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Form preview Authorization embalm form The undersigned acknowledges that this authorization encompasses permission to embalm at the funeral establishment or at another facility equipped for embalming including a school or college of mortuary science. Relationship to Deceased Timea.m. or p.m. Date Received by If no authorization can be obtained complete the following I hereby acknowledge that has made a reasonable effort over a Name of Establishment period of at least three hours to obtain authorization to embalm the deceased. I take full responsibility for performing embalming without permission. Times contact with family attempted Signature and License of Embalmer authority to do so refuses to give permission to embalm the above-named deceased individual. Signature Date. Texas Funeral Service Commission Form 10. 1. 01b AUTHORIZATION TO EMBALM AT FUNERAL ESTABLISHMENT OR OTHER LOCATION Name of Licensed Funeral Establishment Name of DeceasedDate of Death The undersigned understanding that embalming is not required by law except in certain special cases authorizes the funeral establishment to utilize a licensed facility under the same general ownership and management or use licensed embalmers as agents or independent contractors or a commercial embalming establishment to care for embalm and prepare the body of the deceased. The funeral establishment accepts the responsibility of revealing upon request to the next-of-kin or person responsible for making final disposition arrangements the name address and license number of the facility where embalming occurred and the name and license number of the embalmer and any provisional licensee or mortuary student who assisted under the embalmer s direct supervision. The undersigned authorizes and directs the funeral establishment including apprentices provisional licensees and mortuary students under the direct supervision of a licensed embalmer employed by the funeral establishment and the funeral establishment s employees independent contractors and agents to care for embalm and prepare the body of the decedent. Date Signed Signature of next-of-kin or Person Responsible for making arrangements for final disposition NOTE Mortuary Students may only participate in embalming if permission is in writing and in the possession of the Licensed Embalmer at the time of the procedure. If Authorization for embalming is oral complete the following Location of embalming disclosure was discussed with next-of-kin or person responsible for making arrangements. Date Signed Signature of next-of-kin or Person Responsible for making arrangements for final disposition NOTE Mortuary Students may only participate in embalming if permission is in writing and in the possession of the Licensed Embalmer at the time of the procedure. If Authorization for embalming is oral complete the following Location of embalming disclosure was discussed with next-of-kin or person responsible for making arrangements.
Form preview Pharmacy for cigna form CIGNA Specialty Pharmacy Services Fax Order Form Please deliver by: Requests received after 4 p.m. CT will begin processing the following business day Order #: PATIENT NAME: HEALTH
Form preview Cigna form prior auth CIGNA HealthCare Prior Authorization Form - , , , Pharmacy Services Phone: (800)244-6224 Fax: (800)390-9745 Notice: Failure to complete this form in its entirety may
Form preview Cigna policy form CIGNA HealthCare Prior Authorization Form - Pharmacy Services Notice Failure to complete this form in its entirety may result in delayed processing or an adverse determination for insufficient information. Phone 800 244-6224 Fax 800 390-9745 PROVIDER INFORMATION PATIENT INFORMATION Provider Name Specialty Due to privacy regulations we will not be able to respond via fax with the outcome of our review unless all asterisked items ...
Form preview Cigna health assessment form Please check all that apply Gold Penacillamine Which of the following methods was used to measure the patient s disease progression PRIOR to therapy on Check all that apply Health Assessment Questionnaire Disease Index HAQ-DI Visual Analogue scale VAS Likert scales of global response to pain by the patient/doctor Global Arthritis Score GAS Clinical Disease Activity Index CDAI Simplified Disease Activity Index SDAI Progression of radiographic damage of involved joints Disease Activity Scale DAS score If this is a request for CONTINUED THERAPY after at least 16 weeks of treatment has the patient shown beneficial response to treatment with on any of the following measurements Check all that showed a beneficial Additional pertinent information Chronic Plaque Psoriasis Is the patient a candidate for or have they previously received systemic therapy cyclosporin http //www. cigna.com/customercare/healthcareprofessional/coveragepositions Please fax completed form to 800 390-9745. CIGNA HealthCare Prior Authorization Form - Pharmacy Services Phone 800 244-6224 Fax 800 390-9745 Notice Failure to complete this form in its entirety or include chart notes may result in delayed processing or an adverse determination for insufficient information. PROVIDER INFORMATION PATIENT INFORMATION Provider Name Specialty Due to privacy regulations we will not be able to respond via fax with the outcome of our review unless all asterisked items on this form are completed DEA or TIN Office Contact Person Patient Name Office Phone CIGNA ID Office Fax Date Of Birth Is your fax machine kept in a secure location May we fax our response to your office Yes No Office Street Address Patient Street Address City State Medication requested Dose and Quantity Zip Patient Phone Duration of therapy J-Code Where will this medication be obtained CIGNA Tel-Drug CIGNA s nationally preferred specialty pharmacy Retail pharmacy Prescriber s office stock billing on a medical claim form Home Health / Home Infusion vendor Other please specify Please indicate the condition is being used to treat and answer additional questions as necessary. You may include applicable chart notes with this form. Anklyosing Spondylitis Additional Question s Does patient have a history of beneficial clinical response to Answer/Detail contraindication to Non-Steroidal Anti-Inflammatory NSAID medications Psoriatic Arthritis Active Crohn s Disease conventional therapies such as aminosalicylate corticosteroids or immumodulators Rheumatoid Arthritis or Juvenile Idiopathic Arthritis What is the patient s diagnosis Juvenile Idiopathic Arthritis Does the patient have a history of beneficial clinical response to therapy the following disease-modifying anti-rheumatic drugs DMARDs. Please check all that apply Gold Penacillamine Which of the following methods was used to measure the patient s disease progression PRIOR to therapy on Check all that apply Health Assessment Questionnaire Disease Index HAQ-DI Visual Analogue scale VAS Likert scales of global response to pain by the patient/doctor Global Arthritis Score GAS Clinical Disease Activity Index CDAI Simplified Disease Activity Index SDAI Progression of radiographic damage of involved joints Disease Activity Scale DAS score If this is a request for CONTINUED THERAPY after at least 16 weeks of treatment has the patient shown beneficial response to treatment with on any of the following measurements Check all that showed a beneficial Additional pertinent information Chronic Plaque Psoriasis Is the patient a candidate for or have they previously received systemic therapy cyclosporin http //www.
Form preview Authorization designation cuna... Chapter 3: Authorization Designation The Authorization Designation document collects business member information and identifies the persons designated to represent the company and authorized to open
Form preview Business pre authorized debit... Business Pre-Authorized Debit (PAD) Payor's Authorization or Mail to: Manulife Financial GRS Client Services, KC-6 PO BOX 396 STN WATERLOO WATERLOO ON N2J 4A9 Courier to: Manulife Financial GRS Client
Form preview Mutual of omaha prior auth for... INSTRUCTIONS FOR COMPLETING THIS FORM Please complete both sides of this enclosure if applicable. If the signature is missing from the backside of this form, this form is invalid. If mistakes are
Form preview Authorization for living maint... Authorization for Living Maintenance Wage Loss Instructions To be completed by the injured worker Injured worker name Address City Initial Claim number Six-month Check only one Job change Date of
Form preview Direct deposit authorization f... DIRECT DEPOSIT AUTHORIZATION FORM TD Bank makes setting up direct deposit easy with this convenient pre-filled form. There are two types of direct deposit enrollment available Federal Government Benefit Compensation and Payroll Compensation. Steps to enroll for each are outlined below. 1. FEDERAL GOVERNMENT BENEFIT COMPENSATION To sign up for direct deposit of your federal benefit payments such as Social Security SSI or VA Compensation and Pension Payment Go to the U*S* Department of the Treasury website www. godirect. org or Enroll by phone by calling the U* S* Department of the Treasury toll free at 1-800-333-1795 You ll need your Social Security Number or claim number 12-digit federal benefit check number Amount of most recent federal benefit check TD Bank s Routing Transit Number TD Bank Account Number Type of Account checking or savings 2. PAYROLL COMPENSATION Complete and sign this direct deposit form and give it to your employer s payroll representative it s that easy EMPLOYEE NAME AND ADDRESS EMPLOYEE PHONE NUMBER EMPLOYEE ID if applicable EMPLOYEE SOCIAL SECURITY NUMBER Please begin directly depositing my payroll and/or dividend or annuity check into my account at TD Bank. l Total net check amount l The set amount of of my net check each period BANK NAME TD Bank N*A. ADDRESS 32 Chestnut St* PO Box 1377 Lewiston ME 04243-1377 TD BANK ROUTING TRANSIT NUMBER TD BANK ACCOUNT NUMBER TYPE OF ACCOUNT Employee Signature Date 11440C-CHK 09/11. 1. FEDERAL GOVERNMENT BENEFIT COMPENSATION To sign up for direct deposit of your federal benefit payments such as Social Security SSI or VA Compensation and Pension Payment Go to the U*S* Department of the Treasury website www. godirect. org or Enroll by phone by calling the U* S* Department of the Treasury toll free at 1-800-333-1795 You ll need your Social Security Number or claim number 12-digit federal benefit check number Amount of most recent federal benefit check TD Bank s Routing Transit Number TD Bank Account Number Type of Account checking or savings 2. godirect. org or Enroll by phone by calling the U* S* Department of the Treasury toll free at 1-800-333-1795 You ll need your Social Security Number or claim number 12-digit federal benefit check number Amount of most recent federal benefit check TD Bank s Routing Transit Number TD Bank Account Number Type of Account checking or savings 2. PAYROLL COMPENSATION Complete and sign this direct deposit form and give it to your employer s payroll representative it s that easy EMPLOYEE NAME AND ADDRESS EMPLOYEE PHONE NUMBER EMPLOYEE ID if applicable EMPLOYEE SOCIAL SECURITY NUMBER Please begin directly depositing my payroll and/or dividend or annuity check into my account at TD Bank. PAYROLL COMPENSATION Complete and sign this direct deposit form and give it to your employer s payroll representative it s that easy EMPLOYEE NAME AND ADDRESS EMPLOYEE PHONE NUMBER EMPLOYEE ID if applicable EMPLOYEE SOCIAL SECURITY NUMBER Please begin directly depositing my payroll and/or dividend or annuity check into my account at TD Bank. l Total net check amount l The set amount of of my net check each period BANK NAME TD Bank N*A. ADDRESS 32 Chestnut St* PO Box 1377 Lewiston ME 04243-1377 TD BANK ROUTING TRANSIT NUMBER TD BANK ACCOUNT NUMBER TYPE OF ACCOUNT Employee Signature Date 11440C-CHK 09/11.
Form preview Flagstar third party authoriza... Third-Par t y Authorization Form Loan Number Use this Third Party Authorization form to authorize someone other than yourself to access your Flagstar Bank Mortgage Loan Account information. To authorize full access to your loan account this from must be notarized see page 2. I understand that this authorization does not allow the Authorized Party to take any action or request any service or documentation on this loan. Flagstar may reject this or ...
Form preview Authorization for payoff form Date / / AUTHORIZATION FOR PAYOFF Vehicle Identification Number Make of Vehicle License Plate Number Mileage Lender Name Account Number Phone Number Lender Address The undersigned hereby authorizes and directs you to accept from SchoolsFirst Federal Credit Union PO BOX 11547 Santa Ana CA 92711 ETL W36 ELT is only valid for California Titles the payoff amount due to you on my account in the amount of good through / / and to surrender to them or order the properly endorsed Certificate of Ownership to the above described vehicle.
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