President s Message...
|
|
|
- Rafe Elliott
- 5 years ago
- Views:
Transcription
1 May 2016, Volume 10 LAWMAN MONTEREY COUNTY PEACE OFFICERS ASSOCIATION President s Message... I would like to thank all the members of the Association for their support. This is my last presidents message for the year. Well, we have had a great year for the Monterey County Peace Officers Association. All we can go from here is up. We have a great team coming in for the new year and new board with some familiar faces. I would like to welcome my successor to the presidency Matt Atchley, Associate Warden from California Department of Corrections and Rehabilitation. We do have some great events coming up. On June 1 st we are helping the Monterey Elks in support of them putting on their 1 st Public Safety Appreciation Night. We will be honoring Seaside and Salinas PD Officer s for their great work and Valor. Then make sure to put on your calendars October 21 for our 46 th Annual Golf Tournament. I would, again, like to thank everyone for being a supporter of law enforcement and our organization. Thank you, Brandon Casarez INSIDE THIS ISSUE President s Message... 1 Membership Dues Increase Info... 2 Employee of the Year Press Release. 3 Range Schedules... 4 SPD Job Announcement... 5 Save the Date... 6 Job Opportunities & CalStar Info... 6 MCPOA Sponsors Membership Application... 9 CalStar Application Save The Date!!! Oct. 21, th Annual MCPOA Golf Tournament More details to come Board of Directors President - Brandon Casarez casarezbt@co.monterey.ca.us Vice President - Dan Mitchell deputydanmitchell@yahoo.com Secretary - Fred Garcia Hackgolf61@aol.com Treasurer - Darren Chamberlain Darren.Chamberlain@cdcr.ca.gov Past President - Fred Garcia Hackgolf61@aol.com Legal Advisor - Dean Flippo flippodd@co.monterey.ca.us Board Members: Bob Nolan - bnolan@ci.marina.ca.us Michael Kimball - michaelckimball@gmail.com Salvatore Ruccello - 33ideal63@gmail.com Matthew Atchley - matthew.atchley@cdcr.ca.gov Paul Charupoom - pcharupoom@ci.greenfield.ca.us Range Master & Board Mbr - John Carr - ltjohncarr@aol.com Webmaster - Ed Harriger - harriger@mbay.net Executive Director - Joy Junsay - joyjunsay@comcast.net Page - 1 -
2 MEMBERSHIP DUES TO INCREASE EFFECTIVE JULY 1, 2016 Individual Memberships (Regular or Associate Membership) $25/person per year Police Officer Associations (Regular or Associate Membership) Paid as a Group by the Association $20/person per year New Members must complete an application and submit with payment to: MCPOA PO BOX 1823 MONTEREY CA Current Members must complete and submit a MCPOA Membership application if there are any changes in status (Active/Retired, Agency, Job Title, Mailing or address, or Phone number); who have Retired since first joining MCPOA, and provide copy of proof of honorable retirement by mailing or ing Retired I.D. card For inquiries, contact Executive Director Joy Junsay or joyjunsay@comcast.net Application is included in newsletter or go to Page - 2 -
3 Page - 3 -
4 Page - 4 -
5 Page - 5 -
6 Job Opportunities Pacific Grove P.D. Lateral Entry (Ongoing) Please visit for more information. Incomplete applications or those which do not meet stated criteria will not be considered. Page - 6 -
7 Advertise your business in the Lawman! The Lawman Newsletter is a great medium to advertise your products and/or services. Our newsletter is published once a month (12 issues per year). It is posted on the MCPOA website and ed or mailed to over 600 members. If you or someone you know would like to advertise in the Lawman newsletter, please contact Joy Junsay at joyjunsay@comcast.net. LAWMAN NEWSLETTER 2016 Advertising Prices 6 Months 12 Months Business Card (2 x 3.5 )* $ $ Quarter Page (4.5 x 5.5 )* Half Page (8.5 x 5.5 )* Advertisement print must be camera ready and mailed with your payment to: MCPOA, P.O. Box 1823, Monterey, CA *Sizes are approximate Our Advertising Supporters PAUL KEENE INVESTIGATIONS Retired Monterey Co. DA Investigator MCPOA Life Member CIVIL/CRIMINAL INVESTIGATIONS LOCATES SURVEILLANCE BACKGROUNDS P.O. BOX MONTEREY, CA FAX Page - 7 -
8 Page - 8 -
9 MEMBERSHIP APPLICATION/RENEWAL (July 1 to June 30 each year) Monterey County Peace Officers Association PO Box 1823, Monterey CA OFFICE USE ONLY RECEIVED: ENTERED: CARD MAILED: Name: Address, City, Zip: Phone (Office, Home or Cell): Monterey County Agency Affiliation: Position/Job Title: Membership Renewal New Membership STATUS: TYPE OF MEMBERSHIP: Active Retired Regular Member Associate Member Annual Membership Fee: $20 CALSTAR (Air Ambulance): $37 [Complete CalStar Application & submit with MCPOA Membership Application] Donation: $10 $30 Other PAYMENT BY CHECK/MONEY ORDER/ CREDIT CARD TOTAL PAYMENT ENCLOSED: $ Donations most welcome to help defray the costs associated with the newsletter and administration expenses. MCPOA is a registered 501C(4). CREDIT CARD (VISA / MASTERCARD) NO.: Expiration Date: 3-Digit Security Code: Billing/Mailing Address (if different from above): Signature of Authorized Credit Card Holder Date LAWMAN NEWSLETTER PREFERENCE US MAIL NOTE: Information provided within your application is not shared or distributed all remains Confidential and is only for use by MCPOA. Revised 2012September Page - 9 -
10 APPLICATION GROUP NAME: MONTEREY COUNTY PEACE OFFICERS ASSOCIATION GROUP MEMBERSHIP: $37.00 PER INDIVIDUAL/FAMILY Name: DOB: Spouse/Partner DOB: Mailing Address: City: State: Zip Code: Home #: Eligible Family Members:** (You may list additional family members on a separate sheet.) Name: Relationship: Birthdate: BEFORE YOU PURCHASE: If you are currently enrolled in a health maintenance organization (HMO) or other health insurance, the benefits provided by an Ambulance Plan may duplicate the benefits provided by your HMO or other health insurance. If you have a question regarding whether your HMO or other health insurance offers benefits for ambulance services, you should contact that other company directly. WARNING! CALSTAR s Membership Program is not an insurance program. It will not compensate or reimburse another ambulance company that provides emergency transportation to you or your family. This may occur when the 911 Emergency System has independently determined that another could provide more expeditious service or is next in the rotation to receive a call. This might also occur when CALSTAR is unable to perform within a medically appropriate timeframe due to severe weather, a maintenance issue or being committed to another call. For complaints regarding CALSTAR s Membership Program, first attempt to call the plan at LIFE (5433). If CALSTAR fails to resolve the complaint to your satisfaction, contact the Department of Managed Health Care at The Department s Website is: You may obtain complaint forms and instructions online. CALSTAR is operating pursuant to an exemption from the Knox-Keene Health Care Service Plan Act of 1975 (Health and Safety Code Section 1340 et seq.). INITIAL HERE: CALSTAR is an emergency service, activated under county protocols, by an emergency 911 response service or physician s prescription only. CALSTAR membership is secondary to all other insurance carriers. I transfer directly to CALSTAR my rights to air medical insurance payments due me. Such payments shall not exceed CALSTAR s regular charges, and will be accepted as payment in full for air medical services provided by CALSTAR. New member benefits take effect 14 days after receipt of completed enrollment with payment. There is no waiting period for membership renewal. Coverage is only valid for service provided directly by CALSTAR or a reciprocal partner program. Reciprocity between AAMMP member programs is subject to the reciprocating program s rules. CALSTAR membership does not cover ground ambulance charges, including transportation to and from the aircraft. The CALSTAR membership program benefits are for myself, and it I pay the family rate, include my spouse/partner and other eligible family members listed on this form. SIGN HERE: DATE: Payment (Please make checks payable to MCPOA. Do not send cash.) Check Money Order Visa MasterCard American Express Credit Card #: Exp. Date: Name on Credit Card: I hereby authorize my financial institution to make annual recurring payments from the credit card account listed above. I will notify MCPOA if I decide to discontinue this service, or change or close my credit card account. Signature of Cardholder: DATE: Mail to: MCPOA, PO BOX 1823, MONTEREY CA mcpoa.org@hotmail.com or joyjunsay@comcast.net Page
Conditional Cash In Lieu of County Sponsored Health Insurance
Conditional Cash In Lieu of County Sponsored Health Insurance Human Resources Use Only Effective Date: Date of Hire: Amount: Certified by: Medi-Cal Tricare Schools Employer Plan CHIP Medicare Part A Full-Time
GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN (GHC-SCW) INDIVIDUAL APPLICATION FORM
GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN (GHC-SCW) INDIVIDUAL APPLICATION FORM PLEASE COMPLETE THIS APPLICATION This application is a legal document. It is important that you fill it out completely
SPONSORSHIP PACKET NOVEMBER 1, 2018 NEW YORK MARRIOTT MARQUIS. MBE Chair:
NOVEMBER 1, 2018 NEW YORK MARRIOTT MARQUIS MBE Chair: We Turned 45 This Year... Come Celebrate... Join Us! Each year, the New York and New Jersey Minority Supplier Development Council s Partnership Awards
PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC
PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC Your Child: Name Your Child s Full Name: Child Goes By: Gender: Male Female DOB: Age: SS#: Child s Home Address: City: State: Zip: Phone: Primary
PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address
PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH
Pacific Coast Heart Center
Pacific Coast Heart Center Christine M. Theard M.D 33971 Selva Road Ste. 200 (949)495-0800 Office, Dana Point, CA 92629 (949)495-0805 Fax PacificCoastHeartCenter.com Dear patient: These are new patient
Upgrade My Credit Client Agreement
Upgrade My Credit Client Agreement 901 W. Bardin Rd. Suite 306 Arlington, Texas 76017 817-886-0302 off. 817-887-0816 fax www.upgrademycredit.com APPLICANT INFORMATION Mr. Mrs. Ms. PLEASE PRINT CLEARLY
2016 Plan Benefit Letters
TO: FROM: Outreach Partners and Interested Parties Prescription Advantage Date: November 23, 2015 BULLETIN This bulletin is one in a series of routine updates regarding Prescription Advantage. These notices
For Preview Only - Please Do Not Copy
Information about filing fees, filing documents by facsimile transmission and a filing letter to the Secretary of State s office for the certificate of formation for a limited partnership Fax filing &
SUBURBAN UROLOGY ASSOCIATES Please Print
SUBURBAN UROLOGY ASSOCIATES Please Print PATIENT INFORMATION Patient Name: Last First M.I. Address: Street Birth date: Age: City State Zip SS# Sex Marital Status Home Ph. # Cell Ph. # Occupation: Work
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA 98005 Phone 425-301-9869 Fax: 866-546-1618 Welcome to my practice. I look forward to meeting with
SISC PPO 65+ Retiree Medical Coverage Form for Medical and Prescription Drug Benefits (Continuous enrollment in Medicare A&B required)
District Use Only District Name: SISC PPO 65+ Retiree Medical Coverage Form for Medical and Prescription Drug Benefits (Continuous enrollment in Medicare A&B required) SISC will automatically enroll member(s)
DIRECTORS AND OFFICERS including Employment Practices Liability Insurance Application
1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN 46801-2338 1-877-783-1161 Fax 1-260-459-5870 www.kandkinsurance.com CA# 0334819 DIRECTORS AND OFFICERS including Employment Practices Liability Insurance
The agent only pays for the leads received and is able to access them in the EFES Lead Center.
EFES assumes the risk of return rates and provides the agent with a set direct mail lead price of $30 (standard card) per lead. In return we require that the agent pay a deposit equal to three weeks of
PPO/HMO/SELF-PAY PATIENT INFORMATION ACKNOWLEDGMENT FORM PATIENT RIGHTS AND ACKNOWLEDGMENT FORM
PPO/HMO/SELF-PAY Dear New Patient: We know your time is valuable and we strive hard to begin and end our treatment sessions timely. As a new patient we have several forms for you to fill out. If you would
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION DATE Chart # PATIENT NAME AGE DATE OF BIRTH MALE FEMALE PREFFERED LANGUAGE RACE/ETHNICITY SINGLE, MARRIED, DIVORCED, SEPARATED,WIDOWED
FUNDING & REIMBURSEMENT
FUNDING & REIMBURSEMENT Access & manage your reimbursement funds Inside You ll learn how to use your extend health online account. which documents you should save for use. how to submit claims for reimbursement.
SUBURBAN GASTROENTEROLOGY
SUBURBAN GASTROENTEROLOGY DARREN KASTIN, MD 1243 Rickert Dr. Telephone 630-527-6450 Naperville, IL 60540 Fax 630-527-6456 Suburban Gastroenterology, Ltd. would like to welcome you and confirm your appointment.
Patient Welcome Form!
Arthritis and Rheumatology Clinical Center of Northern Virginia, PLLC 8130 Boone Blvd suite 340 Vienna VA 22182 Mahsa Tehrani MD 703-734-2222 Mahnaz Momeni MD Patient Welcome Form Dear new patient, Welcome
California Public Employees Retirement System 888 CalPERS 888 Employer Account Management Division
California Public Employees Retirement System P.O. Box 942709 Sacramento, CA 94229-2709 888 CalPERS (or 888-225-7377) TTY: (877) 249-7442 Fax: (916) 795-4166 www.calpers.ca.gov Employer Account Management
Reinier Van Coevorden, M.D. RVC Medical th Ave NW, suite 204 Issaquah, WA 98027
Reinier Van Coevorden, M.D. RVC Medical 1301 4 th Ave NW, suite 204 Issaquah, WA 98027 Concierge Practice Patient Agreement You have decided to participate in concierge practice with Dr. Van Coevorden
Location of IIT Start date (MONTH) Start date (DAY) Start date (YEAR)
2011 International Intensive Training (IIT) Program Application The Center for Nonviolent Communication 5600 San Francisco Road NE, Suite A Albuquerque, NM 87109 U.S.A. Tel: +1 505 244 4041 (toll free
Send all required documents (including this checklist) to:
Fallon Community Health Plan Fallon Senior Plan Premier HMO Check if Complete To ensure that your applications are processed as quickly as possible, just follow this checklist Employer completes and signs
You are being provided with the background, explanation, and instructions for the Reciprocal Self-Certification Form (PERS-CASD 801).
California Public Employees Retirement System P.O. Box 942709 Sacramento, CA 94229-2709 888 CalPERS (or 888-225-7377) TTY: (877) 249-7442 Fax: (916) 795-4166 www.calpers.ca.gov Employer Account Management
DIRECTORS AND OFFICERS including Employment Practices Liability Insurance Application Rates available through 2/28/19
1712 Magnavox Way P.O. Box 2338 - SCU Fort Wayne, IN 46801-2338 1-877-783-1161 www.kandkinsurance.com DIRECTORS AND OFFICERS including Employment Practices Liability Insurance Application Rates available
Please complete the first page, as well as read, sign, and date the following pages. Please do not hesitate to ask us any questions.
Dear Patient, Please complete the first page, as well as read, sign, and date the following pages. Please do not hesitate to ask us any questions. Thank you, Arsenio Medical, P.C. Arsenio Medical, P.C.
Tufts Health Plan Tufts Medicare Complement (TMC) For Retirees
hsainsurance.com Tufts Health Plan Tufts Medicare Complement (TMC) For Retirees Check if Complete To ensure that your applications are processed as quickly as possible, just follow this checklist Employer
Blue Shield of California Blue Shield of California Life & Health Insurance Company Dental plan, vision plan, and dental + vision package application
Blue Shield of California Blue Shield of California Life & Health Insurance Company Dental plan, vision plan, and dental + vision package application This form is to be used by applicants applying for
Trinity Family Physicians
Trinity Family Physicians Consent and Authorization for Minors By law, a healthcare provider must attempt to contact a birth / custodial parent or legal guardian prior to rendering treatment to a minor
Why you ve received this notice
Human Energy. Yours. TM The enclosed government-required notice applies to retirees and/or their eligible dependents that are currently eligible for Medicare and are currently participating in the Chevron
1804 NW Martin Road ~ Forest Grove, OR ~ Phone: (503) ~~ Fax: (503) or
1804 NW Martin Road ~ Forest Grove, OR ~ 97116 Phone: (503) 648-8551 ~~ Fax: (503) 601-3111 or 503 747-5487 www.oregonroses.com! NET 30 NEW ACCOUNT APPLICATION Please, complete all Forms. Failure to do
HB Dear CalSTRS Member:
California State Teachers Retirement System SR Medicare P.O. Box 15275, MS 47 Sacramento, CA 95851-0275 800-228-5453 CalSTRS.com HB 0985 Dear CalSTRS Member: You may be eligible for CalSTRS to pay your
Arkansas Blue Cross and Blue Shield
Arkansas Blue Cross and Blue Shield November 2005 Inside the November 2005 Issue: Name of Article Page Air and/or Ground Ambulance Claims Filing Procedures 6 Attachments to Claims 8 Bill Types for Facility
BOWLING LEAGUE BEGINS NOVEMBER 18 BASKETBALL LEAGUE BEGINS JANUARY 7 10/17/17
BOWLING LEAGUE BEGINS NOVEMBER 18 BASKETBALL LEAGUE BEGINS JANUARY 7 10/17/17 STAFF INFORMATION Program Information Dan Lancianese Sports Supervisor dlancianese@udsakron.org 330-352-5602 Registration Information/Payment
Welcome To Our Office
Welcome To Our Office Since 1977 The Miami Counseling & Resource Center ( MCRC ) is a large, private Center that has been helping individuals, couples, and families in Miami for over 30 years, and we are
K A R A N J O HA R, M.D.
P: : REGISTRATION FORM - MAJOR MEDICAL Last Name: First and Middle Name: Social Security #: Birthdate: Age: Sex: F M Marital Status: M S D W Home Address: City: State: Zip: *Does the above address, match
Pay over time with low monthly payments. *, ** See Page 10 for details. Step 1 Please follow these guidelines when completing your application:
SM With CareCredit... Start care immediately Pay over time with low monthly payments For yourself and your family Types of Promotional Options Available: No Interest if Paid in Full within 6, 12, 18 or
Action Financial Services, LLC Recurring Payment Authorization Form
Sign and complete this form to authorize Action Financial Services, LLC to make a debit from your account listed below. By signing below, I authorize Action Financial Services, LLC. to charge the account
The Center for ADHD, Inc.
Consent to Evaluate and Treat Date: Patient: Age: Date of Birth Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Work/Cell: Person(s) Responsible for Payment: Address
Experience Choice : OPERS HRA Edition OneExchange Newsletter for Medicare-eligible Retirees
Experience Choice : OPERS HRA Edition OneExchange Newsletter for Medicare-eligible Retirees In This Issue Direct Deposit We Heard You! Step 1: Reimbursement Types & Considerations Step 2: Tips for Submitting
PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP
PATIENT INFORMATION PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP HOME PHONE ( ) WORK PHONE ( ) CELL PHONE ( ) E-MAIL
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very
Please bring your insurance card, photo identification, and corresponding copayment with you when you check in for your appointment for all visits.
DIVISION 22 Silver Spring Office 10313 Georgia Avenue, Suite 202 Silver Spring, MD 20902 Rockville Office 15225 Shady Grove Road, Suite 306 Rockville, MD 20850 Phone:301-681-9101 Fax: 301-681-3525 Dear
2018 Renewing Resident Application. Rye Golf Club 330 Boston Post Road ~ Rye, NY ~ ~
2018 Renewing Resident Application Rye Golf Club 330 Boston Post Road ~ Rye, NY 10580 ~ 914-835-3200 ~ www.ryegolfclub.com RYE GOLF CLUB APPLICATION PROCESS FOR NEW AND RENEWING RESIDENT MEMBERS RESIDENCY
If you do not have access to a fax machine, send the completed application and any additional documents to:
Application Instructions 1. Download and print all pages of the application, including instructions. 2. Complete all questions and sections of the application. Be sure to: Write clearly using a blue or
WELCOME TO SPORTS CONDITIONING AND REHABILITATION
WELCOME TO We are pleased you have chosen, (SCAR) for your physical therapy needs. We know there are many choices and we appreciate your confidence in us. You will find we provide unsurpassed individualized
New Group Checklist. 30 days prior to the effective date, the following Group information is required:
New Group Checklist 30 days prior to the effective date, the following Group information is required: Group Policy Application completed and signed. Enrollment forms; be sure to complete any applicable
California Cardiovascular and Thoracic Surgeons
California Cardiovascular and Thoracic Surgeons 168 North Brent Street, Suite 508 Ventura, CA 93003 Telephone (805) 643-2375 Fax (805) 643-3511 Your assistance in completing the following information thoroughly
LIVE LEARNING All tax practitioners are welcome to attend No credential or membership restrictions.
LIVE LEARNING 2018 All tax practitioners are welcome to attend No credential or membership restrictions. BUSINESS ENTITIES 16 CPE CREDITS TAXATION BASIC LIVE 2 DAYS FOR: CPA, EA, CTEC, CFP, ALL TAX PROS
2019 EBENSBURG COUNTRY CLUB MEMBERSHIP AGREEMENT
2019 EBENSBURG COUNTRY CLUB MEMBERSHIP AGREEMENT This Packet includes the following: 1. Membership Agreement - Must be completed 2. New member contact Information - Must be completed to get discount 3.
or my newly adopted/placed for adoption child(ren): placement date)
Washington Individual Enrollment Application Effective January 1, 2016 This application is for health care coverage purchased directly from Premera Blue Cross (Premera). For timely and proper processing,
HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION
HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION Thank you for choosing our office. In order to serve you properly, we will need the following information. PLEASE PRINT: Name: Date: (Parents/caregivers):
DIABETES & ENDOCRINE CENTER OF ORLANDO, P.A. WELCOME LETTER 3113 LAWTON ROAD, SUITE 100 ORLANDO, FL
DIABETES & ENDOCRINE CENTER OF ORLANDO, P.A. 3113 LAWTON ROAD, SUITE 100 ORLANDO, FL 32803 407-894-3241 WELCOME LETTER We would like to take this opportunity to welcome you to our practice. Our records
CHURCH/MINISTRY/BUSINESS ACCOUNT CHECKLIST
CHURCH/MINISTRY/BUSINESS ACCOUNT CHECKLIST Documentation: Return completed & signed original Church/Ministry/Business Membership Application. Return completed & signed Certification Regarding Beneficial
Attestation of Eligibility for an Enrollment Period
301 S. Vine St., Urbana, IL 61801 Attestation of Eligibility for an Enrollment Period Typically, you may enroll in a health plan only during the Open Enrollment Period. There are exceptions that may allow
Public Employee s Benefits Program
Public Employee s Benefits Program Public Employees Benefits Program 901 S. Stewart Street, Suite 1001 Carson City, NV 89701 www.pebp.state.nv.us mservices@peb.state.nv.us 775-684-7000. 1-800-326-5496
Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other
PATIENT REGISTRATION First Name: Last Name: Middle: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle Initial:
PSYCHOLOGICAL SERVICES AGREEMENT
PSYCHOLOGICAL SERVICES AGREEMENT Jane Allemang, PhD, Clinical Psychologist CLIENT INFORMATION: TODAY S DATE: Name: Date of birth: Age: Sex: Relationship status: (circle) SINGLE MARRIED COHABITING WIDOWED
Camp Annual Membership Dues Instruction Sheet
Camp Annual Membership Dues Instruction Sheet The camp secretary and treasurer will be working with three forms for the collection and submission of the annual dues. 1. Camp Membership Report (Roster)
California Public Employees Retirement System 888 CalPERS 888 Employer Account Management Division
Employer Account Management Division Dear Member, You are being provided with the background, explanation, and instructions for the Reciprocal Self-Certification Form (PERS-EAMD 801). Reciprocity among
MERCER MARKETPLACE 365 HRA INSTRUCTIONAL GUIDE
MERCER MARKETPLACE 365 HRA INSTRUCTIONAL GUIDE Please keep this guide in a convenient location so that you may refer to it as needed. Contact us by: Phone (toll-free): 1-855-698-1568 For deaf or hard of
MONTEREY COUNTY TAX COLLECTOR
MONTEREY COUNTY TAX COLLECTOR MARY A ZEEB, TREASURER TAX COLLECTOR P.O. BOX 891, SALINAS, CA 93902-0891 PHONE 831-755-5017; FAX # 831-759-6623 EMAIL: BUSINESS.TAX@CO.MONTEREY.CA.US BUSINESS LICENSE APPLICATION
Yucaipa Tid-Bits RETIRED PUBLIC EMPLOYEES ASSOCIATION CHAPTER 47, YUCAIPA VALLEY
Yucaipa Tid-Bits We are California public employees who are working together to maintain and improve the quality of our members lives by protecting our retirement and medical benefits. RPEA members include
Metzlers Gymnastics Training Center NON-COMPETE TEAM REGISTRATION FORM Please Print Clearly
Metzlers Gymnastics Training Center NON-COMPETE TEAM REGISTRATION FORM Please Print Clearly Last Name: Parent s Name: Address: City: State: Zip Code: Home Phone: Cell Phone: E-mail address: Work Phone:
MARYLAND GOLF. and Country Clubs Application for Membership East MacPhail Rd Bel Air Maryland
MARYLAND GOLF and Country Clubs Application for Membership 1335 East MacPhail Rd Bel Air Maryland 21015 410-879-2025 www.marylandgcc.org 1 Category Pricing Current Initiation Fee Monthly Dues Food Minimum
MERCER MARKETPLACE 365 HRA INSTRUCTIONAL GUIDE
MERCER MARKETPLACE 365 HRA INSTRUCTIONAL GUIDE Please keep this guide in a convenient location so that you may refer to it as needed. Contact us by: Phone (toll-free): 1-866-321-0967 For deaf or hard of
Welcome,! Scheduled Appointment: at AM/PM Dr. Jamie C. Bales Dr. Brian H. Moore
Welcome,! Thank you for choosing to continue your care at Neurology Specialists, PC! Enclosed is a packet of information that is needed for your upcoming appointment. We will need you to return this information
TERRYTOWN COUNTRY CLUB
P.O. BOX 1285 1785 CAROL SUE AVE GRETNA, LA 70054 TERRYTOWN, LA 70056 terrytowncountryclub@gmail.com 504-392-7191 2018 RENEWAL LETTER & DUES NOTIFICATION Dear TCC Member(s): It is that time of the year
Application for Membership
Application for Membership Vision & Applicant Understanding The National Club is a welcoming community where personal and professional relationship are nurtured, and where innovation, diversity and thought
Selected Terms & Conditions for Wells Fargo Business Debit, ATM and Deposit Cards
Selected Terms & Conditions for Wells Fargo Debit, ATM and Deposit Cards Terms and Conditions effective 04/24/2017. Introduction page 1 Using Your Card page 2 Using Your Card Through a Mobile Device page
First Name MI Last Name. Residential Street Address. City, State, Zip. Address Existing Patient Yes No. Primary Care Physician ID# Medical Group
Individual/Family ENROLLMENT APPLICATION AND MEMBERSHIP AGREEMENT Western Health Advantage -.-,.~~ Mail your completed application to: /Individual Sales 2349 Gateway Oaks Drive, Suite 100, Sacramento,
CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
CONROE WOODLANDS GASTROENTEROLOGY DR. STEPHEN M. KELLY 1501 RIVER POINTE DR, STE 240 CONROE TX 77304 129 VISION PARK BLVD, STE 109 SHENANDOAH, TX 77384 Phone: (936) 760.1900 Fax: (936) 441.1907 CONSENT
NONGROUP ENROLLMENT/CHANGE REQUEST
NONGROUP ENROLLMENT/CHANGE REQUEST Health Republic Insurance of New Jersey A. Type of Activity to be completed by Subscriber. Refer to instructions page 5 before completing this form. Print clearly Activity
NON-GROUP ENROLLMENT/CHANGE REQUEST. Other / / Access to new plan due to permanent move Marketplace changed subsidy determination
NON-GROUP ENROLLMENT/CHANGE REQUEST Mail to: Horizon BCBSNJ Attn: Consumer Enrollment Dept. P.O. Box 1330 Newark, NJ 07101-1330 Email to: individualapplication@horizonblue.com Fax to: 973-274-4413 HorizonBlue.com
New Case Submission Checklist Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees
hsainsurance.com New Case Submission Checklist Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees Check if Complete To ensure that your applications are processed as quickly
Enrollment Application
Enrollment Application Follow these easy steps to apply for a Humana Medicare Supplement insurance policy. 1 Have Your Medicare Card Ready Please print legibly and complete the entire form. You will need
2019 Renewing Non - Resident Application
2019 Renewing Non - Resident Application Rye Golf Club 330 Boston Post Road ~ Rye, NY 10580 ~ 914-835-3200 ~ www.ryegolfclub.com RYE GOLF CLUB APPLICATION PROCESS FOR RENEWING NON RESIDENT MEMBERS RESIDENCY
if applicable if applicable if applicable
For official use only: Customer Name Customer No. Department of the Treasury Bureau of the Fiscal Service (Revised March 2014) CLAIM FOR LOST, STOLEN, OR DESTROYED UNITED STATES SAVINGS BONDS OMB No. 1535-0013
Claims and Appeals Process for the Self-Funded Medical Plans Administered by UnitedHealthcare
SUPPLEMENT TO SUMMARY OF BENEFITS HANDBOOK FOR RETIREES AND SURVIVING DEPENDENTS Claims and Appeals Process for the Self-Funded Medical Plans Administered by UnitedHealthcare Filing a Claim for Benefits
FREQUENTLY ASKED QUESTIONS
FREQUENTLY ASKED QUESTIONS 4-11-13 1. What is the HDIEET-VEBA Partnership? High Desert and Inland Employee-Employer Trust (HDIEET) and California Schools VEBA (VEBA) are both joint labor-management trusts
TRACY UNIFIED SCHOOL DISTRICT VOLUNTEER DRIVER REQUIREMENTS (Athletics / Field Trips)
TRACY UNIFIED SCHOOL DISTRICT VOLUNTEER DRIVER REQUIREMENTS (Athletics / Field Trips) Before you can use your personal vehicle to transport students on field trips or other school activities, you must
Dr. Sarah Y. Vinson s Practice Policies
Dr. Sarah Y. Vinson s Practice Policies FEE SCHEDULE: $230 50 minute psychotherapy and/or psychopharmacology appt. $450 2 hour initial intake appt. $155 30 minute phone, Skype or in-person appt.; $125
PHYSICAL THERAPY & CHIROPRACTIC CARE
PHYSICAL THERAPY & CHIROPRACTIC CARE Patient Information Name: Social Security #: Date of Birth: Telephone: Home: _ Cell: Email: (Communications are for appointments, office information & newsletters)
All information must be stated accurately.
Medical Coverage underwritten by Memorial Hermann Health Insurance Company Your Individual Application Kit is Enclosed Thank You for Applying with Memorial Hermann Health Insurance Company ( MHHIC ). Please
BILL L. JOU, M.D., INC.
BILL L. JOU, M.D., INC. AUTHORIZATION TO TREAT I (and/or the undersigned on behalf of the patient) voluntarily consent to allow Dr. Bill L. Jou and staff to provide such evaluation and/or care and treatments
NMCA 2019 ANNUAL CONVENTION April 12 & 13, 2019
NMCA 2019 ANNUAL CONVENTION April 12 & 13, 2019 EVERYTHING YOU NEED TO REGISTER AS AN EXHIBITOR FOR THE NMCA 2019 CONVENTION IS ENCLOSED!! PLEASE JOIN US!! Enclosed with this letter are a Registration
Enrollment Request Form Please contact Stanford Health Care Advantage if you need information in another language or format (Braille).
Filling out and returning the enrollment request form is your first step to becoming a Stanford Health Care Advantage (HMO) member. If you and your spouse are both applying, you ll each need to fill out
It is very important to bring the following to your first visit:
Dear New Patient: Welcome and thank you for choosing Capital Digestive Care! The enclosed packet contains important information for your upcoming appointment as well as our new patient registration forms.
New Jersey Individual Application/Change Request Form OHI
New Jersey Application/Change Request Form OHI Oxford Health Insurance, Inc. Mailing Address: Attn: Product Department, 14 Central Park Drive, Hooksett, NH 03106 1-800-767-3840 www.oxfordhealth.com INSTRUCTIONS
Patient Name: First Middle Last Address: Number Street (Apt#) City State Zip Address: Okay to Statement? Yes No
****For Internal Use Only**** Name DX Office Ins Today's Date: How did you hear about us?: Patient Name: First Middle Last Address: Number Street (Apt#) City State Zip Email Address: Okay to Email Statement?
Child Resident Street Address (required - a PO Box will not be accepted) City County State Zip. Mailing address (if different) City County State Zip
PO Box 339 400 Warren Avenue Bremerton, WA 98337 APPLICATION FOR INDIVIDUAL/FAMILY PLAN COVERAGE KPS is a health care service contractor licensed and marketing in all of Washington State Please review
AWAY FROM HOME CARE GUEST MEMBERSHIP APPLICATION
AWAY FROM HOME CARE GUEST MEMBERSHIP APPLICATION Please print clearly. Application must be completed and signed by the subscriber. All five pages must be completed and returned. Today s date: Guest membership
6677 W. Thunderbird F N. Hayden Rd. H-100 Glendale, Az Scottsdale, Az
Eye Physicians & Surgeons of Arizona 6677 W. Thunderbird F-101 10603 N. Hayden Rd. H-100 Glendale, Az. 85306 Scottsdale, Az. 85260 George R. Reiss, MD Shamil S. Patel, MD Vinay M. Dewan, MD Christina M.
Met Life Safeguard DHMO DENTAL PLAN* ENROLLMENT INSTRUCTIONS
Met Life Safeguard DHMO DENTAL PLAN* ENROLLMENT INSTRUCTIONS Please Type or Print Clearly using only Black Ink, DO NOT USE Felt Tip Pens. MEMBER / APPLICANT INFORMATION: Member/Applicant: Local REALTOR
Missouri Individual and Family Plan Enrollment Application / Change Form
Primary Applicant Name Enrollment Form ID Cigna Health and Life Insurance Company (Cigna) Missouri Individual and Family Plan Enrollment Application / Change Form Section A. Type of Application New Enrollment
Georgia Individual Enrollment Application
Georgia Individual Enrollment Application IMPORTANT: If you are a new applicant, a separate premium payment is required to be submitted with each application. If you are a current Individual policyholder
Quick Reference Guide
Driver s License State Issued Federal Government Driver s License State Issued Federal Government NO YES NO Quick Reference Guide Merchant Services Hotline 800-333-108 Hours: Monday-Saturday 8:00am-10:00pm
FOOD INDUSTRY SELF INSURANCE FUND
FOOD INDUSTRY SELF INSURANCE FUND OF NEW MEXICO P.O BOX 14710 ALBUQUERQUE, NM 87191-4710 (505)298-9095 1-800-28-0893 FAX (505) 298-9094 FOOD INDUSTRY SELF INSURANCE FUND ACKNOWLEDGMENT MEMBER: ADDRESS:
Here is a checklist of a few things that are commonly overlooked and are mandatory in processing your application.
Application Instructions for Cigna Dental Application 1. Please print all pages of the application. 2. Complete all questions and sections of the applicaton. Please write legibly. 3. Complete the fax cover
Commercial Fisheries Entry Commission Instructions for Emergency Transfer of Entry Permit Request
Commercial Fisheries Entry Commission Instructions for Emergency Transfer of Entry Permit Request PO Box 110302 Juneau, AK 99811-0302 Phone: 907-789-6150 Toll-Free: 1-855-789-6150 Fax: 907-789-6170 www.cfec.state.ak.us