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Credit card authorization form... Credit Card Authorization Form Dear Sir/Madam This form has been created in order to allow you to have third party expenses charged to your credit/debit card. Departure date cannot be extended unless a new authorization form is completed. Printed Guest signature Date Rate Information and Approved Charges - Required Room rate Number of nights All Charges Room Tax Telephone LD Telephone Local Restaurant Room Service Valet Laundry Parking HS Internet Access Movies I certify that all information is complete and accurate. I hereby authorize RENAISSANCE DOHA CITY CENTER HOTEL COURTYARD BY MARRIOTT DOHA CITY CENTER and MARRIOTT EXECUTIVE APARTMENTS DOHA CITY CENTER to collect payment for all charges as indicated in the Rate Information and Approved Charges section of this form by processing a charge to the credit/debit card listed for the entire stay/event. 44195600. Cardholder Information - Required Name as it appears on the credit/debit card Card type Visa Account type Individual personal credit card Corporate MC Amex Diners/CB Discover JCB Company Name Account number Exp. date Address where statement is mailed City State and Zip P hone number F ax or al ternate number Guest Information - Required Guest name Company Confirmation number A rri val date D eparture date Relation to cardholder Relative Friend Business Associate Other I understand that should there be any issues with the credit/debit card being used to settle my charges I will be responsible for all expenses incurred during my stay. Departure date cannot be extended unless a new authorization form is completed. Printed Guest signature Date Rate Information and Approved Charges - Required Room rate Number of nights All Charges Room Tax Telephone LD Telephone Local Restaurant Room Service Valet Laundry Parking HS Internet Access Movies I certify that all information is complete and accurate. Please provide all the information requested below to ensure prompt processing of your application* We ask you to please sign and date the form before submission* Please fax the completed form to RENAISSANCE DOHA CITY CENTER HOTEL COURTYARD BY MARRIOTT DOHA CITY CENTER and MARRIOTT EXECUTIVE APARTMENTS DOHA CITY CENTER at 00974. 44195600. Cardholder Information - Required Name as it appears on the credit/debit card Card type Visa Account type Individual personal credit card Corporate MC Amex Diners/CB Discover JCB Company Name Account number Exp* date Address where statement is mailed City State and Zip P hone number F ax or al ternate number Guest Information - Required Guest name Company Confirmation number A rri val date D eparture date Relation to cardholder Relative Friend Business Associate Other I understand that should there be any issues with the credit/debit card being used to settle my charges I will be responsible for all expenses incurred during my stay. Departure date cannot be extended unless a new authorization form is completed* Printed Guest signature Date Rate Information and Approved Charges - Required Room rate Number of nights All Charges Room Tax Telephone LD Telephone Local Restaurant Room Service Valet Laundry Parking HS Internet Access Movies I certify that all information is complete and accurate.

Slotastix authorization form CREDIT CARD AUTHORIZATION FORM Please fill out and sign and send this form alongside copies of the following documents to support slotastic.com 1) Copy of your valid Driver License or Passport 2)

3rd party authorization form THIRD PARTY AUTHORIZATION SunTrust Mortgage Loan Number 10 digits I/We Borrower and Co-Borrower if applicable hereby authorize SunTrust Mortgage Inc. to release any and all information about my Loan to the third party indicated below. Date Requested Full Name of Authorized Third Party s Relationship to Borrower Borrower Name Borrower Social Security Number last 4 digits Co-Borrower Name Property Street Address City State Zip Code Borrower Signature Co-Borrower Signature Print Name When you have completed and signed this Authorization please return it to the following address or you may fax the Authorization to 804. I/We understand that information released by SunTrust Mortgage may include but may not be limited to information relating to my loan amount and payment transactions history and/or the provision of copies of my loan documents which may contain non-public information relating to me and the Co-Borrower. I/We acknowledge that should I and/or Co-Borrower if applicable wish to terminate this authorization I or CoBorrower must call SunTrust Mortgage at 800. 443. 1032 option 3 Monday through Friday 8 AM to 10 PM ET and submit the request in writing to the address below. 675. 7399. Attention Support Services 1001 Semmes Avenue RVW 3054 Richmond Virginia 23224 Please allow 5 business days from SunTrust s receipt for authorization or termination to be processed*. I/We understand that information released by SunTrust Mortgage may include but may not be limited to information relating to my loan amount and payment transactions history and/or the provision of copies of my loan documents which may contain non-public information relating to me and the Co-Borrower. I/We acknowledge that should I and/or Co-Borrower if applicable wish to terminate this authorization I or CoBorrower must call SunTrust Mortgage at 800. I/We acknowledge that should I and/or Co-Borrower if applicable wish to terminate this authorization I or CoBorrower must call SunTrust Mortgage at 800. 443. 1032 option 3 Monday through Friday 8 AM to 10 PM ET and submit the request in writing to the address below. I/We understand that information released by SunTrust Mortgage may include but may not be limited to information relating to my loan amount and payment transactions history and/or the provision of copies of my loan documents which may contain non-public information relating to me and the Co-Borrower. I/We acknowledge that should I and/or Co-Borrower if applicable wish to terminate this authorization I or CoBorrower must call SunTrust Mortgage at 800. 443. 1032 option 3 Monday through Friday 8 AM to 10 PM ET and submit the request in writing to the address below.

Mpiphp authorization for relea... P.O. Box 1999 ... authorization form will apply to any and all information held by the MPI Pension ... Plans, including, but not limited to: Social Security numbers, addresses, ... (For example: At

Authorization for release of p... HCA PHYSICIAN SERVICES OGDEN INTERNAL MEDICINE AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) Section A: Will the Protected Health Information (PHI) be created or used for research

Medical management authorizati... Indiana University Health Medical Management Authorization Request Form Forward completed form via FAX to IUHMM at 317 962-6219 or 317 962-4005 Please complete all fields for review REQUESTING PHYSICIAN INFORMATION REQUESTING VENDOR INFORMATION Ordering MD Vendor TAX ID Address Phone Fax Contact MEMBER INFORMATION IUHMM USE ONLY Name ID DOB // SS // Date of Service CPT or HCPC Code Requested Service AUTHORIZATION NUMBER Services APPROVED As Requested Request MODIFIED see below for detail Request DENIED Letter To Follow Modifications Made IUHMM Staff Place of Service INP OP OBS Units Diagnosis / ICD9 Code CLINICAL SUMMARY Form will be rejected if CLINICAL SUMMARY is NOT completed.

Prior authorization forms BANNER HEALTH NETWORK REFERRAL/PRIOR AUTHORIZATION FORM ATTENTION PATIENTS THIS IS YOUR REFERRAL FORM. THE SPECIALIST MAY REFUSE TO SEE YOU WITHOUT IT. Incomplete forms will not be processed and will be returned to sending provider. BANNER HEALTH NETWORK REFERRAL/PRIOR AUTHORIZATION FORM ATTENTION PATIENTS THIS IS YOUR REFERRAL FORM. THE SPECIALIST MAY REFUSE TO SEE YOU WITHOUT IT. Incomplete forms will not be processed and will be returned to sending provider. Planned Date of Service Recommend not scheduling until authorization is obtained Patient DOB Patient s Health Plan ID Requested Provider TIN Full Name Specialty Out of Network Inpt OutptOffice Office Contact Name Phone Fax Place of Service TIN Facility Name Referring Provider Phone Fax Requested Action by Specialist Optional for PCP to Complete Consultation Please send the patient back for follow-up and treatment Confirm Diagnosis Advise as to Diagnosis Suggest Medication or Treatment Referral Please provide PCP with summaries of subsequent visits Assume management for this particular problem and return patient after conclusion of care. Assume future management of patient within your area of expertise. Diagnosis/ICD-9 Treatment/Procedure with CPT/HCPCS codes Submit Information for request List units being administered Notes labs x-rays Provider Signature Date THE FOLLOWING APPLIES ONLY TO Banner Choice Plus PATIENTS To access your Banner Option Benefit your Primary Care Physician should refer you to a contracted provider. To ensure recommended provider is contracted call Banner Benefits Service Center at 480-684-7070 within Metro Phoenix area or at 800-827-2464 or go on the web www. BannerHealthPlans. com For Banner Use Only BHN Prior Authorization Dept Phone 480-684-7070 Fax 480-684-7200 within Metro Phoenix Area or 800-697-1441 The information contained in this facsimile message is confidential and intended only for the use of the individual s named above. If the reader of this message is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient you are hereby notified that any dissemination distribution or copying of this communication is strictly prohibited* If you have received this communication in error please immediately notify us by telephone and destroy facsimile. THE SPECIALIST MAY REFUSE TO SEE YOU WITHOUT IT. Incomplete forms will not be processed and will be returned to sending provider. Planned Date of Service Recommend not scheduling until authorization is obtained Patient DOB Patient s Health Plan ID Requested Provider TIN Full Name Specialty Out of Network Inpt OutptOffice Office Contact Name Phone Fax Place of Service TIN Facility Name Referring Provider Phone Fax Requested Action by Specialist Optional for PCP to Complete Consultation Please send the patient back for follow-up and treatment Confirm Diagnosis Advise as to Diagnosis Suggest Medication or Treatment Referral Please provide PCP with summaries of subsequent visits Assume management for this particular problem and return patient after conclusion of care.

Dataformfillcom OVERSEAS PRE-EMPLOYMENT DATA FORM Personal Data: Name: Social Security Number: Citizenship: Date of Birth: Typing-Words Per Minute: Employee Preferences Work Schedule: Full Time: Part Time: Minimum

Authorization for release of p... Form 526A Page 1 of 2 PLEASE FAX OR EMAIL THIS COMPLETED FORM TO: The Little Clinic LLC Attn: Medical Records Department Fax: (615) 425-4344 OR medicalrecords thelittleclinic.com AUTHORIZATION FOR

Dealership form Dealer Payoff Worksheet 4Owner Information OWNER NAME STREET ADDRESS CITY STATE ZIP 4Vehicle Information Y EAR TITLE STATE / TITLE # MAKE MODEL VIN TITLE TYPE Paper 4Lienholder Information LIENHOLDER

Nh magellan medicaid prior aut... Hyaluronic Acid Derivatives Injection New Hampshire Medicaid Prior Authorization Request Form Fax to Magellan if medication is to be dispensed from a pharmacy Magellan Fax 1-888-603-7696 Phone 1-866-675-7755 Fax to KePRO if medication is dispensed/administered by a physician in the office or outpatient setting KePRO Fax 1-800-922-9847 Phone 1-800-299-5921 DATE OF MEDICATION REQUES T Section I Patient Information and Medication Request NAME LAS T ...

Credit card authorization temp... Credit Card Authorization Department of State Division of Licensing Services P.O. Box 22001 Albany, NY 12201-2001 The Department of State's Division of Licensing Services accepts MasterCard and Visa

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