PATIENT INFORMATION* – PLEASE PRINT ALL INFORMATION Sample Clauses

PATIENT INFORMATION* – PLEASE PRINT ALL INFORMATION. If you are a minor (0-17 years of age), legal guardian’s information will be required Patient Name (Last, First, MI) Patient ID# Last 4 Digits of SSN U.S. CITIZEN 🞎 Yes 🞎 No Date of Birth Number of Dependents (other than self & co-applicant) Ages of Dependents Primary Contact - Phone ( )
Sample 1
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Related to PATIENT INFORMATION* – PLEASE PRINT ALL INFORMATION

  • OTHER PERTINENT INFORMATION 1. Applicant owns the upland adjoining the lease premises.

  • Client Information (2) Protected Health Information in any form including without limitation, Electronic Protected Health Information or Unsecured Protected Health Information (herein “PHI”);

  • PERSONAL INFORMATION PRIVACY AND SECURITY CONTRACT 11 Any reference to statutory, regulatory, or contractual language herein shall be to such language as in 12 effect or as amended.

  • - CLEC INFORMATION CLEC agrees to work with Qwest in good faith to promptly complete or update, as applicable, Qwest’s “New Customer Questionnaire” to the extent that CLEC has not already done so, and CLEC shall hold Qwest harmless for any damages to or claims from CLEC caused by CLEC’s failure to promptly complete or update the questionnaire.

  • Student Information Those living in The Village hereby agree that the Owner shall receive all Student information provided in the Agreement and waives and releases Owner from any duty of confidentiality that may apply to such information.

  • Access to Financial Information Buyer’s representatives shall have access to, and Seller and its Affiliates shall cooperate with Buyer and furnish upon request, all financial and other information relating to the Hotel’s operations to the extent necessary to enable Buyer’s representatives to prepare audited financial statements in conformity with Regulation S-X of the Securities and Exchange Commission (the “SEC”) and other applicable rules and regulations of the SEC and to enable them to prepare a registration statement, report or disclosure statement for filing with the SEC on behalf of Buyer or its Affiliates, whether before or after Closing and regardless of whether such information is included in the Records to be transferred to Buyer hereunder. Seller shall also provide to Buyer’s representative a signed representation letter in form and substance reasonably acceptable to Seller sufficient to enable an independent public accountant to render an opinion on the financial statements related to the Hotel. Buyer will reimburse Seller for costs reasonably incurred by Seller to comply with the requirements of the preceding sentence to the extent that Seller is required to incur costs not in the ordinary course of business for third parties to provide such representation letters. The provisions of this Section shall survive Closing or termination of this Contract.

  • Full information You must give us any information we reasonably require for the purposes of this contract. The information must be correct, and you must not mislead or deceive us in relation to any information provided to us.

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