PLEASE READ THIS DOCUMENT CAREFULLY Sample Clauses

PLEASE READ THIS DOCUMENT CAREFULLY. This is a legally binding agreement (the “Registration Agreement”) between you (“you” or “your”) and Health Current (“we” or “us”) about your submission of documents to the AzHDR. If the instructions herein are not followed, your form(s) may be rejected. How to complete this Agreement: • Read the agreement and complete this form. • Fill in all blank spaces on this form. • Sign and date form. • Attach a copy of the witnessed or notarized advance directive(s). DO NOT SEND ORIGINALS TO THE AZHDR. • Mail to: AzHDR – Health Current 0000 X. 0xx Xx., Xxx. 000 Xxxxxxx, XX 00000 • Or fax to: 000-000-0000 • Or email to: xxxxxxxxx@xxxxx.xxx Processing time: up to three weeks. REQUIRED REGISTRANT INFORMATION Last Name: First Name: Middle Name: Address: Date of Birth: MM/DD/YYYY City: State: Zip: Phone: I choose to opt out of SMS text Email: I choose to opt out of email Mailing address if different from above: City: State: Zip: Check the applicable box (check only one box per submission): New registration. Replace an advance directive(s) presently in the AzHDR with the new one(s) attached. Replace all documents presently in the registry with the new one(s) attached. Replace only the following document type(s) presently in the registry with the new one(s) attached while leaving the others in place (check all that apply): Living will Health care power of attorney Mental health care power of attorney DNR Add an additional document to my currently stored directive(s). Inactivate my account: Check this box if you do not want your documents to be active in the registry. Change registrant demographic information previously submitted (update your information on this form). Please note: All documents submitted to Health Current must be copies. Please do not submit originals. Once your account has been activated and your documents have been uploaded to the AzHDR, Health Current will not retain paper copies of your advance directives. Additionally, any documents received by Health Current that are not advance directives or attachments thereto will not be accepted and will be shredded and securely destroyed. Arizona Healthcare Directives Registry Health Current | 0000 X. 0xx Xx., Xxx. 000 | Xxxxxxx, XX 00000 P: 000-000-0000 | F: 000-000-0000 | xxxxx@xxxxxxxxxxxxx.xxx | xxxxx.xxx Arizona Advance Directives Registration Agreement Terms & Conditions
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PLEASE READ THIS DOCUMENT CAREFULLY. I acknowledge that the Company will use this Agreement to govern my actions and responsibilities during my participation in the Puzzle Adventure Room (the “Activity”).
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PLEASE READ THIS DOCUMENT CAREFULLY. University agrees to provide Student space in University-Operated Residence Halls. The term of this Agreement shall be for one academic year, including both the Fall and Spring semesters, and Summer semester, if applicable (the “Term”), unless this Agreement is cancelled in accordance with the section of this Agreement entitled “Termination.” Residing in University-Operated Residence Halls is considered a fundamental part of the Student’s education, therefore this Agreement is only a license to occupy and use the residential space assigned to the Student for limited purposes (the “Residential Space”) and is not a lease of the University’s property. This Agreement is personal and non-transferable, and it is not a commitment of admission to the University. The University reserves the right, at its sole discretion, to determine if any past behavior, conduct, or activity of any individual is such that the interest(s) of the University, the Student, and/or other students would best be served by terminating this Agreement. In addition, the Student acknowledges that convicted and/or registered sexual offenders are not allowed to reside in University-Operated Residence Halls. The Student must pay to the University a one hundred and thirty-five dollar ($135) Application Fee. The Student represents to the University that the Student is eighteen (18) years of age or older at the time this Agreement is executed and the University relies on that representation. If the Student is under the age of eighteen (18) years, then one of the Student’s parents or legal guardians must sign this Agreement and that person is hereby made a party to this Agreement, subject to all terms and conditions of this Agreement. The University’s “Residence Halls Service Agreement Terms and Conditions” shall be considered part of this Agreement although it may not be attached physically hereto. The Student’s occupancy is also governed by the “Living on Campus Housing Guide” and “Winston-Salem State University’s Student Handbook”, as currently written or as may be amended in the future. RESIDENCE HALLS SERVICES AGREEMENT Residence Halls Services Agreement Terms & Conditions
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Related to PLEASE READ THIS DOCUMENT CAREFULLY

  • Required Confidentiality Claim Form This is a requirement of the TIPS Contract and is non-negotiable. TIPS provides the required TIPS Confidentiality Claim Form in the "Attachments" section of this solicitation. Vendor must execute this form by either signing and waiving any confidentiality claim, or designating portions of Vendor's proposal confidential. If Vendor considers any portion of Vendor's proposal to be confidential and not subject to public disclosure pursuant to Chapter 552 Texas Gov’t Code or other law(s) and orders, Vendor must have identified the claimed confidential materials through proper execution of the Confidentiality Claim Form. If TIPS receives a public information act or similar request, any responsive documentation not deemed confidential by you in this manner will be automatically released. For Vendor documents deemed confidential by you in this manner, TIPS will follow procedures of controlling statute(s) regarding any claim of confidentiality and shall not be liable for any release of information required by law, including Attorney General determination and opinion. Notwithstanding any other Vendor designation of Vendor's proposal as confidential or proprietary, Vendor’s submission of this proposal constitutes Vendor’s agreement that proper execution of the required TIPS Confidentiality Claim Form is the only way to assert any portion of Vendor's proposal as confidential.

  • Right to Receive and Release Needed Information Certain facts are needed to apply these COB rules. The Plan has the right to de­ cide which facts it needs. It may get needed facts from or give them to any other organization or person. The Plan need not tell, or get the consent of, any person to do this. Each person claiming benefits under this Benefit Program must give the Plan any facts it needs to pay the Claim. FACILITY OF PAYMENT A payment made under another Benefit Program may include an amount that should have been paid under this Benefit Program. If it does, the Plan may pay that amount to the organization that made the payment under the other Benefit Program. That amount will then be treated as though it were a benefit paid under this Benefit Program. The Plan will not have to pay that amount again. The term “payment made” includes providing benefits in the form of services, in which case “payment made” means reasonable cash value of the benefits provided in the form of services. RIGHT OF RECOVERY If the amount of payments made by the Plan is more than it should have paid un­ der this COB provision, it may recover the excess from one or more of:

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