Professional legal forms

Bank of america forms 3rd part... Short Sale Third-Party Authorization Form BORROWER(S) ACKNOWLEDGMENT Loan Number: Borrower: Property Address: Address City State ZIP Co-Borrower: The undersigned Borrower and Co-Borrower (if any)

Healthfirst eft and era author... EFT/ERA Authorization Form Rev. 11/17/06 Type of Transaction (please choose) Add ERA and EFT Change ERA Change EFT Terminate ERA and EFT Physician Group Notes: You need only fill out one EFT/ERA Authorization

Authorization school form CALIFORNIA DEPARTMENT OF JUSTICE Application for Authorization Pursuant to Education Code 33192 33195. 3 and 45125. 1 School Contractors BUREAU OF CRIMINAL INFORMATION AND ANALYSIS Mail Completed application to Department of Justice Applicant Information and Certification Program P. 3 and 45125. 1 School Contractors BUREAU OF CRIMINAL INFORMATION AND ANALYSIS Mail Completed application to Department of Justice Applicant Information and Certification Program P. O. Box 903387 Sacramento CA 94203-3870 TABLE OF CONTENTS Authorization for Criminal History Information.. Services provided under contract must be performed on school grounds 3. The entity must have a contract entities in the bid process are not authorized 4. Completed applications for authorization must have original signatures only no photocopied signatures or faxed forms will be accepted or processed CONSTRUCTION CONTRACTORS 33193 33195. PAGE 18 Utilized ONLY AFTER receiving DOJ authorization confirmation. PAGE 19 CORI Policy Employee Statement. PAGE 20 Contract for Subsequent Arrest Notification Service BCII 8049 No Longer Interested Notification. PAGE 22 In accordance with California Education Code Sections 33192 33195. 3 and 45125. 1 a school district heritage school or private school may require an entity that has an existing contract with a district/heritiage/private school to obtain a criminal history clearance. We sincerely hope that this information will be useful and will answer your questions about the electronic processing of fingerprints in California. DEPARTMENT OF JUSTICE REQUEST FOR AUTHORIZATION TO RECEIVE STATE SUMMARY CRIMINAL HISTORY INFORMATION - CONTRACT EMPLOYEE FOR PUBLIC/HERITAGE PRIVATE SCHOOLS Name of Contractor Mailing Address City State Zip Code Phone Number Facsimile Number entity that has an existing contract with a school district to obtain a criminal history clearance. CALIFORNIA DEPARTMENT OF JUSTICE Application for Authorization Pursuant to Education Code 33192 33195. 3 and 45125. 1 School Contractors BUREAU OF CRIMINAL INFORMATION AND ANALYSIS Mail Completed application to Department of Justice Applicant Information and Certification Program P. O. Box 903387 Sacramento CA 94203-3870 TABLE OF CONTENTS Authorization for Criminal History Information*. PAGE 1 Applicant Live Scan Overview. PAGE 3 Request for Contributing Agency ORI and/or Response Mail Code BCII 9001 REQUIRED. PAGE 6 Guidelines for Completing Request for Contributing Agency ORI and/or Response Mail Code BCII 9001. PAGE 7 Notification of ORI Mail Code and/or Billing Number Assignment REQUIRED. PAGE 8 Billing Account Application BCII 9000 REQUIRED - Only if your agency will be billed for services. PAGE 11 Applicant Fingerprint Response Subscriber Agreement REQUIRED - Please return Page 14 and 15 with this application. PAGE 12 Criminal Offender Record Information CORI Policy REQUIRED - Head of Contributing Agency/Organization. PAGE 16 CORI Policy REQUIRED - Custodian of Records. PAGE 17 Custodian of Records Application Form BCIA 8374 REQUIRED.

Ach credit authorization form Credit/Debit Authorization Form I (we) hereby authorize City of Tybee Island to initiate entries to my (our) checking/savings account at the financial institution listed below, and, if necessary,

Authorization form to release... Annapolis Baltimore Easton Frederick Owings Mills Salisbury Towson Waldorf 929 West St., Annapolis, MD 21401 330 N. Howard Street, Baltimore, MD 21201 8579 Commerce Drive #102, Easton, MD 21601 170

Authorization to return to can... Please complete this form if you are inadmissible to Canada because you were the subject of a removal order or have been told by Canadian immigration you require an ARC to re-enter Canada. Print Form

Aetna pre cert form AETNA BETTER HEALTH Pharmacy prior authorization form Patient Information Patient Name Member ID# Sex (circle) M DOB Home Phone: F Prescriber Name NPI#(required) Office Address City, State, Zip Code

Prior request form Indiana Health Coverage Programs Prior Authorization Request Form Traditional Hoosier Healthwise Check the box of the plan in which the member is enrolled. Healthy Indiana Plan Care Select Advantage Traditional Anthem Hoosier Healthwise Anthem HHW SFHN MDwise Hoosier Healthwise MHS Hoosier Healthwise Anthem HIP MDwise HIP MHS HIP Advantage Care Select MDwise Care Select P 800-269-5720 F 800-689-2759 P 866-408-7187 F 866-406-2803 P 800-291-4140 F 800-747-3693 See www. mdwise. org P 877-647-4848 F 866-912-4245 P 866-398-1922 F 866-406-2803 P 800-784-3981 F 800-689-2759 P 866-440-2449 F 877-822-7186 Please complete all appropriate fields. Patient Information Requesting Provider Information Medicaid ID/RID NPI DOB Tax ID Patient Name Service Location Code Address Provider Name City/State/Zip Rendering Provider Information Patient/Guardian Phone Ordering Physician NPI PMP Name PMP NPI Name PMP Phone Medical Diagnosis Use of ICD-9 Diagnostic Code is Required Dx1 Dx2 Dx3 Phone Fax Please check the requested assignment category below DME Purchased Rented Home Health Hospice Dates of Service Start Stop Inpatient Physical Therapy Observation Speech Therapy Office Visit Transportation Occupational Therapy Other Outpatient Procedure/ Service Codes Modifier s Requested Service Preparer s Information Taxonomy POS Units Dollars Notes PLEASE NOTE Your request MUST include medical documentation to be reviewed for medical necessity. mdwise. org P 877-647-4848 F 866-912-4245 P 866-398-1922 F 866-406-2803 P 800-784-3981 F 800-689-2759 P 866-440-2449 F 877-822-7186 Please complete all appropriate fields. Patient Information Requesting Provider Information Medicaid ID/RID NPI DOB Tax ID Patient Name Service Location Code Address Provider Name City/State/Zip Rendering Provider Information Patient/Guardian Phone Ordering Physician NPI PMP Name PMP NPI Name PMP Phone Medical Diagnosis Use of ICD-9 Diagnostic Code is Required Dx1 Dx2 Dx3 Phone Fax Please check the requested assignment category below DME Purchased Rented Home Health Hospice Dates of Service Start Stop Inpatient Physical Therapy Observation Speech Therapy Office Visit Transportation Occupational Therapy Other Outpatient Procedure/ Service Codes Modifier s Requested Service Preparer s Information Taxonomy POS Units Dollars Notes PLEASE NOTE Your request MUST include medical documentation to be reviewed for medical necessity.

Pharmacy authorization form Pharmacy Prior Authorization Form INSTRUCTIONS Complete this form in its entirety. Any incomplete sections will result in a delay in processing. We review requests for prior authorization based on medical necessity only. We will notify the provider and the member s pharmacy of our decision. To help us expedite your authorization requests please fax all the information required on this form to 1 800 359 5781. Allow us at least 24 hours to review this request. If you have questions regarding the prior authorization request call us at 1 800 454 3730. If we approve the request payment is still subject to all general conditions of Amerigroup including current member eligibility other insurance and program restrictions. We will notify the provider and the member s pharmacy of our decision. To help us expedite your authorization requests please fax all the information required on this form to 1 800 359 5781. Allow us at least 24 hours to review this request. If you have questions regarding the prior authorization request call us at 1 800 454 3730. The pharmacy is authorized to dispense up to a 72 hour supply while awaiting the outcome of this request. Please contact the member s pharmacy. Access our website at providers. amerigroup.com to view the preferred drug list. If we approve the request payment is still subject to all general conditions of Amerigroup including current member eligibility other insurance and program restrictions. Allow us at least 24 hours to review this request. If you have questions regarding the prior authorization request call us at 1 800 454 3730. The pharmacy is authorized to dispense up to a 72 hour supply while awaiting the outcome of this request. Please contact the member s pharmacy. Access our website at providers. amerigroup*com to view the preferred drug list. An ICD/Diagnosis code is required for all requests. An HCPCS billing code is required for all medical injectable/oncology requests. If the billing facility is different from the requesting physician the billing facility information will need to be completed* Member Information Last name First name MI Member s place of residence Home Nursing Facility Administration site Office Outpatient facility Amerigroup ID Height Date Of Birth Sex circle one F M Medication Information Drug name and strength requested SIG dose frequency and duration HCPCS billing code Diagnosis and/or indication ICD code Has the member tried other medications Drug s name and strength to treat this condition Date range of use SIG dose and frequency Yes. Provide this information in the area to the right. You may be asked to provide Did the member experience any of the below supporting documentation such as Adverse reaction Inadequate response Other Copies of medical records Briefly describe details of adverse reaction inadequate Office notes response or other in the space provided below. Complete FDA Medwatch form No* Explain why not PF ALL 0037 12 June 2012 Describe medical necessity for nonpreferred medication s or for prescribing outside of FDA labeling List all current medications including dose and frequency Other pertinent information Diagnostic Studies and/or Laboratory Tests Performed List all tests done within the past 30 days that are related to diagnosis of medication requested* Labs Diagnostic tests Test Date Result Procedure Prescriber Information NPI required City Address where service was rendered ZIP code Telephone number Office contact name DEA/License State Fax number Contact direct phone number Billing Facility Information Name Address NPI /Tax ID required Pharmacy Information Pharmacy NPI Signature I certify that the information provided is accurate and complete to the best of my knowledge and I understand that any falsification omission or concealment of material may be subject to civil or criminal liability.

Medco health medicare part d p... 35045 *35045* Medicare Part D Prior Authorization Request Form (page 1 of 2) Please complete both pages and return to Medco by fax at 1-800-837-0959. Please indicate if you are requesting urgent processing

Humana prior authorization for... PRIOR AUTHORIZATION REQUEST FORM EOC ID Administrative Product - Universalr r rPhone 800-555-2546 Fax back to 1-877-486-2621 HUMANA INC manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician* Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. For Medicare PFFS members prior authorization is not required for Part B-covered medications. The information below is needed for a Part B versus Part D determination for these members. Patient Name NA Prescriber Name NA Member/Subscriber Number Fax Date of Birth Office Contact Group Number NPI Address City State ZIP Phone Tax ID Specialty/facility name if applicable rExpedited/Urgent Please read if expedited request By signing below I certify that applying the standard 72-hour review time frame may seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function* Drug Name Directions/SIG Signature Qty Please attach any pertinent medical history or information for this patient that may support approval* Please answer the following questions and sign Q1. Please provide J-code if applicable Q3. Is the medication being requested for use in an ongoing investigational trial Yes No. r Q5. Please list therapeutic alternatives previously used with start/end dates and outcome Prescriber Signature Date This telecopy transmission contains confidential information belonging to the sender that is legally privileged* This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient you are hereby notified that any disclosure copying distribution or action taken in reference to the contents of this document is strictly prohibited* If you have received this telecopy in error please notify the sender immediately to arrange for the return of this document. Certain requests for coverage require review with the prescribing physician* Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. For Medicare PFFS members prior authorization is not required for Part B-covered medications. Please note any information left blank or illegible may delay the review process. For Medicare PFFS members prior authorization is not required for Part B-covered medications. The information below is needed for a Part B versus Part D determination for these members. Patient Name NA Prescriber Name NA Member/Subscriber Number Fax Date of Birth Office Contact Group Number NPI Address City State ZIP Phone Tax ID Specialty/facility name if applicable rExpedited/Urgent Please read if expedited request By signing below I certify that applying the standard 72-hour review time frame may seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function* Drug Name Directions/SIG Signature Qty Please attach any pertinent medical history or information for this patient that may support approval* Please answer the following questions and sign Q1.

Express scripts prior authoriz... This form is based on Express Scripts standard criteria and may not be applicable to all patients Amida Care may require additional information beyond what is specifically requested. Fax completed form to 1- 800- 357- 9577 If this an URGENT request please call 1- 800- 417- 8164 Prior Authorization Form and Patient Information Prescriber Information Patient First Name Patient La...

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