ITEMIZED RECEIPTS. A valid photocopy of receipts is required for all travel expenditures regardless of cost. A photocopy of receipts submitted with the invoice must indicate the name of the payee, date paid, amount, and the service rendered. Receipts shall be provided in sequential order. IEHP Board Approval 09-12-16 (MO: 16-131) Master PSA v.9 (IEHP Legal 01-2020) OWNERSHIP INFORMATION Contractor’s Name: Tax Identification Number (TIN): Address: City: State: _ Zip: Phone: President: Contact Person: Person Signing Contract: Broker Representative: Please circle below how your organization is legally organized: • Sole Proprietorship • Partnership (LLC, etc.) • Corporation o Privately Held Company* o Publicly Traded Company o Non-Profit Entity • Government Agency • Other (please indicate): *If Privately Held Company, please indicate the below information of the owners, officers, stockholders, and creditors if such interest is over 5%. Name Ownership/Creditorship % (If greater than 5% interest) Authorized Signature Date HIPAA BUSINESS ASSOCIATE AGREEMENT <Insert CONTRACTOR’S NAME> This HIPAA Business Associate Agreement (the “Agreement”) is an Attachment to the Professional Services Agreement (the “Underlying Agreement”) between the Inland Empire Health Plan (“IEHP”) and <insert Contractor’s Name> (“Business Associate”) as of the “Effective Date”, of the Underlying Agreement.
ITEMIZED RECEIPTS. The employee shall present an itemized receipt for District related business meals not associated with a paid ahead of time conference. The gratuity on such a meal shall not be greater than 20% for reimbursement and will be paid up to the IRS rate.
