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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.
Form preview Notice and authorization perta... FEDERAL DEPOSIT INSURANCE CORPORATION. Notice and Authorization. Pertaining to Consumer Reports. Pursuant to the Fair Credit Reporting Act of 1970 ...
Form preview Authorization to disclose pers... Only PrOPerly cOmPleted FOrms will be PrOcessed AuthorizAtion to Disclose PersonAl heAlth informAtion to self Phone: 206-621-4150 Fax: 206-621-4235 1200 - 12th Ave. S., Seattle, WA 98144 Attn: ROI
Form preview Mc 315 authorization 2006 form Approved, SCAO Original - Records custodian 1st copy - Requesting party 2nd copy - Patient STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE Court address CASE NO. AUTHORIZATION
Form preview Ecmc authorization form 898. 3000 ECMC. EDU Health Information Management Department G30 716. 898. 3257/3258 It is understood that any disclosure is bound by 42 CFR Part 2 governing the confidentiality of alcohol and drug abuse patient records and that re disclosure of alcohol and drug abuse information to a party other than the one designated above is forbidden without your additional written authorization. If this authorization involves alcohol and drug abuse patient information it shall expire six 6 months from the date signed unless a different time period event or condition is specified in Section 2 below. AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION PG 1 OF 3 Name Med* Rec* Visit Service Date Date of Birth Insurance Service Time Age Room This form implements the requirements for patient authorization to use and disclose health information protected by the federal health privacy law 45 C. F*R* parts 160 164. Except as otherwise permitted or required by the privacy law a healthcare provider subject to the privacy law may not use or disclose protected health information without an authorization that complies with the requirements of 45 C. F*R* Section 164. 508. Patient/Resident Name Date of Birth Address Phone E Mail address initials Please initial here if you would like your records electronically I hereby authorize the use or disclosure of protected health information as follows 1. The information that may be used or disclosed includes initial applicable line All treatment records. If this is initialed patient must also separately initial the categories below if Behavioral Health records Drug and Alcohol Treatment records and/or HIV related records are to be used or disclosed* Record of treatment during the following time period Behavioral Health/Psychiatric records discharge summary and information below xh Yyzx xh yzx xh y zx If you authorize the release of behavioral health information the disclosing party named above will disclose such information in accordance with Sections 33. 13 and 33. 16 of the Mental Hygiene Law. Drug and Alcohol Treatment records discharge summary and information indicated below ERIE COUNTY MEDICAL CENTER HEALTHCARE NETWORK Rev* 2/13 LGL*100 Erie County Medical Center Corporation 462 Grider Street Buffalo New York 14215 716. NOTE Any information disclosed through this form will be accompanied by Form ALC 440 Prohibition on Redisclosure of Insurance Concerning Alcoholism Patient. HIV Related records discharge summary and information indicated below Due to NYSDOH Chapter 308 of the Laws of 2010 HIV testing Law Mandated August 2010 all patients should be asked to initial this section from redisclosing any HIV related information without your authorization unless permitted to do so under federal or state law. You also have a right to request a list of people who may receive or use your HIV related HIV related information you may contact the New York State Division of Human Rights at 212 480 2493 or 1 800 523 2437 or the New York City Commission on Human Rights at 212 306 7450.
Form preview Authorization work order form WORK ORDER AUTHORIZATION RELIABLE JET MAINTENANCE DATE: W/O: Billing Information: CUSTOMER NAME: ADDRESS: CITY: PHONE # : CELL PH # : LOCAL ADDRESS : STATE : FAX : ZIP CODE : ALL charges are COD unless
Form preview Direct deposit authorization f... Direct Deposit Authorization for Electronic Funds Transfer (EFT) File Maintenance 400 Centennial Office Bldg 658 Cedar Street St Paul, MN 55155 Instructions for completing this form are on the back.
Form preview City of chicago hipaa authoriz... City of Chicago Benefits Management Office Authorization Form For the Use and Disclosure of Protected Health Information Name City Employee Name Social Security Number City Employee Social Security

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