Healthcare | airSlate SignNow

Form application consent SHORT FORM APPLICATION FOR WRITTEN CONSENT TO ENGAGE IN THE BUSINESS OF INSURANCE PURSUANT TO 18 U.S.C. 1033 AND 1034 Submit Two Recent Identical Photos Notice to Applicant 18 U*S*C. 1033 prohibits certain activities by or affecting persons engaged or proposing to become engaged in the business of insurance e 1 A Any individual who has been convicted of any criminal felony involving dishonesty or a breach of trust or who has been convicted of an offense under this section and who willfully engages in the business of insurance whose activities affect interstate commerce or participates in such business shall be fined as provided in this title or imprisoned not more than 5 years or both. B interstate commerce and who willfully permits the participation described in subparagraph A shall be fined as provided in this title or imprisoned not more than 5 years or both. e 2 A person described in paragraph 1 A may engage in the business of insurance or participate in such business if such person has the written consent of any regulatory official authorized to regulate the insurer which consent specifically refers to this section* This Application will be reviewed by the chief insurance regulatory official in this state to determine whether the Applicant should be given written consent to engage in the business of insurance or You must answer every question on the Application* If a question does not apply indicate N/A in the space provided for the answer. Your answers are not limited to the space provided on the Application* Attach additional pages as needed* The Department of Insurance will not process incomplete Applications. Additional information may be requested* 1998 National Association of Insurance Commissioners PLEASE TYPE SECTION I - APPLICANT INFORMATION Full Name of Applicant Last Name First Name Middle Have you ever been known by or used another name including maiden name o yes o no If yes identify Home Address Street Address City State Zip Mailing Address P. O. Box or Street Address Home Telephone Number Work Telephone Number Social Security No* Have you ever used or been issued another social security number If so provide an explanation and previous/other social security number s Place and Date of Birth Answer all questions fully and completely. Failure to answer the questions fully will result in delays in the application process. You are not limited to the space below. Attach additional pages if needed. SECTION II - CRIMINAL HISTORY List any felony s for which you have been arrested charged indicted or convicted* Include details of any negotiated plea agreements and pleas of nolo contendre to an Information or indictment. Attach a full description of your acts involved in the aforementioned matters. Include dates of charge location and nature of offense. Attach additional pages if needed* Provide details of the conviction for which you are seeking written consent and the final disposition of these matter s including sentence dates of incarceration dates of probation/parole if you are currently under probation/parole include the name and phone number of person supervising your parole or probation restitution paid fines/costs ordered fines/costs paid and pardons granted* Include information as to whether or not your civil and political rights have been restored* Attach additional pages if needed* SECTION III - PRESENT/PROPOSED INSURANCE EMPLOYMENT Please specify the name and address of your current or proposed employer to which the requested exemption will apply.

Consent for radiation therapy... CONSENT FOR RADIATION THERAPY TO THE VAGINAL CUFF/CERVIX/UTERUS WITH INTRACAVITARY BRACHYTHERAPY PATIENT NAME: Print name) MR#: TO THE PATIENT: You have been given information about your condition

Parent revoke consent for spec... Print on District Letterhead REVOCATION OF SPECIAL EDUCATION CONSENT Parent: If you wish to exit your child from special education, please complete this form and submit it to the District Office.

Assurance of consent for home... Department of Student Services MONTGOMERY COUNTY PUBLIC SCHOOLS Rockville Maryland 20850 ASSURANCE OF CONSENT FOR HOME INSTRUCTION PURPOSE This form is used by the Montgomery County Public Schools in accordance with the State Board of Education regulation Title 13A Subtitle 10 Home Instruction Chapter 01 General Regulations.

32 parental consent under 18 o... MARQUETTE UNIVERSITY OFFICE OF RESIDENCE LIFE UNDER 18 OVERNIGHT GUEST FORM Marquette University Residence Life Form #32 PARENTAL/GUARDIAN CONSENT AND MEDICAL INFORMATION Marquette Student Information

Authorization health form AUTHORIZATION TO CONSENT TO HEALTH CARE FOR MINOR (North Carolina General Statutes 32A-34) I, of County, , am the custodial parent having legal custody of , born , . a minor child, age I authorize

Consent to name change of mino... IN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION Child(ren): Civil File No: Petitioner: And Respondent: CONSENT FORM The undersigned and are the (check one) parents guardians

Domestic violence order of pro... Case No. Court DOMESTIC VIOLENCE ORDER OF PROTECTION CONSENT ORDER General Court of Justice District Court Division County NORTH CAROLINA G.S. 50B-2, -3, -3.1 PETITIONER/PLAINTIFF Middle First Date

Blood transfusion consent form... PURPOSE OF TRANSFUSION: During your hospital visit your physician may order, or has ordered, a blood transfusion for you. Reasons for a blood transfusion or the use of blood products may include:

Nyc consent to dissolution 201... TM Finance REQUEST FOR CONSENT TO DISSOLUTION NYC DEPARTMENT OF FINANCE G COLLECTION DIVISION Instructions: Please complete, sign and date where indicated and mail to the address above. Under Section

Consent template combined hipa... Informed Consent Form and HIPAA Authorization Study Title: The Down Syndrome Growing Up Study IRB #: 09-007306 Version Date: December 8, 2009, Babette Zemel, PhD Telephone: 215-590-1669 The Children's

Invisalign consent form Informed Consent and Agreement for the Invisalign Patient Notice to treating office This form is to be signed by your Invisalign patients prior to treatment and kept for your records and should not be sent to Align Technology Inc. Patient s Informed Consent and Agreement Regarding Invisalign Orthodontic Treatment Your doctor has recommended the Invisalign system for your orthodontic treatment. I understand that I should only use the Invisalign products after consultation and prescription from an Invisalign certified doctor and I hereby consent to orthodontic prescribed by my doctor. Although orthodontic treatment can lead to healthy teeth and provide important benefits such as an attractive smile you should also be aware that orthodontic treatment including orthodontic treatment with Invisalign aligners has limitations and potential risks that you should consider before undergoing treatment. Device Description Invisalign aligners developed by Align Technology Inc* Align consist of a series of clear plastic removable appliances that move your teeth in small increments. Invisalign products combine your doctor s diagnosis and prescription with sophisticated computer graphics technology to develop a treatment plan which specifies the desired movements of your teeth during the course of your treatment. Upon approval of a treatment plan developed by your doctor a series of customized Invisalign aligners is produced specifically for your treatment. Procedure You will undergo a routine orthodontic pre-treatment examination including x-rays and photographs. Your doctor will take impressions of your teeth and send them along with a prescription to the Align laboratory. Align technicians will follow your doctor s prescription to create a ClinCheck software model of your prescribed treatment. Upon approval of the ClinCheck treatment plan by your doctor Align will produce and mail a series of customized aligners to your doctor. The total number of aligners will vary depending on the complexity of your doctor s prescription* The aligners will be individually numbered and will be dispensed to you by your doctor with specific instructions for use. Unless otherwise instructed by your doctor you should wear your aligners for approximately 20 to 22 hours per day removing them only to eat brush and floss. As directed by the series every two to three weeks. Treatment duration varies depending on the complexity of your doctor s prescription* Unless instructed otherwise you should follow up with your doctor at a minimum of every 6 to 8 weeks. Some patients may require bonded aesthetic attachments and/or elastics on their teeth during treatment to facilitate specific dental movements. Patients may require additional refinement after the initial series of aligners. Benefits to conventional braces. Aligners are nearly invisible so many people won t realize you are in treatment. Tooth movement can be visualized through the ClinCheck software. Aligners allow for normal brushing and flossing tasks that are generally impaired Aligners do not have the metal wires or brackets associated with conventional braces.

Healthcare forms

Browse over 85,000 state-specific fillable forms for all your business and personal needs. Customize legal forms using advanced airSlate SignNow tools.

Showing results for:

Get legally binding signatures now!