Please attach copy of MEDS Sample Clauses

Please attach copy of MEDS. Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? 🞎 Yes 🞎 No‌ Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service.
Sample 1Sample 2Sample 3See All (7)
Please attach copy of MEDS. Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No‌ Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Pay) Gross Monthly Income (include all in the Household) A. Self $ B. Parents/Spouse/Domestic Partner ….$ C. Other $ Number of Persons Dependent on Income Allowable Expenses A. Court Ordered Monthly Obligation $ B. Monthly Child Care Payments(Only if Necessary for Employment) $ C. Monthly Dependent Support Payments $ D. Monthly Medical Expense Payments $ E. Monthly Mandated Deductions for Retirement Plan (Do not include Social Security)… $ F. Housing Cost (Mortgage/Rent) $ Asset Amount (List all liquid assets) A. Savings… $ B. Checking… $ C. Stocks… $ Health Plan or Insurance Company (Not employer) Name of Company Street Address City State Zip Insurance Co. phone number Policy Number Group Number Name of Insured Person Relationship to Client Social Security Number of Insured Person (if other than client) Does this Client have Healthy Families Insurance? □ Yes □ No If Yes, complete San Mateo County Mental Health SED form. Does this Client have Healthy Kids Insurance? □ Yes □ No Does this Client have HealthWorx Insurance.? □ Yes □ No CLIENT AUTHORIZATION –This section is not required for Full scope Medi-Cal Clients I affirm that the statements made herein are true and correct. I understand that I am responsible for paying the UMDAP liability amount or cost of treatment received by myself or by members of my household during each 1-year period. If the cost of service is more than the UMDAP liability amount, I pay the lesser amount. It is my responsibility and I agree to provide verification of income, assets and expenses. If I do not, I will be billed in full for services received. I authorize San Mateo County Mental Health to xxxx all applicable mental health services to Medi-Care and/or my insurance plan, including any services provided under 26.5. I authorize ...
Sample 1Sample 2See All (6)

Related to Please attach copy of MEDS

  • LIST OF ATTACHMENTS Attachment 1: Acronyms and Abbreviations Attachment 2: Cost/Price – Government Site (Contractor’s Cost/Price- Government Site – Contractor’s Proposal dated 11/17/06 is incorporated herein by reference.) Attachment 3: Cost/Price – Contractor Site (Contractor’s Cost/Price-Contractor Site – Contractor’s Proposal dated 11/17/07 is incorporated herein by reference.) Attachment 4: Labor Category Descriptions Attachment 5: Federal Enterprise Architecture/Department. of Defense Enterprise Architecture Overview Attachment 6: Past Performance Tables (Not Applicable) ACO Administrative Contracting Officer ADR Alternative Dispute Resolution ATM Asynchronous Transfer Mode CAF Contract Access Fee CAS Cost Accounting Standards CAV Contractor Assisted Visits CCR Central Contractor Registration CDA Contract Disputes Act of 1978 CFE Contractor Furnished Equipment CLIN Contract Line Item Number CO Contracting Officer CONUS Continental United States COR Contracting Officer’s Representative COTR Contracting Officer’s Technical Representative CPS Contractor Performance System CRM Customer Relationship Management CSO Cognizant Security Office D&F Determination and Findings DBA Xxxxx Xxxxx Act DCAA Defense Contract Audit Agency DCMA Defense Contract Management Agency DOL Department of Labor DPA Delegation of Procurement Authority DSL Digital Subscriber Line DUNS Data Universal Numbering System EAI Enterprise Application Integration EDI Electronic Data Interchange EEO Equal Employment Opportunity EFT Electronic Funds Transfer eSRS Electronic Subcontracting Reporting System EVMS Earned Value Management System FEA Federal Enterprise Architecture; also Department of Defense Enterprise Architecture (DoDEA). FAS Federal Acquisition Service FOIA Freedom of Information Act FPDS-NG Federal Procurement Data System-Next Generation FTP File Transfer Protocol FTR Federal Travel Regulations G&A General and Administrative GFE Government Furnished Equipment GFM Government Furnished Material GFP Government Furnished Property GPS Global Positioning Systems GSA General Services Administration GWAC Government Wide Acquisition Contract HCA Head of Contracting Activity HTTP HyperText Transfer Protocol ITMRA Information Technology Management Reform Act J&A Justification and Approval JTR Joint Travel Regulations L-H Labor Hour MA/IDIQ Multiple Award Indefinite-Delivery Indefinite-Quantity MOM Messaging-Oriented Middleware MOU Memorandum of Understanding MPIN Marketing Partner Identification Number NAICS North American Industrial Classification System OCI Organizational Conflict of Interest OCO Ordering Contracting Officer OCONUS Outside of Continental United States OCR Optical Character Recognition ODBC Open DataBase Connectivity ODC Other Direct Cost OLAP OnLine Analytical Processing OMB Office of Management and Budget ORB Object Request Broker ORCA Online Representations and Certifications Application PBSOW Performance-Based Statement of Work PCO Procuring Contracting Officer PMO Program Management Office POC Point of Contact PPIRS Past Performance Information Retrieval System PWS Performance Work Statement QASP Quality Assurance Surveillance Plan RADIUS Remote Authentication Dial-In User Service RDF Resource Description Framework RFP Request for Proposal SCA Service Contract Act SMTP Simple Mail Transfer Protocol SOAP Simple Object Access Protocol SOO Statement of Objectives SOW Statement of Work SRM Service Component Reference Model SQL Structured Query Language T&M Time & Materials TOR Task Order Request TRM Technical Reference Model UDDI Universal Description, Discovery and Integration VPN Virtual Private Network VSC Vendor Support Center WSDL Web Services Description Language XML EXtensible Markup Language DD254 Contract Security Classification Specification GSA 527 Contractor’s Qualifications and Financial Information Many functional labor categories below (marked with “#”) are further subdivided by knowledge/skill level. Definitions of these knowledge/skill levels are shown in this chart: Entry-Level Applies fundamental concepts, processes, practices, and procedures on technical assignments. Performs work that requires practical experience and training. Work is performed under supervision. Journeyman Possesses and applies expertise on multiple complex work assignments. Assignments may be broad in nature, requiring originality and innovation in determining how to accomplish tasks. Operates with appreciable latitude in developing methodology and presenting solutions to problems. Contributes to deliverables and performance metrics where applicable. Senior Possesses and applies a comprehensive knowledge across key tasks and high impact assignments. Plans and leads major technology assignments. Evaluates performance results and recommends major changes affecting short-term project growth and success. Functions as a technical expert across multiple project assignments. May supervise others. Master Provides technical/management leadership on major tasks or technology assignments. Establishes goals and plans that meet project objectives. Has domain and expert technical knowledge. Directs and controls activities for a client, having overall responsibility for financial management, methods, and staffing to ensure that technical requirements are met. Interactions involve client negotiations and interfacing with senior management. Decision making and domain knowledge may have a critical impact on overall project implementation. May supervise others. The “G” in the labor identification (ID) numbers below indicate Government-Site Work (see Section J, Attachment 2). The “C” in the labor ID numbers below indicate Contractor-Site Work (see Section J, Attachment 3).

  • Notice of variation of order of application The Agent may give notices under Clause 17.2 from time to time; and such a notice may be stated to apply not only to sums which may be received or recovered in the future, but also to any sum which has been received or recovered on or after the third Business Day before the date on which the notice is served.

  • Notice of Completion; Copy of Record Set of Plans Within ten (10) days after completion of construction of the Tenant Improvements, Tenant shall cause a Notice of Completion to be recorded in the office of the Recorder of the county in which the Building is located in accordance with Section 3093 of the Civil Code of the State of California or any successor statute, and shall furnish a copy thereof to Landlord upon such recordation. If Tenant fails to do so, Landlord may execute and file the same on behalf of Tenant as Tenant’s agent for such purpose, at Tenant’s sole cost and expense. At the conclusion of construction, (i) Tenant shall cause the Architect and Contractor (A) to update the Approved Working Drawings as necessary to reflect all changes made to the Approved Working Drawings during the course of construction, (B) to certify to the best of their knowledge that the “record-set” of as-built drawings are true and correct, which certification shall survive the expiration or termination of this Lease, and (C) to deliver to Landlord two (2) sets of copies of such record set of drawings within ninety (90) days following issuance of a certificate of occupancy for the Premises, and (ii) Tenant shall deliver to Landlord a copy of all warranties, guaranties, and operating manuals and information relating to the improvements, equipment, and systems in the Premises.

  • of Attachment Z The Interconnection Customer shall be responsible for all System Upgrade Facility costs as required by Section 32.3.5.3.2 of Attachment Z or its share of any System Upgrade Facilities and System Deliverability Upgrades costs resulting from the final Attachment S process, as applicable, and Attachment 6 to this Agreement shall be revised accordingly.

  • LIST OF APPENDICES APPENDIX -------- General Information Relating to the Partnerships........................ A Table 1 Jurisdiction of Organization, Initial Investment by Limited Partners and Number of Limited Partners Table 2 Aggregate Merger Value Table 3 Merger Value Attributable to Partnership Interests of Limited Partners Table 4 Ownership Percentage and Merger Value Attributable to Nonmanaging General Partners Other Than Pioneer USA Table 5 Ownership Percentage and Merger Value Attributable to Pioneer USA Held in Its Capacities as General Partner, Nonmanaging General Partner and Limited Partner Table 6 Voting Percentage in Partnerships Beneficially Owned by Pioneer USA in Its Capacity as a Limited Partner Table 7 Historical Partnership Distributions Table 8 Annual Repurchase Prices and Aggregate Annual Repurchase Payments Table 9 Participation in Costs and Revenues of the Partnerships Table 10 Average Oil, Natural Gas Liquids and Gas Sales Prices and Production Costs Table 11 Proved Reserves Attributable to Pioneer USA, Other Nonmanaging General Partners and Limited Partners Table 12 Oil, Natural Gas Liquids and Gas Production Table 13 Productive Wellx xxx Developed Acreage Table 14 Recent Trades of Partnership Interests Summary Reserve Report of Willxxxxxx Xxxroleum Consultants, Inc. for the B Partnerships.......................................................... Form of Fairness Opinion of Robexx X. Xxxxxxx & Xo., Inc................

  • Optional Xactimate Response Attachment (Part 2)

  • RECEIPT AND PUBLICATION OF NOTICES 10.1 Immediately after it receives a demand or notice from any Noteholder in accordance with the Conditions, the Agent shall forward a copy to the Issuer. 10.2 On behalf of and at the request and expense of the Issuer, the Agent shall cause to be published all notices required to be given by the Issuer to the Noteholders in accordance with the Conditions.

  • Attachment C, Standard State Provisions for Contracts and Grants Attachment C is hereby deleted in its entirety and replaced by the Attachment C December 15, 2017 attached to this Amendment. Child Support (Applicable to natural persons only; not applicable to corporations, partnerships or LLCs). Contractor is under no obligation to pay child support or is in good standing with respect to or in full compliance with a plan to pay any and all child support payable under a support order as of the date of this amendment.

  • EXECUTION COPY Each of Holdings and the Borrower agrees that all Indebtedness of Holdings, the Borrower and each of its Subsidiaries that is owing to any Credit Party shall be evidenced by one or more global intercompany promissory notes in the form of Exhibit J.

  • Variation of order of application The Agent may, with the authorisation of the Majority Lenders and the Swap Bank, by notice to the Borrowers, the Security Parties and the other Creditor Parties provide for a different manner of application from that set out in Clause 17.1 either as regards a specified sum or sums or as regards sums in a specified category or categories.