state and the PBA agree to drug testing of employees in accordance with section 112.0455, F.S., the Drug-Free Workplace Act. (B) All classes covered by this Agreement are designated special risk classes for drug testing purposes. Special risk means employees who are required as a condition of employment to be certified under Chapter 633 or Chapter 943, F.S. (C) An employee shall have the right to grieve any disciplinary action taken under section 112.0455, the Drug-Free Workplace Act, subject to the limitations on the grievability of disciplinary actions in Article 10. If an employee is not disciplined but is denied a demotion, reassignment, or promotion as a result of a positive confirmed drug test, the employee shall have the right to grieve such action in accordance with Article 6.

  • Prescription Drugs The agreement may impose a variety of limits affecting the scope or duration of benefits that are not expressed numerically. An example of these types of treatments limit is preauthorization. Preauthorization is applied to behavioral health services in the same way as medical benefits. The only exception is except where clinically appropriate standards of care may permit a difference. Mental disorders are covered under Section A. Mental Health Services. Substance abuse disorders are covered under

  • Shift Rotation Routine shift rotation is not an approach to staffing endorsed by the Employer. Except for emergency situations where it may be necessary to provide safe patient care, shift rotation will not be utilized without mutual consent. If such an occasion should ever occur, volunteers will be sought first. If no one volunteers, the Employer will rotate shifts on an inverse seniority basis until the staff vacancies are filled.

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