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Flood acknowledgement form DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. NO. 1660-0015 Expires February 28, 2014 COMMUNITY ACKNOWLEDGMENT FORM PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting

Cleveland clinic florida autho... AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Patient Name: Last First Middle Home Address: Home Telephone: Date of Birth: Social Security Number: Specify Information to be Disclosed/Brief

Los colinas medical center aut... ' #$% &$' ( )*++ , $- #$% ./& ' ! & #& &50'* 0 1& 2 3- 1 #3+ # & +$ - 4+$ 50 & 0464 ' 7 8 *0& + 6 '0& ' & & )0& 9+ 6* 8 ' &$

Authorization form mim 710 s u... AUTHORIZATION FORM ? MIM #710-S For Radiology Films please send: 500 Eastowne Drive Chapel Hill, NC 27514 For all other record requests please send: ATTN: IMAGING SUPPORT ATTN: RELEASE OF MEDICAL

Concentra patient form Patient Information Patient Last name: First name: Social Security #: Date of birth (MM/DD/YYYY): Driver s License number: Issued in what state: License classification: Address: City: ST: Contact

Concentra authorization form f... Concentra for UVM Patient Must Present Photo ID at Time of Service AUTHORIZATION for EXAMINATION or TREATMENT Due to the nature of these specific services only the patient staff are allowed in the testing/treatment area. Please alert your employee so that s/he can make arrangements for children or others that might otherwise accompany her/him to the medical center.

Pacificare authorization form ROUTINE TREATMENT AUTHORIZATION FORM Prior Auth. Fax 800 457-3828 Home Health Auth. Fax 800 207-1833 DME Auth. Fax 800 710-8812 PLAN TYPE Commercial Secure Horizons URGENT STAT From Name Address City State Zip Phone Fax Back No. THIS PORTION TO BE COMPLETED BY PHYSICIAN Patient Name Primary Care MD Refer To City State Zip Specialty Home Sex DOB Age Member ID Office Type of Service Inpatient Outpatient Home Health DME Office Fax Initial Visit Return Visit Other CLINICAL HISTORY PHYSICAL FINDINGS REASON FOR REFERRAL Consultation Testing Follow-up Procedure No. of Visits Requested DIAGNOSIS ICD-9 CM CODE EVALUATION TREATMENT PLAN RVS/CPT 4 CODE REQUESTED FACILITY Accident Yes No Occurrence Work Auto Other Insurance MD Signature Date NOTE The member has the right to appeal denial of services through PacifiCare/Secure Horizons PLEASE CHECK ELIGIBILITY PRIOR TO PROVIDING SERVICE. Authorization Provider Contracted Yes Facility Contracted Assigned Length of Stay Authorized Initials Pended Modified CPT Codes Authorized/No. of Visits Reason SE 7-26-00. ROUTINE TREATMENT AUTHORIZATION FORM Prior Auth. Fax 800 457-3828 Home Health Auth. Fax 800 207-1833 DME Auth. Fax 800 710-8812 PLAN TYPE Commercial Secure Horizons URGENT STAT From Name Address City State Zip Phone Fax Back No* THIS PORTION TO BE COMPLETED BY PHYSICIAN Patient Name Primary Care MD Refer To City State Zip Specialty Home Sex DOB Age Member ID Office Type of Service Inpatient Outpatient Home Health DME Office Fax Initial Visit Return Visit Other CLINICAL HISTORY PHYSICAL FINDINGS REASON FOR REFERRAL Consultation Testing Follow-up Procedure No* of Visits Requested DIAGNOSIS ICD-9 CM CODE EVALUATION TREATMENT PLAN RVS/CPT 4 CODE REQUESTED FACILITY Accident Yes No Occurrence Work Auto Other Insurance MD Signature Date NOTE The member has the right to appeal denial of services through PacifiCare/Secure Horizons PLEASE CHECK ELIGIBILITY PRIOR TO PROVIDING SERVICE* Authorization Provider Contracted Yes Facility Contracted Assigned Length of Stay Authorized Initials Pended Modified CPT Codes Authorized/No* of Visits Reason SE 7-26-00.

Title iv authorization form 20... AUTHORIZATION TO APPLY TITLE IV PROGRAM FUNDS PLEASE PRINT (use ink) Undergraduate Health Sciences Chiropractic CAOM Last name First name Middle Initial MT MHS NWHSU ID Number (6 digits) In order

Employee payroll deduction aut... To confirm your understanding of the purpose of this form and to authorize the deduction sign and date below I authorize a payroll deduction to cover all my Smith College charges. SMITH COLLEGE EMPLOYEE PAYROLL DEDUCTION AUTHORIZATION FORM Check one Begin Deduction Cancel Deduction If you wish to arrange for an automatic payroll deduction to cover all your Smith College charges you must complete this form and return it to the Controller s Offic...

Crowne plaza credit card autho... CREDIT CARD AUTHORIZATION FORM This form must be completed signed and accompanied by a copy of the front and back of the credit card noted below in order to process your request. We recommend that the card copy be enlarged and lightened. I hereby authorize the Crowne Plaza Chicago O Hare to charge my personal / corporate credit card for Today s Date Function Date s Group Name Type of Card MC VISA AMEXP Will the card holder be on site YES Diners Discover NO If no who will sign for charges PLEASE PRINT Credit Card Exp. Date Name as Printed on the Card Card Holders Signature Address City State Zip Telephone Fax Charges to be billed to this credit card All Guest Room Charges Guest Room /Room Tax Only Catering Function / Event Charges Hotel Representative /. CREDIT CARD AUTHORIZATION FORM This form must be completed signed and accompanied by a copy of the front and back of the credit card noted below in order to process your request. We recommend that the card copy be enlarged and lightened* I hereby authorize the Crowne Plaza Chicago O Hare to charge my personal / corporate credit card for Today s Date Function Date s Group Name Type of Card MC VISA AMEXP Will the card holder be on site YES Diners Discover NO If no who will sign for charges PLEASE PRINT Credit Card Exp* Date Name as Printed on the Card Card Holders Signature Address City State Zip Telephone Fax Charges to be billed to this credit card All Guest Room Charges Guest Room /Room Tax Only Catering Function / Event Charges Hotel Representative /.

Vanguard agent authorization f... IRS Form W-9 and any substitute IRS Form W-9. 9. Enter into all other lawful transactions on any account to which this authorization applies. 10. Request a Vanguard Financial Plan VFP engage in consultations over the phone and take advice from a Certified Financial Planner professional. 3 of 8 You may give your agent authority to conduct transactions on any existing and future accounts of the same registration type established under the Social Se...

Confidential character referen... O. Box City/Town Province/State Country Postal Code/Zip Code hereby consent the following referee Please print referee s name to provide the Ministry of Education with this confidential character reference as part of my application for authorization to teach in BC and I acknowledge that this confidential character reference is not a teaching report. Confide nt ia l Cha r a ct e r Re fe re nce for Aut hor iza t ion t o Te a ch in Br it ish Colum bia Pa ge 1 Applicant please complete this page. I Full given names Applicant s legal surname Date of Birth YYYYMMDD Birth Surname Previous Surnames Street Address/P. Date Signature of Applicant Notes This two-page character reference form is to be provided by the applicant to a referee who shall complete page 2. The referee must not be a relative partner or spouse or equivalent of the applicant and must have known the applicant for a minimum of two years. trb. certification gov*bc*ca. This character reference will not be accepted as a teaching report. Delay in the receipt of this form will result in delay in the processing of the application* Ministry of Education Teacher Regulation Branch Mailing Address 400-2025 West Broadway Vancouver BC V6J 1Z6 Telephone 604 731-8170 Toll Free 1 800 555-3684 Facsimile 604 731-9142 Pa ge 2 Referee please complete this page and send it directly to the Ministry of Education by mail fax or scanned email trb. certification gov*bc*ca. Applicant s Name How long have you known this applicant A referee must have known the applicant for a minimum of two years. In what capacity have you known this applicant A referee must not be a relative partner or spouse or equivalent of the applicant. Describe situation s in which you have observed the applicant working with children or youth. If you have not observed the applicant working with children or youth what characteristics and/or qualities have you seen the applicant exhibiting that would be valuable in working with young people Explain why you consider the applicant to be a fit and proper person to be working with students. Do you have any reason to believe the applicant should not be granted authorization to teach To the best of my knowledge the above information is complete and correct. Name of Referee Please print full name Signature of Referee Address Telephone H W Should the applicant under the Freedom of Information and Protection of Privacy Act request a copy of this reference do you consent to its release Yes No Delay in receipt of this form will result in delay in the processing of the application* This is a character reference only and may not be used as a teaching report or professional evaluation*. Confide nt ia l Cha r a ct e r Re fe re nce for Aut hor iza t ion t o Te a ch in Br it ish Colum bia Pa ge 1 Applicant please complete this page. I Full given names Applicant s legal surname Date of Birth YYYYMMDD Birth Surname Previous Surnames Street Address/P. Date Signature of Applicant Notes This two-page character reference form is to be provided by the applicant to a referee who shall complete page 2. The referee must not be a relative partner or spouse or equivalent of the applicant and must have known the applicant for a minimum of two years.

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