Intake Form definition

Intake Form means the checklist used during the student Intake Meeting which ensures the inclusion of behavioral, academic, and other necessary information to facilitate the placement of a student at a Consortium Discipline Alternative Program.
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Intake Form means the form to be used by CHR to gather information regarding, among other things, Patient demographics, referral information, primary and secondary insurance, and physician and medical information.
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Intake Form means the form included in a Deaf inmate’s base file to be provided by DPSCS and completed by all deaf inmates to allow them to select which, if any, Auxiliary Aids and Services they would prefer for all programs, activities, medical appointments and procedures, disciplinary hearings, and all other complex or lengthy communication with prison staff. The name of the Intake Form will be determined upon the creation of an executive directive.
Sample 1

Examples of Intake Form in a sentence

  • The Letter of Submittal, excluding the signed Certifications and Assurances and Contractor Intake Form, shall be a maximum of one (1) page.

  • The weighted drawing will be advertised on the Housing Department website, jhaffordablehousing.org, and via email to all households that have completed the Online Intake Form.

  • Self-Certification should be submitted with the Contractor Intake Form (Exhibit D).

  • Adhere to the following additional service delivery requirements: i Document in CMBHS a Withdrawal Management Intake Form.

  • The Letter of Submittal, the attached Certifications and Assurances, and the attached Contractor Intake Form must be signed and dated by a person authorized to legally bind the Consultant to a contractual relationship, (e.g., the President or Executive Director if a corporation, the managing partner if a partnership, or the proprietor if a sole proprietorship).

  • Contractor’s report (“Initial Report”) shall be provided on that certain Privacy & Incident Intake Form, developed by the Covered California Privacy Office and attached and incorporated by reference herein as Attachment 2.

  • Self-Certification should be submitted with the Contractor Intake Form (Exhibit E).

  • All Bidders must complete and sign the Contractor Intake Form (Form 27-043) attached to this competitive Solicitation as Attachment E.

  • All advertising of homes available will be done through email to those who have completed the Online Intake Form and on the Housing Department website.

  • Participating Agencies should use:• Adult Intake form (Appendix I)• Minor Intake Form (Appendix J)• Interim/Exit Form (Appendix K)• Client Consent Form - Release of Information (ROI) (Appendix A) During the HMIS training, Participating Agency End Users will learn how to use these forms to fulfill their data collection obligations.

Related to Intake Form

  • Database application form means the application form required by the Hibiscus Coast Municipality to be filled in by the successful tenderer, following the award of the contract, for inclusion on the HCM database before payment is made.

  • Slot machine means a mechanical or electronic gambling game device into which a player may deposit currency or forms of cashless wagering and from which certain numbers of credits are awarded when a particular configuration of symbols or events is displayed on the machine.

  • Hospital system means a hospital and one or more

  • Sample means urine, blood, breath, saliva, or hair.

  • Hospital pharmacy means a pharmacy providing pharmaceutical care to

  • machine-readable format means a file format structured so that software applications can easily identify, recognize and extract specific data, including individual statements of fact, and their internal structure;

  • Machine gun means any firearm known as a machine gun,

  • Centralized prescription processing means the processing by a pharmacy of a request from another pharmacy to fill or refill a prescription drug order or to perform processing functions such as dispensing, drug utilization review, claims adjudication, refill authorizations, and therapeutic interventions.

  • PIDs shall have the meaning set forth in Exhibit B.

  • Prescription drugs means drugs, medicine and controlled substances which by law can only be prescribed for human use by persons authorized by law.

  • Hospital pharmacist means an Iowa-licensed pharmacist who meets the requirements for participating in a hospital practice protocol as determined by the hospital’s P&T committee.

  • Prescription device means an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, and any component part or accessory, which is required under federal or state law to be prescribed by a practitioner and dispensed by or through a person or entity licensed under this chapter or exempt from licensure under this chapter.

  • FACE Form means the Funding Authorization and Certificate of Expenditure Form attached to this Agreement. The FACE Form is used for (i) requests for cash advances, direct payments or reimbursements and (ii) financial reporting by the Partner.

  • Dispenser means a practitioner who dispenses.

  • Filter means material placed in the useful beam to preferentially absorb selected radiations.

  • Application Form means any application form to be completed by subscribers for Shares as prescribed by the Company from time to time.

  • Facsimile (FAX) prescription means a written prescription or order that is transmitted by an electronic device over telephone lines that sends the exact image to the receiving pharmacy in hard copy form.

  • Driver means a person who drives or is in actual physical control of a vehicle.

  • Prescription drug means any drug required by federal law or regulation to be dispensed only

  • E-Verify system means an Internet-based system operated by the United States Department of Homeland Security that allows participating employers to electronically verify the employment eligibility of newly hired employees; and

  • Alcohol abuse means any pattern of pathological use of alcohol that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

  • Radiation therapy simulation system means a radiographic or fluoroscopic x-ray system intended for localizing the volume to be exposed during radiation therapy and confirming the position and size of the therapeutic irradiation field.

  • EPSDT means early and periodic screening, diagnosis, and treatment.

  • Physical therapy aide means a person who has

  • Template means a qualified software solution – based on Software - created by Partner in accordance with the solution qualification guidelines for Software. For details contact your Partner Service Advisor.

  • Prescription monitoring program “PMP,” or “program” means the program established pursuant to 657—Chapter 37 for the collection and maintenance of PMP information and for the provision of PMP information to authorized individuals.