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Form preview Kentucky cremation authorizati... Date Cremation Received Cremation Number Name of person performing cremation COMMONWEALTH OF KENTUCKY OFFICE OF THE ATTORNEY GENERAL PRE-NEED CREMATION AUTHORIZATION FORM CR-3 11-02 NMS INC. CARE CREMATION SERVICE 1014 EASTLAND DRIVE LEXINGTON KY 40505 Phone 859 388-9442 Fax 859 388-9443 In making a pre-need authorization for the cremation of your remains you are the authorizing agent. Please read carefully the items below. In the statement titled Final Disposition you must indicate your desire pertaining to the disposition of your cremated remains. After you have read and completed each item your signature is required on the item titled Signature of Authorizing Agent. IDENTIFICATION Please Print All Information On This Form Name Address City State Zip Home Telephone Age Sex Does the Decedent Authorizing Agent have any infectious or contagious disease YES NO If yes please explain Mechanical or radioactive devices or implants in the Authorizing Agent may create a hazardous condition when placed in a cremation chamber. Page 1 of 4 other device that could be explosive YES NO If any such device s exist the next class of authorizing agent is responsible for disclosing their existence at the time of death. Has the Decedent Authorizing Agent been treated with therapeutic radionuclides such as Strontium 89 or any other treatment that would result in residual radioactive material remaining as part of the Decedent Authorizing Agent s remains YES If yes what was the treatment Date treatment was last administered The Decedent Authorizing Agent shall carefully read and understand the following statements before signing this authorization* The decedent authorizing agent shall complete the segment directing the final disposition of his/her cremated remains. CARE CREMATION SERVICE will not conduct any cremation nor accept a body for cremation unless it has a cremation authorization form signed by the Decedent Authorizing Agent clearly stating the final disposition* All cremations are performed individually. It is unlawful to cremate the remains of more than one individual within the same cremation chamber at the same time. The consumer may choose cremation without choosing embalming services. However if the crematory does not have a refrigerated holding facility it cannot accept human remains for anything other than immediate cremation* The consumer is not required to purchase a casket for the purpose of cremation* a casket or an alternative cremation container for cremation* If an alternative container is provided it must meet the following standards 1 be composed of readily combustible materials suitable for cremation 2 be able to be closed to provide a complete covering for the human remains 3 be resistant to leakage or spillage and 4 be rigid enough to support the weight of the deceased* including opening if necessary and in the event there is leakage or damage SERVICE may refuse to accept the Decedent Authorizing Agent s remains for the purpose of cremation or refrigeration* Type of casket or alternative container selected Due to the nature of the cremation process any personal possessions or valuable materials such as dental gold or jewelry as well as any body prostheses or dental bridgework that are left with the Decedent Authorizing Agent and not removed from the casket or alternative container prior to cremation will be destroyed or will otherwise not be recoverable.
Form preview Tennessee form hipaa release TENNESSEE DEPARTMENT OF HUMAN SERVICES HIPAA AUTHORIZATION FOR RELEASE OF MEDICAL/HEALTH INFORMATION TO 3RD PARTY Information will be released for PRINT NAME Date Street Address Identify Signer Self Parent of minor Guardian Other authorized representative explain Proof of legal authorization may be required. Parent/guardian sign here if two signatures required by State law Phone Number with area code City State Zip I give permission for the following medical/health records about me to be released by the Tennessee Department of Human Services TDHS and its authorized agents/contractors to the persons/organizations and for the purposes described below Specific Description of medical/health information to be provided Additional approval required for certain records TDHS can also release drug or alcohol treatment/referral records Yes No TDHS can release my medical/health information to the following persons/organizations My medical/health records will be used for the following purposes For the medical/health records I have given permission to be disclosed TDHS can talk to or give copies of my medical/health records to any of the person/organizations I have permitted and can give this information by paper fax computer or electronic copies of those records. YOU DO NOT HAVE TO SIGN THIS FORM. I understand that my eligibility for benefits or services from the Tennessee Department of Human Services will not be affected if I do not sign this form. I will get a copy of this form after I sign it. I can ask TDHS to let me see a copy of the information it sends after I sign this form. This permission is good for 12 months from the date I sign this form unless I take back my permission sooner. TENNESSEE DEPARTMENT OF HUMAN SERVICES HIPAA AUTHORIZATION FOR RELEASE OF MEDICAL/HEALTH INFORMATION TO 3RD PARTY Information will be released for PRINT NAME Date Street Address Identify Signer Self Parent of minor Guardian Other authorized representative explain Proof of legal authorization may be required* Parent/guardian sign here if two signatures required by State law Phone Number with area code City State Zip I give permission for the following medical/health records about me to be released by the Tennessee Department of Human Services TDHS and its authorized agents/contractors to the persons/organizations and for the purposes described below Specific Description of medical/health information to be provided Additional approval required for certain records TDHS can also release drug or alcohol treatment/referral records Yes No TDHS can release my medical/health information to the following persons/organizations My medical/health records will be used for the following purposes For the medical/health records I have given permission to be disclosed TDHS can talk to or give copies of my medical/health records to any of the person/organizations I have permitted and can give this information by paper fax computer or electronic copies of those records. YOU DO NOT HAVE TO SIGN THIS FORM. I understand that my eligibility for benefits or services from the Tennessee Department of Human Services will not be affected if I do not sign this form* I will get a copy of this form after I sign it.
Form preview Envision rx prior authorizatio... PRIOR AUTHORIZATION REQUEST FORM EOC ID: EnvisionRxOptions General Prior Auth Formr rPhone: 855-872-0005 Fax back to: 877-503-7231 r r ENVISION RX OPTIONS manages the pharmacy drug benefit for your
Form preview Vendor ach payment authorizati... THE SENIOR ALLIANCE Vendor ACH Authorization Form SECTION I Vendor Information Company Name: Address: State: Zip: Accounts Receivable Contact: Phone: E-Mail: SECTION II Authorization Agreement I (we)
Form preview Instructions for form f 11075... DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11075 (10/11) STATE OF WISCONSIN DHS 107.10(2), Wis. Admin. Code FORWARDHEALTH PRIOR AUTHORIZATION / PREFERRED DRUG
Form preview Pa medical command authorizati... MEDICAL COMMAND AUTHORIZATION FORM ALS Service Affiliate # Last Name (ALS Practitioner) Street Address City E-mail Address Check One: EMT-Paramedic PHRN HP Physician Other Calendar Year First MI State
Form preview Credit card authorization form... Credit Card Authorization Form Dear Sir/Madam This form has been created in order to allow you to have third party expenses charged to your credit/debit card. Departure date cannot be extended unless a new authorization form is completed. Printed Guest signature Date Rate Information and Approved Charges - Required Room rate Number of nights All Charges Room Tax Telephone LD Telephone Local Restaurant Room Service Valet Laundry Parking HS Internet Access Movies I certify that all information is complete and accurate. I hereby authorize RENAISSANCE DOHA CITY CENTER HOTEL COURTYARD BY MARRIOTT DOHA CITY CENTER and MARRIOTT EXECUTIVE APARTMENTS DOHA CITY CENTER to collect payment for all charges as indicated in the Rate Information and Approved Charges section of this form by processing a charge to the credit/debit card listed for the entire stay/event. 44195600. Cardholder Information - Required Name as it appears on the credit/debit card Card type Visa Account type Individual personal credit card Corporate MC Amex Diners/CB Discover JCB Company Name Account number Exp. date Address where statement is mailed City State and Zip P hone number F ax or al ternate number Guest Information - Required Guest name Company Confirmation number A rri val date D eparture date Relation to cardholder Relative Friend Business Associate Other I understand that should there be any issues with the credit/debit card being used to settle my charges I will be responsible for all expenses incurred during my stay. Departure date cannot be extended unless a new authorization form is completed. Printed Guest signature Date Rate Information and Approved Charges - Required Room rate Number of nights All Charges Room Tax Telephone LD Telephone Local Restaurant Room Service Valet Laundry Parking HS Internet Access Movies I certify that all information is complete and accurate. Please provide all the information requested below to ensure prompt processing of your application* We ask you to please sign and date the form before submission* Please fax the completed form to RENAISSANCE DOHA CITY CENTER HOTEL COURTYARD BY MARRIOTT DOHA CITY CENTER and MARRIOTT EXECUTIVE APARTMENTS DOHA CITY CENTER at 00974. 44195600. Cardholder Information - Required Name as it appears on the credit/debit card Card type Visa Account type Individual personal credit card Corporate MC Amex Diners/CB Discover JCB Company Name Account number Exp* date Address where statement is mailed City State and Zip P hone number F ax or al ternate number Guest Information - Required Guest name Company Confirmation number A rri val date D eparture date Relation to cardholder Relative Friend Business Associate Other I understand that should there be any issues with the credit/debit card being used to settle my charges I will be responsible for all expenses incurred during my stay. Departure date cannot be extended unless a new authorization form is completed* Printed Guest signature Date Rate Information and Approved Charges - Required Room rate Number of nights All Charges Room Tax Telephone LD Telephone Local Restaurant Room Service Valet Laundry Parking HS Internet Access Movies I certify that all information is complete and accurate.
Form preview Slotastix authorization form CREDIT CARD AUTHORIZATION FORM Please fill out and sign and send this form alongside copies of the following documents to support slotastic.com 1) Copy of your valid Driver License or Passport 2)
Form preview 3rd party authorization form THIRD PARTY AUTHORIZATION SunTrust Mortgage Loan Number 10 digits I/We Borrower and Co-Borrower if applicable hereby authorize SunTrust Mortgage Inc. to release any and all information about my Loan to the third party indicated below. Date Requested Full Name of Authorized Third Party s Relationship to Borrower Borrower Name Borrower Social Security Number last 4 digits Co-Borrower Name Property Street Address City State Zip Code Borrower Signature Co-Borrower Signature Print Name When you have completed and signed this Authorization please return it to the following address or you may fax the Authorization to 804. I/We understand that information released by SunTrust Mortgage may include but may not be limited to information relating to my loan amount and payment transactions history and/or the provision of copies of my loan documents which may contain non-public information relating to me and the Co-Borrower. I/We acknowledge that should I and/or Co-Borrower if applicable wish to terminate this authorization I or CoBorrower must call SunTrust Mortgage at 800. 443. 1032 option 3 Monday through Friday 8 AM to 10 PM ET and submit the request in writing to the address below. 675. 7399. Attention Support Services 1001 Semmes Avenue RVW 3054 Richmond Virginia 23224 Please allow 5 business days from SunTrust s receipt for authorization or termination to be processed*. I/We understand that information released by SunTrust Mortgage may include but may not be limited to information relating to my loan amount and payment transactions history and/or the provision of copies of my loan documents which may contain non-public information relating to me and the Co-Borrower. I/We acknowledge that should I and/or Co-Borrower if applicable wish to terminate this authorization I or CoBorrower must call SunTrust Mortgage at 800. I/We acknowledge that should I and/or Co-Borrower if applicable wish to terminate this authorization I or CoBorrower must call SunTrust Mortgage at 800. 443. 1032 option 3 Monday through Friday 8 AM to 10 PM ET and submit the request in writing to the address below. I/We understand that information released by SunTrust Mortgage may include but may not be limited to information relating to my loan amount and payment transactions history and/or the provision of copies of my loan documents which may contain non-public information relating to me and the Co-Borrower. I/We acknowledge that should I and/or Co-Borrower if applicable wish to terminate this authorization I or CoBorrower must call SunTrust Mortgage at 800. 443. 1032 option 3 Monday through Friday 8 AM to 10 PM ET and submit the request in writing to the address below.
Form preview Mpiphp authorization for relea... P.O. Box 1999 ... authorization form will apply to any and all information held by the MPI Pension ... Plans, including, but not limited to: Social Security numbers, addresses, ... (For example: At
Form preview Authorization for release of p... HCA PHYSICIAN SERVICES OGDEN INTERNAL MEDICINE AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) Section A: Will the Protected Health Information (PHI) be created or used for research
Form preview Medical management authorizati... Indiana University Health Medical Management Authorization Request Form Forward completed form via FAX to IUHMM at 317 962-6219 or 317 962-4005 Please complete all fields for review REQUESTING PHYSICIAN INFORMATION REQUESTING VENDOR INFORMATION Ordering MD Vendor TAX ID Address Phone Fax Contact MEMBER INFORMATION IUHMM USE ONLY Name ID DOB // SS // Date of Service CPT or HCPC Code Requested Service AUTHORIZATION NUMBER Services APPROVED As Requested Request MODIFIED see below for detail Request DENIED Letter To Follow Modifications Made IUHMM Staff Place of Service INP OP OBS Units Diagnosis / ICD9 Code CLINICAL SUMMARY Form will be rejected if CLINICAL SUMMARY is NOT completed.

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