WHO WILL REVIEW THE INFORMATION DISCLOSED ON THE RELATIONSHIP DISCLOSURE FORM AND ANY UPDATES? The information disclosed on this form and any updates will be a public record as defined by Chapter 119, Florida Statutes, and may therefore be inspected by any interested person. Also, the information will be made available to the Mayor and the BCC members. This form and any updates will accompany the information for the applicant’s project or item. However, for development-related items, if an applicant discloses the existence of one or more of the relationships described above and the matter would normally receive final consideration by the Concurrency Review Committee or the Development Review Committee, the matter will be directed to the BCC for final consideration and action following committee review.
Service Information Service Visit Date Mode of service Face-to face, telephone, etc. Responsibility for payment Used to exclude federal govt., WCB, etc. Main and secondary diagnoses ICD10-CA codes Main and other interventions and attributes CCI procedure codes and attributes Type of Anesthetic Identifies the type used for interventions (general, spinal, local, etc.) Provider types NACRS code assigned to provider type (MD, Dentist, RN, etc.) Doctor name and identifier Physician specific information Admit via Ambulance Used if a Client is brought to the service delivery site by ambulance Institution from and institution to Used when a Client is transferred from or to another acute care facility Visit disposition Discharged, admitted, left without being seen, etc. Schedule “D” Appendix 2 Additional Elements Required for Data Management (XXX) Client Identifying Information Province Client‟s Home Province AB, BC, SK, MB, NL, PE, NS, NB, QC, ON, NT, YT, NU, US, OC (Other Country), NR (Unsp. Non-resident) Service Information Facility Code AHS provided code that indicates service being provided. Facility Fee Dollar value of service being provided Alberta Health Physician Fee Billing Code Alberta Health Physician Service Fee code that further defines facility code Regional standard format and submission method remains as is via excel file and email. NOTE: Submission method may be adjusted in accordance with security standards of AHS. Schedule “D” Appendix 3
Secure Information Handling and Transfers 7.1 Physical and electronic handling, processing and transferring of DWP Data, including secure access to systems and the use of encryption where appropriate.
For More Information To obtain more information concerning the rules governing this Agreement, contact the Prototype Sponsor or Custodian listed on the Adoption Agreement.
What To Do If You Find A Mistake On Your Statement If you think there is an error on your statement, write to us at the address(es) listed on your statement. In your letter, give us the following information:
More Information For more specific information about the terms and conditions of the ICA or DCA program, please see the ICA Disclosure Booklet or DCA Disclosure Booklet (as applicable) available from IAR or on xxx.xxxxxxxxxxxx.xxx.xxx/xxxxxxxxxxx.
Submission of Grievance Information a) Upon appointment of the arbitrator, the appealing party shall within five days after notice of appointment forward to the arbitrator, with a copy to the School Board, the submission of the grievance which shall include the following:
Scope of Cooperation 1. The Authorities recognise the importance of close communication concerning the Covered CCPs and intend to cooperate regarding:
Accurate Information All information heretofore, herein or hereafter supplied to Secured Party by or on behalf of Debtor with respect to the Collateral is and will be accurate and complete in all material respects.
Balance Information To open any account, you must deposit or already have on deposit at least the par value of one full share in any account. The par value amount is stated in the Fee Schedule. Some Accounts may have additional minimum opening deposit requirements. The minimum balance requirements applicable to each account are set forth in the Rate Schedule. . For Regular Share 1, Christmas Share 90, IRA Share 20, Vacation Share 15, Money Market 80 and Share Draft 40 Accounts, there is a minimum daily balance required to obtain the annual percentage yield for the dividend period. If the minimum daily balance is not met, you will not earn the stated annual percentage yield. For all Accounts using a daily balance method, dividends are calculated by applying a daily periodic rate to the principal in the account each day.