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Ohio department of insurance s... Insurance. ohio. gov Ohio Department of Insurance John R. Kasich Governor Mary Taylor Lt. Governor/Director Standardized Credentialing Form Part B Agency/Program/Organization Providers Please complete each section leaving no blank spaces. Product Regulation rd 50 W* Town St* 3 Fl Suite 300 Columbus OH 43215 614 644-2661 Fax 614 728-5238 www. Clearly state if information requested is not applicable or not available and why. Attach additional sheets when necessary. Separate forms may be required for each National Provider Identifier NPI practice location and provider type. You must include copies of the following documents as applicable with this completed application* Use this checklist as a guide State License Local Business License Registrations or Certifications DEA and/or CDS Certificate CLIA Certificate Terminal Distributor License Current Certificate of General Liability Insurance Form W-9 Workers Compensation Certificate of Coverage Accreditation Letter and Certificate Medicare Certification Letter If the Provider is not accredited please include the following information C. V. of Medical Director C. V. of Clinical Director Credentialing Plan Most recent CMS or State Surveys Correction Action Plans and Revisit Reports Documented staff attendance at OSHA Training Documented compliance with OSHA record keeping rules regarding workplace injuries and illness Confidentiality Plan NA Note Please submit this form directly to health plans and other entities that credential facility providers for participation in their networks. DO NOT send this form to the Ohio Department of Insurance the Department does not use the form for any reporting purposes. Accredited by the National Association of Insurance Commissioners NAIC INS5036 Rev* 01/2011 Page 1 of 8 Provider Identification Legal Name of Applicant Federal Tax Identification Number Doing Business As DBA Type of Provider NPI Primary Office Address Mailing Address if different from business address City State Zip Code Date and State of Incorporation or Registration List all other states in which applicant is approved to conduct external reviews Length of time in business with this legal name and Tax ID Year Applicant Opened Address If different from above Phone Fax Email Applicant Owner/Parent Company Type of Entity Corporation Partnership Check one Joint Venture Other List all memberships in professional organizations and trade associations Limited Liability Company Medical Director Name Last First Middle Degree Specialty Office Address Provider Practice Information Name Street Address/PO Box Website Primary Contact Name and Title Hours of Monday Operation Included in Provider Directory Yes No Federal Tax ID number Tuesday Wednesday Thursday Friday Saturday Sunday List language and sign language interpreters/ contractors Is teletype available Administrator/ Site Manager Service Areas Counties Handicapped Access On Bus Route Number of Beds Additional Practice Location Billing Information To whom shall checks be made payable Billing Address Street/PO Box Type of Claim Form Used CMS1500 UB04 UB92 Accrediting Agency Name Have you ever been denied accreditation by any accrediting body If yes please provide details Licensure and Certifications Medicaid Provider Number and Status License Number and Status CLIA Number Scope of Services List all services offered attach separate page if necessary Does the Provider have a toll free number Yes Is the Provider part of a national network of providers Yes If Yes please describe What is the accepted age range of the Provider s patients Liability Insurance General Liability Coverage Attach certificate showing current coverage amounts and effective dates Name of Carrier Policy Number Coverage Type Occurrence Based Claims Based Effective Date Expiration Date Per Incident Aggregate Professional Liability Malpractice Coverage Staffing Provide a list of the types numbers of professional disciplines licensures and/or certifications represented on the staff* Electronic Capabilities What are the Provider s current electronic capabilities What billing and documentation software is the Provider currently using What version is the software Sent in groups Batch Or one at a time Real Time What is the name of the EMR software Is the EMR software compatible with your billing and documentation software Disclosure Questions Please answer the following questions by checking the appropriate box.

Standard family law interrogat... INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 12.930(c), STANDARD FAMILY LAW INTERROGATORIES FOR MODIFICATION PROCEEDINGS (09/09) When should this form be used? This form should be used

Zimbabwe standard chartered re... REMITTANCE APPLICATION FORM Please fill in using BLOCK LETTERS Branch Applicant's Information (Sender) Name of Sender* Address Resident Transfer Instructions Payment Method Debit A/C No.* Charges

A method for estimating insect... A method for estimating insect abundance and patch occupancy with potential applications in large-scale monitoring programmes G. Sileshi* World Agroforestry Centre (ICRAF), SADC-ICRAF Agroforestry

Form adopted for mandatory use... Form Adopted for Mandatory Use Judicial Council of California FL-110 Rev. July 1 2009 Deputy Asistente Clerk by Secretario por as an individual. a usted como individuo. FL-110 CITACI N Derecho familiar SUMMONS Family Law FOR COURT USE ONLY NOTICE TO RESPONDENT Name AVISO AL DEMANDADO Nombre You are being sued. Lo est n demandando. S LO PARA USO DE LA CORTE To keep other people from seeing what you entered on your form please press the Clear This Form button at the end of the form when finished* Petitioner s name is Nombre del demandante CASE NUMBER N MERO DE CASO You have 30 calendar days after this Summons and Petition are served on you to file a Response form FL-120 or FL-123 at the court and have a copy served on the petitioner. A letter or phone call will not protect you. Tiene 30 d as corridos despu s de haber recibido la entrega legal de esta Citaci n y Petici n para presentar una Respuesta formulario FL-120 FL-123 ante la corte y efectuar la entrega legal de una copia al demandante. Una carta o llamada telef nica no basta para protegerlo. If you do not file your Response on time the court may make orders affecting your marriage or domestic partnership your property and custody of your children* You may be ordered to pay support and attorney fees and costs. If you cannot pay the filing fee ask the clerk for a fee waiver form* Si no presenta su Respuesta a tiempo la corte puede dar rdenes que afecten su matrimonio o pareja de hecho sus bienes y la custodia de sus hijos. La corte tambi n le puede ordenar que pague manutenci n y honorarios y costos legales. Si no puede pagar la cuota de presentaci n pida al secretario un formulario de exenci n de cuotas. If you want legal advice contact a lawyer immediately. You can get information about finding lawyers at the California Courts Online Self-Help Center www*courtinfo*ca*gov/selfhelp at the California Legal Services Web site www. lawhelpcalifornia*org or by contacting your local county bar association* Si desea obtener asesoramiento legal p ngase en contacto de inmediato con un abogado. Puede obtener informaci n para encontrar a un abogado en el Centro de Ayuda de las Cortes de California www. sucorte. ca*gov en el sitio Web de los Servicios Legales de California www. lawhelpcalifornia*org o poni ndose en contacto con el colegio de abogados de su condado. NOTICE The restraining orders on page 2 are effective against both spouses or domestic partners until the petition is dismissed a judgment is entered or the court makes further orders. These orders are enforceable anywhere in California by any law enforcement officer who has received or seen a copy of them* AVISO Las rdenes de restricci n que figuran en la p gina 2 valen para ambos c nyuges o pareja de hecho hasta que se despida la petici n se emita un fallo o la corte d otras rdenes. Cualquier autoridad de la ley que haya recibido o visto una copia de estas rdenes puede hacerlas acatar en cualquier lugar de California* NOTE If a judgment or support order is entered the court may order you to pay all or part of the fees and costs that the court waived for yourself or for the other party.

Superintendent letter ets ets... Educational Testing Service CAHSEE Support Center 2731 Systron Dr. Concord, CA 94815 800-241-5687 CAHSEE-Support ets.org FROM: DATE: TO: James Pisano Ph.D, ETS, Project Director June 8, 2011 Select

Fha clause form FHA DISCLOSURES AMENDATORY CLAUSE / REAL ESTATE CERTIFICATION Buyer(s) Seller(s) Property Address : Date of Agreement: File No.: FHA AMENDATORY CLAUSE It is expressly agreed that notwithstanding any

Settlement brief form Clear Print ATTORNEY OR PARTY WITHOUT ATTORNEY Name and Address TELEPHONE NO. FOR COURT USE ONLY ATTORNEY FOR Name SUPERIOR COURT OF CALIFORNIA COUNTY OF SAN BERNARDINO STREET ADDRESS MAILING ADDRESS CITY AND ZIP CODE BRANCH NAME PETITIONER/PLAINTIFF RESPONDENT/DEFENDANT CASE NUMBER MANDATORY SETTLEMENT CONFERENCE BRIEF Date of Hearing Time Dept/Rm Judge NOTE THE WORD HUSBAND MEANS FATHER AND THE WORD WIFE MEANS MOTHER IN CASES WHERE THE PARTIES ARE NOT MARRIED. I. STATISTICAL DATA A. Date of Marriage B. Date of Separation C. Date Jurisdiction Acquired D. Length of Marriage E* Marital Status Terminated F* Husband s Age Yes No If so date and Employment G* Husband s Net Monthly Income H. Wife s Age I. Wife s Net Monthly Income J* Minor Children NAME DATE OF BIRTH AGE SEX RESIDING WITH K. Child Care Costs Per Month -1ACIS Code 37154 01 13-18598-356 SB-598 II. INCOME AND EXPENSE California Rule 243 The latest Income and Expense Declaration form No* 1285. 50 filed by Husband is dated If a party s Income and Expense Declaration is over six months old or if there have been significant changes since the filing of the last Income and Expense Declaration a new declaration must be prepared and filed with this statement. III. The parties agree on the following issues Check applicable items. Custody of Children Visitation Rights Child Support or Spousal Support Restraining Orders Division of Property Division of Debts Other IV. EXISTING ORDERS Briefly summarize date and nature of each existing order concerning any issue that is not agreed to V. DISPUTED ISSUES AND HUSBAND S/WIFE S PROPOSALS RE ISSUES If more space is needed please attach additional sheet s of paper. VI. ATTACHMENTS AND EXHIBITS A. Where issues include division of assets counsel or party shall attach relevant schedules of proposed division* Or if property declaration Forms 1285. 56 have been filed attach copies. B. If a party requests reimbursements for community debts paid from separate funds Smith/Epstein attach a schedule and canceled checks receipts or other supporting materials. attach a schedule and canceled checks or receipts or other supporting materials. D. Other appropriate attachments may be included to set forth the contentions of a party to provide the relevant information and pro thereto and to promote settlement. VII. STIPULATIONS In the event a trial is required Husband/Wife will stipulate to the following facts or legal issues I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I. STATISTICAL DATA A. Date of Marriage B. Date of Separation C. Date Jurisdiction Acquired D. Length of Marriage E* Marital Status Terminated F* Husband s Age Yes No If so date and Employment G* Husband s Net Monthly Income H. Wife s Age I. Wife s Net Monthly Income J* Minor Children NAME DATE OF BIRTH AGE SEX RESIDING WITH K. Wife s Age I. Wife s Net Monthly Income J* Minor Children NAME DATE OF BIRTH AGE SEX RESIDING WITH K. Child Care Costs Per Month -1ACIS Code 37154 01 13-18598-356 SB-598 II. INCOME AND EXPENSE California Rule 243 The latest Income and Expense Declaration form No* 1285.

Biopreferred brand guidelines... www.biopreferred.gov United States Department of Agriculture Brand guidelines and graphic standards for the usda biopreferred program The Voluntary Labeling, Biobased Product Certification and Federal

Hacienda fillable forms 2010 Hacienda.gobierno. pr/patronos. Therefore if you file such forms using magnetic media they will be considered as not filed. If you filed the W-2 Forms using magnetic media CD and you are required to file a W-2c you must file this form through our website you must file this form through our website i FILING REMINDERS Make sure each data file submitted is complete. CODE SU THROUGH CODE RF RECORDS ARE ALL REQUIRED. For an example of the file layout see Appendix E page 38. We require that each record have a record delimiters CR - Carriage Return followed by LF - Line Feed at end of the record and placed immediately following character position 512. Government of Puerto Rico Department of the Treasury PUBLICATION 10-02 FORM 499R-2c/W-2cPR ELECTRONIC FILING REQUIREMENTS FOR TAX YEAR 2010 Analysis and Programming Division November 2010 EFW2CPR WHAT S NEW The Department of the Treasury Department has established that the W-2c filing will only be accepted through electronic transfer at the Hacienda s website www. hacienda.gobierno. pr/patronos. Therefore if you file such forms using magnetic media they will be considered as not filed. If you filed the W-2 Forms using magnetic media CD and you are required to file a W-2c you must file this form through our website you must file this form through our website i FILING REMINDERS Make sure each data file submitted is complete. CODE SU THROUGH CODE RF RECORDS ARE ALL REQUIRED. For an example of the file layout see Appendix E page 38. Government of Puerto Rico Department of the Treasury PUBLICATION 10-02 FORM 499R-2c/W-2cPR ELECTRONIC FILING REQUIREMENTS FOR TAX YEAR 2010 Analysis and Programming Division November 2010 EFW2CPR WHAT S NEW The Department of the Treasury Department has established that the W-2c filing will only be accepted through electronic transfer at the Hacienda s website www. CODE SU THROUGH CODE RF RECORDS ARE ALL REQUIRED. For an example of the file layout see Appendix E page 38. We require that each record have a record delimiters CR - Carriage Return followed by LF - Line Feed at end of the record and placed immediately following character position 512. All records included in the Electronic Filing must be for the SAME TAX YEAR* We are only accepting one employer per file EFW2C. TXT PDF OR W-2c FORMS* You must request authorization from the Forms and Publications Division to reproduce substitute forms of W-2c* Data filed through magnetic media will not be processed* Therefore the forms will be considered as not filed with the Department. ii AVOID COMMON MISTAKES Be sure to enter the Tax Year being Corrected in the Code SU record Submitter Record location 3-6. Remember to enter in the Code E0 record Employee Wage Record location 320-328 the Control Number assigned by the Department of the Treasury for the W-2c* This number is not the same as the Control Number of the W-2 that is being corrected* location 329-337 the Original Control Number assigned by the All money fields must be numeric* No decimal punctuation or high and low order signs are allowed in these fields.

Oir b1 1571 2004 2019 form 736 4 b Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim. OIR-B1-1571 Pub. OFFICE OF INSURANCE REGULATION Bureau of Property Casualty Forms and Rates Standard Disclosure and Acknowledgement Form Personal Injury Protection - Initial Treatment or Service Provided The undersigned insured person or guardian of such person affirms 1. The services or treatment set forth below were actually rendered* This means that those services have already been provided* I have the right and the duty to confirm that the services have already been provided* I was not solicited by any person to seek any services from the medical provider of the services described above. The medical provider has explained the services to me for which payment is being claimed* 5. If I notify the insurer in writing of a billing error I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled my share would be at least 20 of the amount of the reduction up to 500. Insured Person patient receiving treatment or services or Guardian of Insured Person Name PRINT or TYPE Signature Date and also A. I have not solicited or caused the insured person who was involved in a motor vehicle accident to be solicited to make a claim for Personal Injury Protection benefits. B. The treatment or services rendered were explained to the insured person or his or her guardian sufficiently for that person to sign this form with informed consent. C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein* This means that each request for information has been responded to truthfully accurately and in a substantially complete manner. D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded unbundled or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627. 732 15 and 16 Florida Statutes or Section 627. 736 5 b 6 Florida Statutes. Licensed Medical Professional Rendering Treatment/Services or Medical Director if applicable Signature by his/ her own hand Any person who knowingly and with intent to injure defraud or deceive any insurer files a statement of Claim or an application containing any false incomplete or misleading information is guilty of a felony of the third degree per Section 817. 234 1 b Florida Statutes. Note The original of this form must be furnished to the insurer pursuant to Section 627. OFFICE OF INSURANCE REGULATION Bureau of Property Casualty Forms and Rates Standard Disclosure and Acknowledgement Form Personal Injury Protection - Initial Treatment or Service Provided The undersigned insured person or guardian of such person affirms 1. The services or treatment set forth below were actually rendered* This means that those services have already been provided* I have the right and the duty to confirm that the services have already been provided* I was not solicited by any person to seek any services from the medical provider of the services described above.

York childrens foundation form York Children's Foundation Guidelines for Submitting Grant Applications The York Children's Foundation was established in 1992 to disburse funds to non-profit organizations that work for the benefit

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