Examples of Financially responsible person in a sentence
If you are admitted to a non-Plan Hospital, you, your Parent/Guardian, Financially Responsible Person or someone else must notify us within the later of forty-eight (48) hours of a Member’s hospital admission or on the first working day following the admission unless it was not reasonably possible to notify us within that time.
Signature of the Financially Responsible Person:.......................
Any applications, forms or statements specified in this Agreement, or that we request in our normal course of business, must be completed by you or your Authorized Representative or Financially Responsible Person, if applicable.
The Financially Responsible Person has been informed of the regulations and the norms of behavior required at the School, as stated in the book of School rules, and guarantees that the pupil(s) will respect them.
The Financially Responsible Person accepts the obligation to pay the school fees mentioned in this contract, for all the services provided by the School to the pupil.
Name of Financially Responsible Person (printed) Signature Date Signed HIPAA NOTICE OF PRIVACY PRACTICES The effective date of this Notice is July 15, 2015.
Having read and approved it in full: ………………………………………, (Date) ………………… Name of the Financially Responsible Person Signature For the School Headmaster This contract must be return to the School Secretary in two copies, signed at each page, in order to validate de registration of the pupil(s).
The tuition fees include, in addition to the schooling fees, complementary services as follow: Obligatory fees: * School supplies fees (obligatory) for all the pupils enrolled at school, including learning books, school reports books, notebooks, “carnet de correspondence” for pupils of grades 6th to 12th, etc.; Signature of the Financially Responsible Person:.......................
Having read and approved it in full: ………………………………………, (Date) ………………… Name of the Financially Responsible Person Signature For the School X.
Name of Financially Responsible Person (printed) Signature Date Signed CREDIT CARD AUTHORIZATION I authorize Mid Cities Counseling Center, PLLC to charge my credit card $55 if I “no show” to a scheduled appointment or cancel with less than 24 hours’ notice.