Required Medical Documentation Sample Clauses

Required Medical Documentation. This section of the Medical Expense Certificate must be fully completed in order for your claim to be considered. Any corrections or additional information necessary to cure an incomplete Medical Expense Certificate must be submitted to NCSBT within two months of the expiration of the one-year deadline to file a claim. Provide all information required below regarding all medical expenses for which you are seeking reimbursement/payment (i.e., expenses not covered under the insurance, plans, or benefits programs identified above). You must provide updated, itemized medical provider statements which reflect date(s) of service, services rendered, International Classification of Diseases diagnostic codes (ICD-9 or ICD-10 diagnostic codes), charges for services, payments, and any outstanding balances. You must also provide all applicable Explanation of Benefit statements. If additional space is needed, please list on a separate page and attach. “See attached” is not an acceptable response to this section: • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ _ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ I, , hereby certify that the information provided on this Medical Expense Certificate and the attached documentation represent all true, correct, current, and up-to-date information supporting this claim, and I have completed this form and provided such documentation to the best of my ability. This the day of , 20 . Signature of Injured Party (if a minor, signature of parent or guardian) Print Name NORTH CAROLINA COUNTY OF I, , a Notary Public of the County and State aforesaid, do certify that personally appeared before me this day and acknowledged the due exec...
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Required Medical Documentation. A physician’s statement as to the fitness of the employee for the performance of his/her duties may be required at any time before such leave commences, and may be required prior to the employee’s return to duty. Further, the Employer may request that the employee submit to a physical examination at the Employer’s expense by a physician of the Employer’s choice. Such physician shall be Board certified within the appropriate specialty providing such Board certified physician is reasonably available.
Sample 1

Related to Required Medical Documentation

  • Medical Documentation The teacher must supply a letter from a medical 3 doctor, who treated the patient, stating that in his/her opinion, there is a strong 4 probability that the illness was contracted at school.

  • Technical Documentation Prior to commencement of the Tests on Completion, the Contractor shall supply to the Engineer the technical documentation as specified in the Employer’s Requirements. The Works or Section shall not be considered to be completed for the purposes of taking- over under sub-clause 10.1 [Taking Over of the Works and Sections] until the Engineer has received the technical documentation as defined in this sub-clause 5.7, the "history file" including design calculations and certain certification as well as any other documents required to meet the CE Marking requirements.

  • Technical documents Not applicable.

  • Additional Documentation Execute and deliver, or cause to be executed and delivered, any and all other agreements, instruments or documents which Lender may reasonably request in order to give effect to the transactions contemplated under this Loan Agreement and the other Loan Documents.

  • ENVIRONMENTAL DOCUMENTATION Each environmental service provided by the Engineer shall have a deliverable. Deliverables shall summarize the methods used for the environmental services, and shall summarize the results achieved. The summary of results shall be sufficiently detailed to provide satisfactory basis for thorough review by the State, The Federal Highway Administration (FHWA), and (where applicable) agencies with regulatory oversight. All deliverables shall meet regulatory requirements for legal sufficiency, and shall adhere to the requirements for reports enumerated in the State’s NEPA MOU.

  • Tax Documentation Xxxxxx agrees to provide a completed IRS 1099 for its payments to, and Xxxxxxx agrees to provide IRS W-9 forms for, each of the following payees under this Settlement Agreement:

  • Project Documentation All documentation provided to the City other than Project drawings shall be furnished on a Microsoft compatible compact disc.

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