Participant Information My address is: My Social Security Number is:
Contact Numbers The Parties agree to provide one another with toll-free nation- wide (50 states) contact numbers for the purpose of ordering, provisioning and maintenance of services.
Agreement Number 2705 TRACT Total Ag CRP Hay Grazing Grazing Aftermath Unsuitable LOCATION Acres Acres Acres Acres Acres AUMs AUMs Acres 24N 11E 20Description: W2 320.00 231.06 0.00 0.00 88.94 18 0 0.00 Agreement Number: 2706 LOCATION Acres Acres Acres Acres Acres AUMs AUMs Acres 24N 11E 24Description: S2 320.00 288.50 0.00 0.00 0.00 0 0 31.50 TRACT Total Ag CRP Hay Grazing Grazing Aftermath Unsuitable Agreement Number: 2707 TRACT Total Ag CRP Hay Grazing Grazing Aftermath Unsuitable LOCATION Acres Acres Acres Acres Acres AUMs AUMs Acres 24N 11E 36 Description: 644.56 631.50 0.00 0.00 0.00 0 0 13.06 LOTS 1 - 4, N2S2, N2 Agreement Number: 2708 TRACT Total Ag CRP Hay Grazing Grazing Aftermath Unsuitable LOCATION Acres Acres Acres Acres Acres AUMs AUMs Acres 25N 4E 13 Description: NW4NE4 40.00 0.00 0.00 0.00 40.00 10 0 0.00 TRACT Total Ag CRP Hay Grazing Grazing Aftermath Unsuitable LOCATION Acres Acres Acres Acres Acres AUMs AUMs Acres 26N 4E 36Description: ALL 640.00 627.90 0.00 0.00 0.00 0 0 12.10 Chouteau County Agreement Number: 2709 TRACT Total Ag CRP Hay Grazing Grazing Aftermath Unsuitable LOCATION Acres Acres Acres Acres Acres AUMs AUMs Acres 25N 3E 36 Description: ALL 640.00 0.00 0.00 0.00 638.00 164 0 2.00 Agreement Number: 2710 LOCATION Acres Acres Acres Acres Acres AUMs AUMs Acres 25N 4E 26Description: X0XX0, XX0 240.00 55.63 0.00 0.00 184.37 37 0 0.00 TRACT Total Ag CRP Hay Grazing Grazing Aftermath Unsuitable LOCATION Acres Acres Acres Acres Acres AUMs AUMs Acres 25N 4E 35Description: N2NE4 80.00 38.89 0.00 41.11 0.00 0 10 0.00 TRACT Total Ag CRP Hay Grazing Grazing Aftermath Unsuitable
Participant Agreement I understand that as a condition for participating in the Program I must comply with the Program’s rules and standards of conduct and follow all reasonable direction of the Program Staff. Failure to comply with the Program’s rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my being dismissed from the Program. Participant Signature: Date: PARENT/LEGAL GUARDIAN AGREEMENT I understand that my child will be subject to the rules and standards of conduct of the Program, Valdosta State University and the University System of Georgia. I further understand that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my child’s dismissal from the Program. I accept responsibility for all costs associated with removing my child from the Program, including but not limited to transportation costs to return the Participant home. I understand that Dismissed Participants are not eligible for a refund of any fees or expenses. Parent/Guardian Signature: Date:
Account Number 2. This authorization shall remain in effect until revoked or until a subsequent Notice of Account Designation is provided to the Administrative Agent.
Project Number The project number has been assigned by the Commission as the unique identifier for your project, and it cannot be changed. The project number should appear on each page of the grant agreement preparation documents to prevent errors during its handling.
Programs to Keep You Healthy Many health problems can be prevented by making positive changes to your lifestyle, including exercising regularly, eating a healthy diet, and not smoking. As a member, you can take advantage of our wellness programs at no additional cost. Wellness Programs We offer wellness programs to our members from time to time. These programs include, but are not limited to: • online and in-person educational programs; • health assessments; • coaching; • biometric screenings, such as cholesterol or body mass index; • discounts We may provide incentives for you to participate in these programs. These incentives may include credits toward premium, and a reduction or waiver of deductible and/or copayments for certain covered healthcare services, as permitted by applicable state and federal law. For the subscriber of the plan, wellness incentives may also include rewards, which may take the form of cash or cash equivalents such as gift cards, discounts, and others. These rewards may be taxable income. Additional information is available on our website. Your participation in a wellness program may make your employer eligible for a group wellness incentive award. Your participation in our wellness programs is voluntary. We reserve the right to end wellness programs at any time. Member Incentives From time to time, we may offer you coupons, discounts, or other incentives as part of our member incentives program. These coupons, discounts and incentives are not benefits and do not change or affect your benefits under this plan. You must be a member to be eligible for member incentives. Restrictions may apply to these incentives, and we reserve the right to change or stop providing member incentives at any time. Care Coordination Care coordination gives you access to dedicated BCBSRI healthcare professionals, including nurses, dietitians, behavioral health providers, and community resources specialists. These care coordinators can help you set and meet your health goals. You can receive support for many health issues, including, but not limited to: • making the most of your physician’s visits; • navigating through the healthcare system; • managing medications or addressing side effects; • better understanding new or pre-existing medical conditions; • completing preventive screenings; • losing weight. Care Coordination is a personalized service that is part of your existing healthcare coverage and is available at no additional cost to you. For more information, please call (000) 000-XXXX (2273) or visit our website. Disease Management If you have a chronic condition such as asthma, coronary heart disease, diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease, we’re here to help. Our tools and information can help you manage your condition and improve your health. You may also be eligible to receive help through our care coordination program. This voluntary program is available at no additional cost you. To learn more about disease management, please call (000) 000-0000 or 0-000-000-0000. About This Agreement Our entire contract with you consists of this agreement and our contract with your employer. Your ID card will identify you as a member when you receive the healthcare services covered under this agreement. By presenting your ID card to receive covered healthcare services, you are agreeing to abide by the rules and obligations of this agreement. Your eligibility for benefits is determined under the provisions of this agreement. Your right to appeal and take action is described in Appeals in Section 5. This agreement describes the benefits, exclusions, conditions and limitations provided under your plan. It shall be construed under and shall be governed by the applicable laws and regulations of the State of Rhode Island and federal law as amended from time to time. It replaces any agreement previously issued to you. If this agreement changes, an amendment or new agreement will be provided.
STATEWIDE PAYEE DESK Contractor represents and warrants that it is registered with the Statewide Payee Desk, which registration is a condition to payment.
Identification Badges Identification badges will be supplied by Advanced Behavioral Health (ABH) to all credentialed individuals who are providing services to children. Badges must be presented to the child/youth and any present adults at the time of service and must be worn for the duration of the service. Badges will be updated every two years during the re- credentialing process. Any individual or agency who fails to submit a photo ID to ABH within the designated timeframe will have their credentialing status terminated.
Telephone Numbers Customer Service and Preauthorization: In state: 000-000-0000; Out of state: 0-000-000-0000; Hearing impaired: 711 Appeals: 000-000-0000 Preauthorization and notification for Behavioral Health services: 0-000-000-0000 Customer Service: In state: 000-000-0000; Out of state: 0-000-000-0000; Hearing impaired: 711 Home Delivery (Mail Order): 0- 000-000-0000 Preauthorization: 0-000-000-0000 Customer Service: In state: 000-000-0000; Out of state: 0-000-000-0000; Hearing impaired: 711 Customer Service and Appeals: 0-000-000-0000 Website: xxx.xxxxxx.xxx xxx.xxxxxx.xxx xxx.xxxxxx.xxx xxx.xxxxxx.xxx Fax: Appeals: 000-000-0000 Preauthorization and Appeals: 0-000-000-0000 Not Applicable Appeals: 0-000-000-0000 Mailing address to file a claim: Blue Cross & Blue Shield of Rhode Island Claims Department 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, XX 00000 Prime Therapeutics, LLC. P.O. Box 21870 Lehigh Valley, PA 18002-1870 Blue Cross & Blue Shield of Rhode Island Dental Claims Administrator P.O. Box 69427 Harrisburg, PA 17106-9427 Blue Cross Vision c/o EyeMed Vision Care Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111 Mailing address to submit an appeal: Blue Cross & Blue Shield of Rhode Island Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, XX 00000 Prime Therapeutics, LLC. Clinical Review Dept. 0000 Xxxxxxxxx Xxxxxx Xxxxx Xxxxx, XX 00000 Blue Cross & Blue Shield of Rhode Island Dental Customer Service – Appeals P.O. Box 69420 Harrisburg, PA 17106-9420 EyeMed Vision Care Attn: Quality Assurance Dept. 0000 Xxxxxxxxx Xxxxx Xxxxx, XX 00000 BCBSRI Customer Service Department Call Center hours are: • Monday thru Friday 8:00 AM to 8:00 PM • Saturday thru Sunday 8:00 AM to 12:00 PM Your Blue Store You may also visit one of our retail walk-in service centers. Please check our website for specific locations and business hours.
