Official Payee and Party Representatives. 1.2.1 The name, address, telephone number and e-mail address of the Provider’s official payee to whom the payment shall be directed on behalf of the Provider are: Name: Address: City: State: Zip Code: Phone: Ext: E-mail:
Official Payee and Party Representatives. Upon change of representatives (names, addresses, telephone numbers, or e-mail addresses) by either party, notice shall be provided in writing to the other party and the notification attached to the originals of this contract.
Official Payee and Party Representatives. Upon change of representatives (names, addresses, telephone numbers, or e-mail addresses) by either party, notice shall be provided in writing to the other party and the notification attached to the originals of this contract. a. The name, address, and telephone number of the Network Service Provider shown above and the official payee to whom the payments shall be made are: c. The name, address, and telephone number of the Network Manager for the Managing Entity for this contract: Name: Name: Address: 0000 Xxxxxxxxxx Xx; Xxx 000 Address: City: Jacksonville State: FL Zip Code: 32256 City: State: Zip Code: Phone/Ext: Phone/Ext: E-mail: b. The name, address, telephone number, and e- mail address where financial and administrative records are maintained: Name: d. The name, address, telephone number, and e-mail address of the representative of the Network Service Provider responsible for administration of the program under this contract: Address: Name: City: State: Zip Code: Address: Phone/Ext: City: State: Zip Code: E-mail: Phone/Ext: E-mail:
Official Payee and Party Representatives. The name, address, telephone number and e-mail address of the Department and the Provider’s representatives for this Contract are as follows:
Official Payee and Party Representatives. The name, address, telephone number and e-mail address of the Provider’s official payee to whom the payment shall be directed on behalf of the Provider are: Name: Address: City: State: Zip Code: Phone: Ext: E-mail: The name of the contact person and address, telephone, and e-mail address where the Provider’s financial and administrative records are maintained are: Name: Address: City: State: Zip Code: Phone: Ext: E-mail: The name, address, telephone number and e-mail of the Provider’s representative responsible for administration of the program under this Contract (and primary point of contact) are: Name: Address: City: State: Zip Code: Phone: Ext: E-mail: The name, address, telephone number and e-mail address of the Contract Manager for the Department for this Contract are: Name: Address: City: State: Zip Code: Phone: Ext: E-mail: Per section 402.7305(1)(a), F.S., the Department’s Contract Manager is the primary point of contact through which all contracting information flows between the Department and the Provider. Upon change of representatives (names, addresses, telephone numbers or e-mail addresses) by either party, notice shall be provided in writing to the other party. Effective and Ending Dates This Contract shall be effective on __________ or the last date executed by a party, whichever is later. The service performance period under this Contract shall commence on __________ or the effective date of this Contract, whichever is later, and shall end at midnight, time, on _________, subject to the survival of terms provisions of Section 7.4. This Contract may not be renewed. This Contract may be renewed in accordance with Section 26 of the PUR 1000 Form and, if renewed, costs for the renewal may not be charged to this Contract. This Contract may be renewed in accordance with Section 26 of the PUR 1000 Form and, if renewed, the renewal price(s) set forth in the bid, proposal, or reply are shown in Exhibit F , subject to negotiation at renewal per section 287.057(13), Florida Statutes (F.S.).
Official Payee and Party Representatives. The name, address, telephone number and e-mail address of the Provider’s official payee to whom the payment shall be directed on behalf of the Provider are: Name: Address: City: State: Zip Code: Phone: Ext: E-mail: The name, address, telephone number and e-mail of the Provider’s contact person responsible for the Provider’s financial and administrative records: Name: Address: City: State: Zip Code: Phone: Ext: E-mail: The name, address, telephone number and e-mail of the Provider’s representative responsible for administration of the program under this Contract (and primary point of contact) are: Name: Address: City: State: Zip Code: Phone: Ext: E-mail: The name, address, telephone number and e-mail address of the Contract Manager for the Department for this Contract are: Name: Address: City: State: Zip Code: Phone: Ext: E-mail: Per section 402.7305(1)(a), Florida Statutes (F.S.), the Department’s Contract Manager is the primary point of contact through which all contracting information flows between the Department and the Provider. Upon change of representatives (names, addresses, telephone numbers or e-mail addresses) by either party, notice shall be provided in writing to the other party. Effective and Ending Dates This Contract shall be effective __________ or the last party signature date, whichever is later. The service performance period under this Contract shall commence on __________ or the effective date of this Contract, whichever is later, and shall end at midnight, time, on _________, subject to the survival of terms provisions of Section 7.4. This contract may be renewed in accordance with SS. 287.057(13) or 287.058(1)(g), F.S.
Official Payee and Party Representatives. Upon change of representatives (names, addresses, telephone numbers, or e-mail addresses) by either party, notice shall be provided in writing to the other party and the notification attached to the originals of this contract. a. The name, address, and telephone number of the Network Service Provider shown above and the official payee to whom the payments shall be made are: c. The name, address, and telephone number of the Network Manager for the Managing Entity for this contract: Name: Name: Address: 0000 Xxxxxxxxxx Xx; Ste 320 Address: City: Jacksonville State: FL Zip Code: 32256 City: State: Zip Code: Phone/Ext: Phone/Ext: E-mail:
Official Payee and Party Representatives. 1.2.1. The name, address, telephone number and e-mail address of the Provider’s official payee to whom the payment shall be directed on behalf of the Provider are: Name: South Florida Behavioral Health Network, Inc. Address: 0000 Xxxxxxxxx Xxxxxx Xxxxx, Xxxxx 000 City: Miami State:FL Zip Code:33126 Phone: 000-000-0000 Ext: E-mail:
Official Payee and Party Representatives. Upon change of representatives (names, addresses, telephone numbers, or e-mail addresses) by either party, notice shall be provided in writing to the other party and the notification attached to the originals of this contract. a. The name, address, and telephone number of the Network Service Provider shown above and the official payee to whom the payments shall be made are: c. The name, address, and telephone number of the Network Manager for the Managing Entity for this contract: Name: Xxxxxxxx Xxxxxx Name: Alachua County Board of County Commissioners Address: 0000 Xxxxxxxxxx Xx; Xxx 000 Address: 0000 XX 00xx Xxxxx Xxxx: Xxxxxxxxxxxx Xxxxx: XX Xxx Xxxx: 00000 City: Gainesville State: FL Zip Code: 32607 Phone/Ext: (000) 000-0000 Phone/Ext: (000) 000-0000 E-mail: xxxxxxxx.xxxxxx@xxxxxx.xxx b. The name, address, telephone number, and e- mail address where financial and administrative records are maintained: Name: Xxxx Xxxxx d. The name, address, telephone number, and e-mail address of the representative of the Network Service Provider responsible for administration of the program under this contract: Address: Refer to 6.a. Name: Xxx Xxxxx Address: Refer to 6.a. City: Refer to 6.a. State: FL Zip Code: Refer to 6.a. City: Refer to 6.a. State: FL Zip Code: Refer to 6.a. Phone/Ext: (000) 000-0000 Ext. 2519 Phone/Ext: (000) 000-0000 E-mail: xxx@xxxxxxxxxxxx.xxx E-mail: XXxxxx@xxxxxxxxxxxxx.xx
Official Payee and Party Representatives. 1.2.1 The name, address, telephone number and e-mail address of the Provider’s official payee to whom the payment shall be directed on behalf of the Provider are: Name: Pinellas County License Board Address: C/O Pinellas County Health Department, 0000 Xxxxxxxx Xxxx, Xxxxx 0000 City: Largo State:FL Zip Code:33771-3832 Phone: (000) 000-0000 Ext: E-mail: Xxxxx.Xxxxxxx@xxxxxxxx.xxx
