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Submitter Information Sample Clauses

Submitter Information. For the claims for which you will CHARITY CARE check boxes located at the top of the form, indicate the type of be submitting electronic claims. Check one box only. A separate New Jersey Medicaid HIPAA EDI Agreement is required for each provider number you will be electronically submitting claims for unless the provider is a group practice and the group is responsible for the billing of the individual providers associated with the provider group.
Submitter Information. Please complete the appropriate submitter information. Your email address will be kept confidential, and will only be used as a means of distributing general information to New Mexico Medicaid Program.
Submitter Information. Every EDI submitter assigned a Submitter ID by New Jersey Medicaid must complete, sign and submit this New Jersey Medicaid Submitter ID/Provider Relationship Agreement before the submitter is authorized to submit claims for a New Jersey Medicaid provider. In some cases the submitter may be a New Jersey Medicaid provider and in other cases the submitter may be a third party billing service. Regardless, New Jersey Medicaid cannot process claims submitted with a specific Submitter ID for a specific New Jersey Medicaid provider number unless this agreement has been properly completed and submitted to New Jersey Medicaid or their designated agent. By signing this agreement, the New Jersey Medicaid provider is authorizing the submitter to submit claims electronically to New Jersey Medicaid on their behalf. All services will be furnished in full compliance with the non-discrimination requirements of Title VI of the Federal Civil Rights Act, Section 504 of the Rehabilitation Act of 1973 and the Standards of Privacy of Individual Identifiable Health Information, the Electronic Transactions Standards and the Security Standards under the Health Insurance Portability and Accountability Act of 1996 as enacted, promulgated and amended from time to time. I understand that payment and satisfaction of all claims will be from Federal and State funds and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws, or both. 1) Submitter Name: 2) Submitter ID: 3) Submitter Street Address: (P.O. Boxes not accepted. Agreement will be rejected and returned if P.O. Box listed. This must be the physical street address of the submitter.) 4) City, State, Zip Code: 5) Submitter Representative's Signature (must be original) 6) Date Signed
Submitter Information. 1. Submitter Name: Enter the name of the Pharmacy or Clearing house/Billing Service Name as registered with New Jersey Medicaid/DXC Technology. 2. Submitter ID: Leave blank if new provider or change of ownership. Enter existing Submitter ID if adding additional providers to Submitter file (example: chain pharmacies).
Submitter Information. Please complete the appropriate submitter information. Your email address will be kept confidential, and will only be used as a means of distributing general information to Colorado Medical Assistance Program submitters.
Submitter Information. First Name: Degree: Academic Position (or Title): Institution: Department: Street Address: City: State/Province: Zip/Postal Code: Country: Phone: FAX: Institutional E-mail Address: Point of Contact (POC) Name (if different from the Submitter): POC Phone: POC E-mail Address:
Submitter Information. If your company intends to exchange transactions directly with OHA, enter the name (as listed in Section 1) as this will become the submitter name; or • If you intend to use a submitter or clearinghouse, complete this part with their information.

Related to Submitter Information

  • User Information Any user or usage data or information collected via Station’s digital properties or related to Station’s digital properties, or any information collected from websites operated by Station’s affiliates under this Agreement, shall be the property of Station and/or such affiliates. Advertiser shall have no rights in such information by virtue of this Agreement.

  • Buyer Information True and complete copies of all documents listed in the Buyer Disclosure Schedule have been made available or provided to Seller. The books of account, stock record books and other financial and corporate records of Buyer and the Buyer Subsidiaries, all of which have been made available to Seller, are complete and correct in all material respects.

  • Seller Information The Company may require each seller of Registrable Securities as to which any registration is being effected to furnish, and such seller shall furnish, to the Company such information regarding the distribution of such securities as the Company may from time to time reasonably request in writing.

  • Information The Buyer and its advisors, if any, have been, and for so long as the Note remain outstanding will continue to be, furnished with all materials relating to the business, finances and operations of the Company and materials relating to the offer and sale of the Securities which have been requested by the Buyer or its advisors. The Buyer and its advisors, if any, have been, and for so long as the Note remain outstanding will continue to be, afforded the opportunity to ask questions of the Company. Notwithstanding the foregoing, the Company has not disclosed to the Buyer any material nonpublic information and will not disclose such information unless such information is disclosed to the public prior to or promptly following such disclosure to the Buyer. Neither such inquiries nor any other due diligence investigation conducted by Buyer or any of its advisors or representatives shall modify, amend or affect Buyer’s right to rely on the Company’s representations and warranties contained in Section 3 below. The Buyer understands that its investment in the Securities involves a significant degree of risk. The Buyer is not aware of any facts that may constitute a breach of any of the Company's representations and warranties made herein.

  • Member Information a. ODM, or its designee, will provide membership notices, informational materials, and instructional materials to members and eligible individuals in a manner and format that may be easily understood. At least annually, ODM or its designee will provide current MCP members with an open enrollment notice which describes the managed care program and includes information on the MCP options in the service area and other information regarding the managed care program as specified in 42 CFR 438.10. b. ODM will notify members or ask the MCP to notify members about significant changes affecting contractual requirements, member services or access to providers. c. If the MCP elects not to provide, reimburse, or cover a counseling service or referral service due to an objection to the service on moral or religious grounds, ODM will provide coverage and reimbursement for these services for the MCP’s members. d. As applicable, ODM will provide information to MCP members on what services the MCP will not cover and how and where the MCP’s members may obtain these services.

  • Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

  • KYC Information (i) Upon the reasonable request of the Lender made at least 1 day prior to the Closing Date, the Borrower shall have provided to the Lender the documentation and other information so requested in connection with applicable “know your customer” and anti-money-laundering rules and regulations, including the PATRIOT Act, in each case at least five days prior to the Closing Date. (ii) [reserved].

  • Purchaser Information Each Purchaser covenants that it will promptly notify the Company of any changes in the information set forth in the Registration Statement regarding such Purchaser or such Purchaser's "Plan of Distribution."

  • - CLEC INFORMATION 3.1 Except as otherwise required by law, CenturyLink will not provide or establish Interconnection, Unbundled Network Elements, ancillary services and/or resale of Telecommunications Services in accordance with the terms and conditions of this Agreement prior to CLEC's execution of this Agreement. The Parties shall complete CenturyLink's "New Customer Questionnaire," as it applies to CLEC's obtaining of Interconnection, Unbundled Network Elements, ancillary services, and/or resale of Telecommunications Services hereunder. 3.2 Prior to placing any orders for services under this Agreement, the Parties will jointly complete the following sections of CenturyLink's "New Customer Questionnaire:" General Information Billing and Collection (Section 1) Credit Information Billing Information Summary Billing OSS and Network Outage Notification Contact Information System Administration Contact Information Ordering Information for LIS Trunks, Collocation, and Associated Products (if CLEC plans to order these services) Design Layout Request – LIS Trunking and Unbundled Loop (if CLEC plans to order these services) 3.2.1 The remainder of this questionnaire must be completed within two (2) weeks of completing the initial portion of the questionnaire. This questionnaire will be used to: Determine geographical requirements; Identify CLEC identification codes; Determine CenturyLink system requirements to support CLEC's specific activity; Collect credit information; Obtain Billing information; Create summary bills; Establish input and output requirements; Create and distribute CenturyLink and CLEC contact lists; and Identify CLEC hours and holidays. 3.2.2 CLECs that have previously completed a Questionnaire need not fill out a New Customer Questionnaire; however, CLEC will update its New Customer Questionnaire with any changes in the required information that have occurred and communicate those changes to CenturyLink. Before placing an order for a new product, CLEC will need to complete the relevant New Product Questionnaire and amend this Agreement.

  • Subscriber Information Please print your individual or entity name and address. Joint subscribers should provide their respective names. Your name and address will be recorded exactly as printed below. 1. Subscriber’s Printed Name 2. Title, if applicable: 3. Subscriber’s Address: Street City, State, Zip Code 4. Telephone: 5. E-mail Address: