XXXXXXX/CHAMPV A Authorization Sample Clauses

XXXXXXX/CHAMPV A Authorization. I request payment of authorized benefits to the facility on my behalf for any services furnished me by the above named facility. I authorize any holder of medical or other information about me to release to undersigned signs this document either as the patient or as the agent representative of the patient authorized to execute this document and to accept and agree to its terms on behalf of the patient. I have read the foregoing and have had the opportunity to ask any questions I may have about the foregoing. Such questions have been answered to my satisfaction, and I understand what I am agreeing to by signing below. I understand that I am entitled to request and obtain a copy of this document. Patient Signature: Date Signed: Patient’s agent or representative Relationship to patient:
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Related to XXXXXXX/CHAMPV A Authorization

  • LEGAL AUTHORIZATION (a) The Sub-Recipient certifies that it has the legal authority to receive the funds under this Agreement and that its governing body has authorized the execution and acceptance of this Agreement. The Sub-Recipient also certifies that the undersigned person has the authority to legally execute and bind Sub-Recipient to the terms of this Agreement.

  • Prior Authorization A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.

  • Medical Authorization In the event of illness or injury while participating in the above referenced activity, I hereby consent to whatever x-ray, examination, anesthetic, medical, surgical, dental diagnosis or treatment, hospital care and emergency transportation from a licensed physician, surgeon, and/or dentist as deemed necessary for my safety and welfare.

  • Licenses and Similar Authorizations The Contractor, at no expense to the City, shall secure and maintain in full force and effect during the term of this Contract all required licenses, permits, and similar legal authorizations, and comply with all related requirements.

  • Network Authorization For services that cannot be provided by a network provider, you can request a network authorization to seek services from a non-network provider. With an approved network authorization, the network benefit level will apply to the authorized covered healthcare service. If we approve a network authorization for you to receive services from a non- network provider, our reimbursement will be based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit. For more information, please see the How Non-Network Providers Are Paid section.

  • Credit Card Authorization TO THE EXTENT PERMITTED BY APPLICABLE LAW, YOU IRREVOCABLY AND UNCONDITIONALLY AUTHORIZE XXXXXXX TO CHARGE ALL AMOUNTS DUE UNDER THIS AGREEMENT TO ANY CREDIT CARD YOU PROVIDE TO US, AND YOU AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS XXXXXXX WITH RESPECT TO THE SAME.

  • Xxxxxxxx, 121 Cal App.4th Supp. 7 (2004), CIV Code 1962 Colorado $50.00 or 5% of past due rent C.R.S. § 00-00-000 Connecticut Not defined No statute Delaware 5% of the monthly rent amount Title 25, § 5501(d) Florida Not defined No statute Georgia “All contracts for rent shall bear interest from the time the rent is due” Hawaii 8% of the monthly rent amount § 521-21(f) Idaho Not defined No statute Illinois Outside Chicago – Not defined Chicago only – $10.00 per month for the first $500.00 in monthly rent plus five percent per month for any amount in excess of $500.00 in monthly rent for the late payment of rent. No statute 5-12-140(h) Indiana Not defined No statute Iowa If the rent does not exceed $700/month, the late fee cannot exceed more than $12/day per day or $60/month. If the rent is greater than $700/month, the late cannot exceed more than $20/day or $100/month.

  • E1 Authority Data E1.1 For the purposes of clauses E1 and 2, the terms “Data Controller”, “Data Processor”, “Data Subject”, “

  • New Work Authorization If the Engineer does not complete the services authorized in a work authorization before the specified completion date and has not requested a supplemental work authorization, the work authorization shall terminate on the completion date. At the sole discretion of the State, it may issue a new work authorization to the Engineer for the incomplete work using the unexpended balance of the preceding work authorization for the project. If approved by the State, the Engineer may calculate any additional cost for the incomplete work using the rates set forth in the preceding work authorization and in accordance with Attachment E, Fee Schedule.

  • Xxxxxxx, P E./Project Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

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