Examples of Potential Claimant in a sentence
Any Potential Claimant who fails to return an Interest-in-Relief Form by the deadline shall be deemed to have waived any right to be considered for an award of Individual Relief under this Agreement, except for good cause as determined by the United States.
Diagnosis CardFor death claims, the Potential Claimant should submit the following in addition to the Death Certificate in order to receive the claim.1. Spouse of the Insured Person Marriage Certificate First Page of Bank passbook2.
Any Potential Claimant who wishes to be considered for an award of Individual Relief under this Agreement must return a completed Interest-in-Relief Form in accordance with the requirements set forth in the Instructions for Completing the Interest-in-Relief Form and Interest-in-Relief Form.
Date: Counsel Signature By signing this Census Form, Potential Claimant confirms the accuracy of the information provided herein.
Date: Potential Claimant SignatureLIMITED AUTHORIZATION TO DISCLOSE HEALTH INFORMATION(Pursuant to the Health Insurance Portability and Accountability Act "HIPAA" of 4/14/03) TO: Philips RS North America LLC Patient Name: DOB: SSN: City/State: I, , hereby authorize you to release and furnish to: Litigation Management Inc., PO Box 241370, Cleveland, OH 44124 COPIES ONLY of the following information:* Usage, temperature and humidity data from Care Orchestrator, DreamMapper and/or EncoreAnywhere.