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Form preview Cvs prior form CAREMARK PRIOR AUTHORIZATION FORM REQUEST Please complete and fax this form to Caremark at 888-836-0730 to request a Drug Specific Prior Authorization Form. Once we receive your request, we will fax
Form preview Fin 146 authorization use this... Title: FIN 146, Authorization Author: British Columbia, Ministry of Finance Subject: Use this form to authorize how the Ministy of Finance will communicate and ...
Form preview Fl direct deposit 2011 2019 fo... STATE OF FLORIDA DIRECT DEPOSIT AUTHORIZATION PLEASE TYPE OR PRINT CLEARLY Payee Social Security Number Payee Last Name First Name M. FAX to 850 413-5549 If you fax your form retain the original. Please do not mail it. Or mail to Department of Financial Services 200 E. Gaines Street Tallahassee FL 32399-0359 Please allow 4 to 6 weeks for your direct deposit to begin. DFS-A1-26R Rev. Jan 2011. 2 Change. 3 Name Change Only. 4 Stop. For State of Florida Retirement Benefits Only. NOTE If you were a State employee and already had DIRECT DEPOSIT no additional authorization is needed for your retirement benefit unless you cancelled your previous authorization. Account Type 1 Checking. 2 Savings. Your Account Number Start at left leave unused spaces blank Transit Routing Number of Your Financial Institution Address Please notify the Division of Retirement of any address changes or corrections by calling toll free 1-888-377-7687 or local 850 488-4742 writing PO Box 3090 Tallahassee FL 32315-3090 or E-Mailing them at Retired dms. PLEASE READ AND CAREFULLY FOLLOW INSTRUCTIONS For a Start or Change all boxes must be completed do not leave information blank Please leave this area blank This form will start change or stop direct deposit for all payments received by you from the State of Florida. You may not have direct deposit to more than one account at one time. I. Payee Home Mailing Address Number Street City State Zip Code Home Telephone Other Telephone work cell etc. Direct Deposit Action Requested Check Only One 1 Start. 2 Change. 3 Name Change Only. 4 Stop. For State of Florida Retirement Benefits Only. NOTE If you were a State employee and already had DIRECT DEPOSIT no additional authorization is needed for your retirement benefit unless you cancelled your previous authorization. Account Type 1 Checking. 2 Savings. Your Account Number Start at left leave unused spaces blank Transit Routing Number of Your Financial Institution Address Please notify the Division of Retirement of any address changes or corrections by calling toll free 1-888-377-7687 or local 850 488-4742 writing PO Box 3090 Tallahassee FL 32315-3090 or E-Mailing them at Retired dms. myflorida.com for more information. 1. Check Start if you don t have direct deposit and wish to start. Stops are processed the day they are received. Account Number Please make sure the account number on this form is correct. bottom left-hand corner of your personal check. If you re not sure about your Account information PLEASE CONTACT YOUR FINANCIAL INSTITUTION. AGREEMENT I hereby authorize and request the State of Florida to initiate credit entries and if necessary a debit entry reversing a credit entry made in error to my account at the financial institution named. This direct deposit is to remain in effect until withdrawn by a me in writing with sufficient notice to the State to allow adequate time to effect termination b my death or legal incapacity c the financial institution or d the State of Florida. It will purge approximately six 6 months after my last state retirement payment. Bottom left-hand corner of your personal check. If you re not sure about your Account information PLEASE CONTACT YOUR FINANCIAL INSTITUTION. AGREEMENT I hereby authorize and request the State of Florida to initiate credit entries and if necessary a debit entry reversing a credit entry made in error to my account at the financial institution named. This direct deposit is to remain in effect until withdrawn by a me in writing with sufficient notice to the State to allow adequate time to effect termination b my death or legal incapacity c the financial institution or d the State of Florida. It will purge approximately six 6 months after my last state retirement payment. It will remain in effect if I start receiving FRS benefits within 6 months of the final state wage payment.
Form preview Mortgage authorization form fi... Borrower's Authorization Form Privacy Act Notice: This information is to be used by the agency collecting it or its assignees in determining whether you qualify as a prospective mortgagor under its
Form preview Third party authorization form... Short Sale or Pre-Foreclosure Sale Application Submit your completed request for assistance today. For Borrowers Is a Short Sale right for you? Check to see if all three of the following scenarios
Form preview Borrower certification and aut... Borrowers' Certification and Authorization CERTIFICATION The Undersigned certify the following: Truth-In-Lending Mortgage 1. I/We have applied for a mortgage loan through . In applying for the loan,
Form preview Contractor work authorization... WORK AUTHORIZATION REQUEST FORM 2012 IADC/SPE Drilling Conference & Exhibition 6 - 8 March 2012 The San Diego Town and Country Resort & Convention Center San Diego, California DEADLINE DATE:
Form preview What is the function of the bo... Borrowers' Certification and Authorization ... In applying for the loan, I/We completed a loan application containing various information on the purpose of the ...
Form preview Credit card authorization form CREDIT CARD AUTHORIZATION FORM Hotel Hyatt Place and HYATT house properties do not accept this form. Individual/Business/Group or Event Name Reservation Confirmation Number Arrival or Event Date s Credit Card Billing Address City / State / Zip / Country Contact Phone Number Contact Email Address I hereby authorize the following charges to be applied to the following credit card. Check all that apply Room Tax Only Specific Incidentals Gift Certificate All Stay Charges Food Beverage All Banquet Charges Guest Amenity Other - see comments All Incidentals Resort Services Fee Parking credit card applicable sales tax and service charges may apply A service charge of 1. 5 will be applied when using this form for Hyatt hotels in Australia excluding Park Hyatt Sydney Comments The credit card listed below may be billed for the estimated charges Ten 10 days prior to event/reservation date. Credit Card Number Name on Card Expiration Date Cardholder Phone Current Date 11/21/13 Signature of Card Holder By submitting this form and any supporting documents I confirm that I have read and agreed to the use of the personal information I am giving you in accordance with your Global Privacy Policy for Guests which is available at privacy. hyatt. com Please fax this completed form to Hotel Fax Please transmit this form at least 72 hours prior to your planned arrival in order to ensure your request is processed* For a list of all hotels and their contact information please visit http //www. hyatt. com/hyatt/site-map*jsp All information is kept confidential and used only for the purposes as noted above. Check all that apply Room Tax Only Specific Incidentals Gift Certificate All Stay Charges Food Beverage All Banquet Charges Guest Amenity Other - see comments All Incidentals Resort Services Fee Parking credit card applicable sales tax and service charges may apply A service charge of 1. 5 will be applied when using this form for Hyatt hotels in Australia excluding Park Hyatt Sydney Comments The credit card listed below may be billed for the estimated charges Ten 10 days prior to event/reservation date. 5 will be applied when using this form for Hyatt hotels in Australia excluding Park Hyatt Sydney Comments The credit card listed below may be billed for the estimated charges Ten 10 days prior to event/reservation date. Credit Card Number Name on Card Expiration Date Cardholder Phone Current Date 11/21/13 Signature of Card Holder By submitting this form and any supporting documents I confirm that I have read and agreed to the use of the personal information I am giving you in accordance with your Global Privacy Policy for Guests which is available at privacy. Credit Card Number Name on Card Expiration Date Cardholder Phone Current Date 11/21/13 Signature of Card Holder By submitting this form and any supporting documents I confirm that I have read and agreed to the use of the personal information I am giving you in accordance with your Global Privacy Policy for Guests which is available at privacy. hyatt. com Please fax this completed form to Hotel Fax Please transmit this form at least 72 hours prior to your planned arrival in order to ensure your request is processed* For a list of all hotels and their contact information please visit http //www.
Form preview Authorization information Also please explain your relationship to the beneficiary. Please use this step by step instruction sheet when completing your 1-800-MEDICARE Authorization to Disclose Personal Health Information Form. Be sure to complete all sections of the form to ensure timely processing. 1. You should make a copy of your signed authorization for your records before mailing it to Medicare. Use this form if you want 1-800-MEDICARE to give your personal health information to someone other than you. Your letter will revoke your authorization and Medicare will no longer give out your personal health information except for the personal health information Medicare has already given out based on your permission. This form is used to advise Medicare of the person or persons you have chosen to have access to your personal health information. Where to Return Your Completed Authorization Forms After you complete and sign the authorization form return it to the address below Medicare BCC Written Authorization Dept. Instructions for Completing Section 2B of the Authorization Form Please select one of the following options. Option 1 To include all information in the space provided write all information including information about alcohol and drug abuse mental health treatment and HIV. 6. Send your completed signed authorization to Medicare at the address shown here on your 7. If you change your mind and don t want Medicare to give out your personal health information write to the address shown under number six on the authorization form and tell Medicare. Name Address I authorize 1-800-MEDICARE to disclose my personal health information listed above to the person s or organization s I have named on this form. I understand that my personal health information may be re-disclosed by the person s or organization s and may no longer be protected by law. Your authorization or refusal to authorize disclosure of your personal health amount Medicare pays for the health services you receive. Print Form According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number. PO Box 1270 Lawrence KS 66044 For New York Medicare Beneficiaries ONLY The New York State Public Health Law protects information that reasonably could identify someone as having HIV symptoms or infection and information regarding a person s contacts. Because of New York s laws protecting the privacy of information related to alcohol and drug abuse mental health treatment and HIV there are special instructions for how you as a New York resident should complete this form* For question 2A check the box for Limited Information even if you want to authorize Medicare to release any and all of your personal health information* Then proceed to question 2B. Instructions for Completing Section 2B of the Authorization Form Please select one of the following options. Option 1 To include all information in the space provided write all information including information about alcohol and drug abuse mental health treatment and HIV.
Form preview Di 1020 form DEPARTMENT OF THE INTERIOR. TRAVEL AUTHORIZATION. 2. FORM NO. DI- 1020. FORM APPROVED BY COMP. GEN. U.S.. (DATE). NOVEMBER 8, 1949 ...
Form preview Real estate disbursement form San Jac Real Estate 713 894-9436 Office 281 476-6533 Fax TO FROM PROPERTY ADDRESS BUYER SELLER TITLE COMPANY GF COMMISSION DISBURSEMENT FORM Per the terms of the contract San Jac Real Estate is to receive commission as the circle one SELLER S BUYER S Broker to be divided as follows an agent with San Jac Real Estate is to receive 100 commission minus 129. San Jac Real Estate is to receive the 129 as the broker. MUST HAVE BOTH SIGNATURES Agent TREC License Broker TREC License 0469898 Dave Turnquist Dave SanJacRealEstate.
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