Healthcare forms

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Form preview Authorized signatory template... Sample Authorization Letter to Open an FRG Checking Account Unit Letterhead Office Symbol (600-20) Bank Name ATTENTION: New Business Accounts Bank Address City, State ZIP SUBJECT: Authorization to
Form preview 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
Form preview 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
Form preview Los colinas medical center aut... ' #$% &$' ( )*++ , $- #$% ./& ' ! & #& &50'* 0 1& 2 3- 1 #3+ # & +$ - 4+$ 50 & 0464 ' 7 8 *0& + 6 '0& ' & & )0& 9+ 6* 8 ' &$
Form preview 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
Form preview 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
Form preview 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.
Form preview 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.
Form preview 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
Form preview 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...
Form preview 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 /.
Form preview 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...
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