MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS
|
|
- Byron Bailey
- 5 years ago
- Views:
Transcription
1 MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Prvider s Electin t Emply Electrnic Data Interchange f Claims fr Prcessing in the Luisiana Medical Assistance Prgram (EDI Cntract fr Business/Entity) and Pwer f Attrney NOTE: Original signature is required and the frm must be ntarized 2018 Annual Certificatin frm. WHERE SHOULD I SEND THE FORM(S)? Mail the frm t: Mlina EDI Department PO Bx Batn Ruge, LA WHAT IS THE TURNAROUND TIME? Standard prcessing time is 3 weeks. HOW DO I CHECK STATUS? Yu will receive a letter frm Medicaid LA infrming yu f yur apprval. Yu may als call Medicaid LA at (225) and ask if yu have been linked t Office Ally s Submitter ID Once yu receive cnfirmatin that yu ve been linked t Office Ally, yu must supprt@fficeally.cm with the belw infrmatin prir t submitting claims electrnically. Subject: Medicaid Luisiana (MCDLA) - EDI Apprval Bdy f Please lg my EDI apprval fr Medicaid Luisiana. Prvider Name NPI Tax ID Office Ally P.O. Bx Vancuver, WA Phne: Fax:
2 PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (EDI CONTRACT FOR BUSINESS/ENTITY) INSTRUCTIONS Prir t submitting electrnic claims t Luisiana Medicaid, a seven-digit Submitter number (450XXXX) must be btained frm the Mlina Medicaid Slutins Prvider Enrllment Unit. The Submitter number must be linked t all prvider numbers fr whm claims will be submitted. The fllwing frm(s) is (are) t be cmpleted if the Entity/Business enrlling at this time plans t submit claims electrnically t Luisiana Medicaid. Prvider s Electin t Emply Electrnic Data Interchange f Claims fr Prcessing in the Luisiana Medical Assistance Prgram (EDI Cntract fr Business/Entity) Luisiana Medicaid Prvider Number enter the Luisiana Medicaid prvider number fr which claims will be electrnically submitted t Mlina Medicaid Slutins. (Leave blank if applying fr new Prvider Number.) Natinal Prvider Identifier (NPI) enter the NPI f the prvider fr which claims will be electrnically submitted. Nte: Atypical prviders leave this blank. DBA Name f Enrlling Business/Entity enter the name f the entity / business enrlling r the business prvider name assciated with the prvider number and NPI listed abve. Billing Agent/Submitter Name/Business Name enter the business name f the billing / submitting agent. Name f Cntact Persn enter the name f the persn designated as the pint f cntact fr questins regarding this request. Cntact Phne Number enter the phne number f Cntact Persn. Submitter Number if linking t a submitter wh already has a Luisiana Submitter number, then yu are required t enter the Luisiana Medicaid submitter number yu want t link t. (Leave blank if applying fr a new submitter number.) Printed Name f Authrized Representative print the name f the persn authrized t enter int a binding Title/Psitin enter the title/psitin f the persn authrized t enter int a binding agreement with Luisiana Medicaid. Signature f Authrized Representative enter the signature f the persn authrized t enter int a binding Date f Signature enter the date the authrized representative signed the frm. Entity/Business Medicaid Electrnic Media Limited Pwer f Attrney (EDI Pwer f Attrney) Luisiana Medicaid Prvider Number enter the Luisiana Medicaid prvider number fr which claims will be electrnically submitted t Mlina Medicaid Slutins. (Leave blank if applying fr a new Prvider Number.) Natinal Prvider Identifier (NPI) enter the NPI f the prvider fr which claims will be electrnically submitted. Nte: Atypical prviders leave this blank. DBA Name f Enrlling Business/Entity enter the name f the entity / business enrlling r the business prvider name assciated with the prvider number and NPI listed abve. Service Address f Business/Entity enter the service address f the prvider name entered. Submitter Number if linking t a submitter wh already has a Luisiana Submitter number, then yu are required t enter the Luisiana Medicaid submitter number yu want t link t. (Leave blank if applying fr a new submitter number.) Billing Agent/Submitter Business Name enter the business name f the Billing Agent/Submitter. Billing Agent/Submitter Cntact Persn enter the name f the persn designated as the pint f cntact fr the Billing Agent/Submitter business. Billing Agent/Submitter Phne Number enter the phne number f the Billing Agent/Submitter cntact persn. Enter the Parish (r Cunty) Name where the Ntary Public is lcated Enter City, State and Date f Ntarizatin Signature f Authrized Representative enter the signature f the persn authrized t enter int a binding Printed Name f Authrized Representative print the name f the persn authrized t enter int a binding Ntary Public Signature the Ntary Public shuld sign the frm and affix his/her seal. If the prvider will be using a Third Party Biller r Clearinghuse, a Limited Pwer f Attrney MUST be cmpleted and ntarized. Please cmplete the enclsed Limited Pwer f Attrney in its entirety t be mailed with yur cmpleted EDI Cntract. Entity/Business EDI Instructins Page 1
3 PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (EDI CONTRACT FOR BUSINESS/ENTITY) Luisiana Medicaid Prvider Number (7 digits) Submitter Number (7 digits) (leave blank if applying fr new number) Natinal Prvider Identifier (NPI) (10 digits) DBA Name f Enrlling Business/Entity: Billing Agent/Submitter Name/Name f Business that will be submitting claims (prvider name r third party biller s name): Name f Cntact Persn: Cntact Phne Number: The Medicaid File can hld a maximum f three Submitter Numbers per Medicaid Prvider Number at any ne time. Current plicy is t clse ld Submitter Numbers as new nes are pened unless therwise requested by the prvider. It is als vital t identify which Submitter Number will be designated t dwnlad the Electrnic Remittance Advices (ERA). In rder fr Lusiana Medicaid t gather this infrmatin, cmplete the fllwing, if applicable: When a new Submitter Number is issued, it will be set up t retrieve ERAs. If a previusly assigned Submitter Number is t be used t retrieve ERAs as well, then place it in the spaces prvided belw. By checking this bx yu are giving authrizatin t have 835s prduced and made available fr dwnlad by either this new submitter number r the previusly assigned submitter number. List ther Submitter Number(s) that are currently n file which will NOT be used fr 835 ERA, but which need t remain pen in the spaces belw: I am currently enrlled r am requesting enrllment in Luisiana Medicaid and wish t submit my wn claims electrnically t Luisiana Medicaid. I am currently enrlled r am requesting enrllment in Luisiana Medicaid and wish t use a Third Party (Clearinghuse, Billing Agent, Submitter, etc.) t submit my claims electrnically t Luisiana Medicaid. (Pwer f Attrney frm is required.) PROVIDER ACKNOWLEDEGEMENT 1. The prviders attest that all infrmatin supplied with this Agreement is true, accurate and cmplete. 2. On the date f signature belw, the undersigned elects and agrees t submit Luisiana medical assistance claims by means f the electrnic media claims prcessing methd in accrdance with Paragraphs 1 thrugh 17 belw. This is dne in cnsideratin fr the Luisiana Department f Health (LDH), Bureau f Health Services Financing's (BHSF) prcessing f prvider claims, as well as ther valuable cnsideratins. 3. All published specificatins set frth shall be met as t every entry sught t be prcessed. The effective date fr EDI submissin will be set by Prvider Enrllment nce the cntract has prcessed. Entity/Business EDI Frm Page 1
4 Prvider Name: 4. The Prvider, r his agent, shall be respnsible fr ttal cmpliance with said specificatins including 42CFR which gverns the payment ptins fr Third Party Billers. The Prvider's data prcessing agent fr submissin f medical assistance claims is stated abve and any changes in the Prvider's data prcessing agent shall be preceded by 30 days written ntice t LDH. 5. The Prvider shall prvide upn request f LDH r any authrized agent f LDH any supprtive dcumentatin t ensure that all technical requirements are being met, i.e. prgram listings, data submissins, flw charts, file descriptins, accunting prcedures, etc. 6. The undersigned Prvider shall cntinue t be ultimately respnsible fr the accuracy and truthfulness f all medical assistance claims submitted fr payment. Nevertheless, the Prvider, if electing a data prcessing agent t submit medical assistance claims directly, must give a legal pwer f attrney t that agent in rder t submit electrnic claims and the Annual Certificatin frm. A cpy f the certificatin statement is attached and is hereby incrprated by reference int this paragraph. 7. It is expressly understd that LDH r its Fiscal Intermediary (Mlina Medicaid Slutins) may reject an entire submissin at any time fr failure t cmply with the fficial specificatins fr submitting claims n electrnic media r fr any ther reasn. 8. The Prvider agrees that this electin des nt in any way mdify the requirements t the Plicies and Prcedures applicable t their prvider type, except as the claims submissin prcedures which will be transmitted in electrnic frmat rather than hardcpy. 9. LDH and the Prvider mutually agree that this Agreement may be amended by mutual cnsent f the cntracting parties. Such amendments must, hwever, be in writing and must be signed by the authrized representatives f cntracting parties. This Agreement shall nt be verbally amended. 10. The Prvider agrees t submit t LDH, Fiscal Intermediary r any ther authrized agent, upn request, sufficient dcumentatin t substantiate the scpe and nature f services prvided fr thse claims submitted and fr which reimbursement is claimed. 11. The Prvider acknwledges and accepts respnsibility fr the prvisins f Public Law pertaining t fraud. 12. The Prvider and LDH agree that each party t this Agreement shall have the right t unilateral terminatin f this Agreement upn delivery f written ntice f terminatin upn the ther party. The effective date f such terminatin shall be 30 days frm the receipt f the ntice f terminatin. 13. Further, fr a perid f five years, during the curse f a Federal/state audit r investigatin, shuld dcumentatin f the existence, nature and scpe f the services pertaining t a medical assistance claim be requested, the Prvider shall prvide the dcumentatin as requested and prduce such fr examinatin and cpying at n cst. 14. The Prvider agrees that this electin shall be enfrced in accrdance with the laws f the State f Luisiana and that this electin des nt in any way mdify LDH's limited bligatins as set in a certain Prvider Agreement between LDH and the Prvider. 15. I attest that all claims submitted under the cnditins f this Agreement are certified t be true, accurate and cmplete. 16. I understand that all claims submitted under the cnditins f this Agreement will be paid and satisfied frm Federal and state funds, and that any falsificatin r cncealment f a material fact, may be prsecuted under Federal and State laws. 17. Applicable t thse receiving 835s: I authrize the Medicaid Fiscal Intermediary t send all HIPAA required data in the 835 transactin which includes claims infrmatin; payment infrmatin; and bank accunt infrmatin, prvided by me and currently n file if enrlled in Electrnic Funds Transfer, t the submitter identified abve. This authrizatin will remain in effect until discntinued by written request r changed by a future request. Printed Name f Authrized Representative Title/Psitin Signature f Authrized Representative Date f Signature Entity/Business EDI Frm Page 2
5 ENTITY / BUSINESS MEDICAID ELECTRONIC MEDIA LIMITED POWER OF ATTORNEY (EDI POWER OF ATTORNEY) This frm is required by all prviders wh will have electrnic claims submitted by a third party. Luisiana Medicaid Prvider Number (7 digits) Submitter Number (7 digits) (leave blank if applying fr new number) Natinal Prvider Identifier (NPI) (10 digits) DBA Name f Enrlling Business/Entity (Prvider Name): Service Address f Business/Entity: Billing Agent /Submitter Business Name: Billing Agent /Submitter Cntact Persn: Billing Agent /Submitter Phne Number: BE IT KNOWN that n this day, BEFORE ME, A Ntary Public duly cmmissined and qualified in and fr the Parish f, State f Luisiana, therein residing: PERSONALLY CAME AND APPEARED the abve named prvider, represented herein by the prvider r its duly authrized representative wh is f majrity and a resident f and dmiciled in the State shwn under Prvider Address abve wh declared unt me, Ntary, that he des by these presents, name, cnstitute and appint the abve named Billing / Submitter Agent, a persn r entity with full legal capacity, t be his true and lawful agent and attrney-in-fact, t execute fr him, and in his name, place and stand, the Luisiana Medical Assistance Prgram s applicable claims, by prvider type, fr electrnic submissin f claims prcessing, the said appearer further authrizing the said agent t receive all infrmatin regarding payments made t the appearer fr such claims, and appearer finally declaring that he r it by these presents des agree t indemnify and hld harmless the said agent frm any and all liability resulting frm claims submitted by the said agent fr the said appearer. THUS DONE AND PASSED BEFORE ME, Ntary, in the City f, State f n the day f, 20. Signature f Authrized Representative Ntary Public Signature Printed Name f Authrized Representative Ntary Seal r Ntary Identificatin Number (required) Entity/Business Pwer f Attrney Frm Page 1
6 Prvider Number (7-Digits) EDI ANNUAL CERTIFICAT ION OF ELECTRONIC FILES Certificatin Perid: January 1 t December 31, 2018 Submitter Number 2018 Natinal Prvider Identifier (10 Digits) Submitter Name: Primary Cntact Name: Address: Secndary Cntact Name: Address: Submissins by Prvider Rendering Services Using their wn Submitter ID: I certify that all services rendered during the abve identified Certificatin Perid were necessary, medically indicated and were rendered by me r under my persnal supervisin. I have reviewed the claims infrmatin submitted and certify that it is true, accurate and cmplete. I agree t keep such recrds which will disclse fully the extent f services prvided t individuals under the state s Title XIX plan and t furnish infrmatin regarding any payments claimed fr prviding such services as the state agency, Medicaid Fraud Cntrl Unit r the Secretary f the United States Department f Health and Human Services (DHHS) may request fr five years frm date f service r therwise required by law r regulatin. I agree t accept payment frm the Bureau f Health Services Financing as payment in full fr services and nt seek additinal payment frm the recipient fr any unpaid prtin f a bill except t Spend-dwn Medically Needy recipients as indicated n Frm 110-MNP. I agree t adhere t the published regulatins f the Secretary f DHHS and the regulatins, plicies, criteria and prcedures f BHSF Medical Assistance Prgram including thse rules regarding recupment. I understand that payment and satisfactin f these claims will be frm federal and state funds, and that any false claims, statements, dcuments, r cncealment f material fact, may be prsecuted under applicable federal and state laws. Attach a list f all Prviders Names, Medicaid ID#s and NPI Numbers assciated with this Submitter Number NOTICE: This is t certify that the freging infrmatin is true, accurate and cmplete. Submissins by Third Party Biller (Billing Agents/Clearinghuses) Using their Submitter ID: I certify that the claim infrmatin submitted t Luisiana Medicaid is an exact duplicate f detailed claim line infrmatin received frm the prvider and has nt been materially altered r revised except fr translatin t the current 837 transactin frmat r insertin f minr data. I certify that the infrmatin submitted in electrnic frmat is true, accurate and cmplete as received frm the prvider. Additinally, I understand that payment f these claims will be Federal and State funds, and that any falsificatin, r cncealment f a material fact may be prsecuted under Federal and State laws. I als certify that prvider(s) with whm I have a direct relatinship have furnished me with an EDI Annual Certificatin f Medicaid Claims Submitted Electrnically Frm n which the prvider has attested t the truth, accuracy and cmpleteness f the claim infrmatin. If I d nt have a direct relatinship with submitting prviders (fr instance, if the relatinship is with a vendr), Luisiana Medicaid understands that I will nt have an EDI Annual Certificatin Frm frm the individual(s) r entity(ies) with whm I d nt maintain a cntractual relatinship. I agree t maintain all frms I am required t cllect fr a perid f five (5) years. Identify all claim types that will be submitted during this Certificatin Perid: CLAIM TYPE 837P 1500 Claim Frm 837D Dental Claim Frm 837I UB4 Claim Frm Other DATE SUBMITTER SIGNATURE (ORIGINAL) NOTE: Updated certificatin frms MUST be submitted annually. Failure t maintain a cmpleted Certificatin Frm n file will result in the clsure f the submitter number withut ntice t submitter. All files submitted with clsed submitter numbers will be drpped frm the system withut being prcessed. This Certificatin Frm can nly be mailed t either address lcated belw. The frm can t be faxed r scanned and ed. Submit t: Mlina EDI Department, PO Bx 91025, Batn Ruge, LA Phne #: 225/ Or: 8591 United Plaza Blvd., Bldg. V, Suite 300, Batn Ruge, LA 70809
MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS
MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Provider s Election to Employ Electronic Data Interchange of Claims for Processing in the Louisiana Medical Assistance Program
More informationMEDICAID LOUISIANA (MCDLA) ERA ENROLLMENT INSTRUCTIONS
MEDICAID LOUISIANA (MCDLA) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Luisiana Medicaid Electrnic Remittance Advice (ERA) Authrizatin Agreement WHERE SHOULD I SEND THE FORM(S)? Mail the frm
More informationChange Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account
THIS FORM MUST BE PROCESSED BY CHANGE HEALTHCARE PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy
More informationLOUISIANA MEDICAID CONTRACT INSTRUCTIONS (SKLA0)
LOUISIANA MEDICAID CONTRACT INSTRUCTIONS (SKLA0) Please MAIL all pages of the completed and signed agreement to: ABILITY One Metro Center 4010 Boy Scout Blvd Suite 900 Tampa, FL 33607 INSTRUCTIONS Do not
More informationMEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS
MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Provider s Election to Employ Electronic Data Interchange of Claims for Processing in the Louisiana Medical Assistance Program
More informationLouisiana Medicaid Election to Employ Electronic Data Interchange (EDI) Form For Entity/Business Providers
Louisiana Medicaid Program Louisiana Medicaid Election to Employ Electronic Data Interchange (EDI) Form For Entity/Business Providers (Enrollment packet is subject to change without notice) PROVIDER'S
More informationLouisiana Medicaid Election to Employ Electronic Data Interchange (EDI) Form For Individual Providers
Louisiana Medicaid Program Louisiana Medicaid Election to Employ Electronic Data Interchange (EDI) Form For Individual Providers (Enrollment packet is subject to change without notice) PROVIDER'S ELECTION
More informationMEDICAID LOUISIANA PRE ENROLLMENT INSTRUCTIONS MCDLA
MEDICAID LOUISIANA PRE ENROLLMENT INSTRUCTIONS MCDLA HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 3 weeks. WHERE SHOULD I SEND THE FORMS? Mail the form to: Unisys Provider Enrollment
More informationINSTRUCTIONS FOR PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM
Individual Louisiana s Medicaid Program INSTRUCTIONS FOR PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM Prior to submitting
More informationCRG PATIENT REGISTRATION FORM
CRG PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: Birth : (Last) (First) (Middle) Scial Security Number: Male: Female: Hme Address: (Street / RR Bx # / Apt. #) (City/State) (Zip) Preferred
More informationInsulet Corp. Securities Litigation
Page 1 f 8 ELECTRONIC FILING INSTRUCTIONS Insulet Crp. Securities Litigatin READ THESE INSTRUCTIONS CAREFULLY AND IN THE ENTIRETY. YOU MUST COMPLY. Part I - Overview Electrnic claim submissin is available
More informationPROOF OF CLAIM AND RELEASE
PROOF OF CLAIM AND RELEASE Deadline fr Submissin: July 11, 2015 IF YOU PURCHASED THE COMMON STOCK OF, INC., ( ) DURING THE PERIOD FROM NOVEMBER 14, 2013 THROUGH APRIL 9, 2014, INCLUSIVE (THE CLASS PERIOD
More informationPROOF OF CLAIM AND RELEASE
Deadline fr Submissin: June 9, 2018 PROOF OF CLAIM AND RELEASE IF YOU PURCHASED THE COMMON STOCK OF MAGNACHIP SEMICONDUCTOR CORP. ( MAGNACHIP ) BETWEEN FEBRUARY 1, 2012 AND MARCH 11, 2014, INCLUSIVE (TH
More informationHIPAA Privacy Rule LINKS AND RESOURCES AFFECTED ENTITIES IMPACT ON EMPLOYERS. Provided by Brown & Brown of Louisiana, LLC
Prvided by Brwn & Brwn f Luisiana, LLC HIPAA Privacy Rule The HIPAA Privacy Rule establishes natinal standards t prtect individuals medical recrds and ther persnal health infrmatin. The Privacy Rule applies
More informationWhat do you need? Copy of the HIPAA Policy on Amendment of Protected Health Information
HIPAA Privacy Prcedure #4 Effective Date: April 14, 2003 Reviewed Date: February, 2011 Amendment f Prtected Health Revised Date: February, 2011 Infrmatin Scpe: Radiatin Onclgy ************************************************************************************
More informationLSI Securities Litigation
Page 1 f 8 ELECTRONIC FILING INSTRUCTIONS I. Imprtant Ntes PLEASE READ In additin t these instructins, please review the details set frth in the claim frm and ntice prir t submitting claims. Electrnic
More informationCAREVEST MORTGAGE INVESTMENT CORPORATION Directions for Completing Retraction Requests
This package is ONLY fr Class A sharehlders f. Cntents f this package (5 pages): - Instructins fr cmpleting yur retractin request - Retractin Request frm fr CareVest Mrtgage Investment Crpratin The February
More informationaddress: Driver license number: Date of birth: Occupation:
MEMBERSHIP APPLICATION PRIMARY MEMBER INFORMATION Name: Scial security Member Number: Hme phne: Cell phne: Business phne: Mther s Maiden Name: Security passwrd: Mailing address: City: State: ZIP Cde: Street
More informationPROOF OF CLAIM AND RELEASE
Deadline fr Submissin: FEBRUARY 16, 2015 Tel.: 866-274-4004 Fax: 610-565-7985 inf@strategicclaims.net PROOF OF CLAIM AND RELEASE IF YOU PURCHASED OR OTHERWISE ACQUIRED AMERICAN DEPOSITORY SHARES ( ADS
More information220 Burnham Street South Windsor, CT Vox Fax LOUISIANA MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION
220 Burnham Street South Windsor, CT 06074 Vox 888-255-7293 Fax 860-289-0055 LOUISIANA MEDICAID DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION PAYER ID NUMBER EPSDT CKLA1 ADULT CKLA2 SPECIAL NOTES Effective
More informationNHCAC North Hudson Community Action Corporation
NHCAC Nrth Hudsn Cmmunity Actin Crpratin RFP 340B Prgram Auditing Services INQUIRIES SHOULD BE DIRECTED TO: Name: Title: Entity: Address: Manny Diaz Directr f Cmmunity Develpment Nrth Hudsn Cmmunity Actin
More informationStandard Operating Procedure Payment Requisition
Office f the Cmptrller Accunts Payable Divisin f Finance and Administratin Standard Operating Prcedure Payment Requisitin Effective Date: January 2016 Descriptin: This dcument prvides instructins n hw
More informationDetails of Rate, Fee and Other Cost Information
Details f Rate, Fee and Other Cst Infrmatin Accunt terms are nt guaranteed fr any perid f time. All terms, including fees and APRs fr new transactins, may change in accrdance with the Credit Card Agreement
More informationThank you for your consideration, and if you have further questions or you need more information, please do not hesitate to contact me.
Dc 2011-20523 (6 pgs) September 23, 2011 Michael Caballer Internatinal Tax Cunsel United States Department f the Treasury 1500 Pennsylvania Avenue, NW Washingtn, DC 20220 Michael Danilack Deputy Cmmissiner
More informationPATIENT LIABILITY STATEMENT
PATIENT LIABILITY STATEMENT (Updated 6/17) We will nt initiate therapeutic services until signed authrizatin is prvided. I understand that I am persnally respnsible fr charges incurred fr services rendered
More informationVision Service Plan (VSP) New Group Implementation Guide
Visin Service Plan (VSP) New Grup Implementatin Guide Nrth Ranch Benefits Trust (NRBT) Administered by HealthSmart Benefit Slutins, Inc. Agents shuld submit the cmpleted New Grup Implementatin Guide back
More informationMichigan Dispute Resolution Procedure for McKinney-Vento Homeless Education Programs REVISED AUGUST 2013
Office f Field Services, Special Ppulatins Unit McKinney-Vent Prgram fr the Educatin f Hmeless Children and Yuth Michigan Dispute Reslutin Prcedure fr McKinney-Vent Hmeless Educatin Prgrams REVISED AUGUST
More informationFOR PLAN ADMINISTRATORS
QDRO INFORMATIONAL KIT FOR PLAN ADMINISTRATORS T ensure cmpliance with requirements impsed by the IRS, we infrm yu that any infrmatin cntained in this cmmunicatin (including any attachments) was nt intended
More informationINDEPENDENT ACCOUNTANTS' REPORT ON APPLYING AGREED-UPON PROCEDURES
d^^ GRIFFIN & COMPANY, LLC CERTIFIED PUBLIC ACCOUNTANTS Stephen M. Griffin, CPA Rbert J. Furman, CPA INDEPENDENT ACCOUNTANTS' REPORT ON APPLYING AGREED-UPON PROCEDURES T the Bard Members Luisiana State
More informationA-1110 Wien. Privacy Notice
Eurfins Lebensmittelanalytik Tel. +43 (1) 944 33 44-0 ffice@eurfins.at www.eurfins.at Privacy Ntice Table f cntents 1 Cntrller infrmatin... 2 2 What infrmatin shuld yu give Eurfins?... 2 3 Why d we use
More informationCommvault Systems, Inc. Securities Litigation
Page 1 f 8 ELECTRONIC FILING INSTRUCTIONS Cmmvault Systems, Inc. Securities Litigatin I. Imprtant Ntes PLEASE READ Electrnic claim submissin is available t institutins filing n their wn behalf r n behalf
More informationHawaii Division of Financial Institutions 2019 Renewal Checklist
Hawaii Divisin f Financial Institutins 2019 Renewal Checklist Instructins Renewal requests must be submitted thrugh by the date specified by yur state regulatr(s). Click here t review all renewal deadlines,
More informationHOME IMPROVEMENT CONTRACT
HOME IMPROVEMENT CONTRACT YOU ARE ENTITLED TO A COMPLETELY FILLED-IN COPY OF THIS CONTRACT, SIGNED BY BOTH YOU AND THE CONTRACTOR BEFORE ANY WORK MAY BE STARTED. CONTRACTOR S NAME: ADDRESS: PHONE: FAX:
More informationSiding Program Application
Siding Prgram Applicatin Please read the attached Plicy Guidelines and prvide the requested infrmatin. 1. Address f Prperty: 2. Applicant s name & mailing address: Telephne: ( ) - E-mail 3. Applying fr:
More informationThere are two ways to submit your banking information for direct deposit into your personal bank account:
Cmpleting Yur Master Student Financial Assistance (MSFAA) Agreements Alberta and Canada have lifetime Master Student Financial Assistance Agreements (MSFAAs) that will cver yu fr all f the time yu are
More informationELECTRONIC FILING INSTRUCTIONS
ELECTRONIC FILING INSTRUCTIONS IN RE VIRTUS INVESTMENT PARTNERS, INC. SECURITIES LITIGATION I. Imprtant Ntes PLEASE READ Electrnic claim submissin is available t institutins filing n their wn behalf r
More informationChanges to the Sterilization Consent Form and Instructions, Approval Process, and Denial Letter
Changes t the Sterilizatin Cnsent Frm and Instructins, Apprval Prcess, and Denial Letter Infrmatin psted July 15, 2016 Nte: This article applies t transactins submitted t TMHP fr prcessing. Fr transactins
More informationPAYMENT BY CARD TERMS & CONDITIONS
PAYMENT BY CARD TERMS & CONDITIONS Versin 2.0 - June 2013 Effective frm 1 st June 2013 Issued n 1 st June 2013 Terms & Cnditins fr use f Credit/Debit card fr Payments (POS) Intrductin This Service is ffered
More informationSnap Deposit User Agreement
Snap Depsit User Agreement This Agreement cntains the terms and cnditins fr the use f LGE Snap Depsit, the mbile depsit capture service ( Snap Depsit r Services ) and/r ther remte services that LGE Cmmunity
More informationELECTRONIC FILING INSTRUCTIONS Commvault Systems, Inc. Securities Litigation
ELECTRONIC FILING INSTRUCTIONS Cmmvault Systems, Inc. Securities Litigatin I. Imprtant Ntes PLEASE READ Electrnic claim submissin is available t institutins filing n their wn behalf r n behalf f thers
More informationPAYMENT PLAN REQUEST INFORMATION Texas Property Code - Section (Not Applicable for Condominium Associations Governed Under Section 82)
PAYMENT PLAN REQUEST INFORMATION Texas Prperty Cde - Sectin 209.0062 (Nt Applicable fr Cndminium Assciatins Gverned Under Sectin 82) This dcument includes infrmatin regarding a payment plan request in
More informationTD Bank Mobile Deposit Addendum to the Online Banking Service Agreement
TD Bank Mbile Depsit Addendum t the Online Banking Service Agreement Please carefully review these terms and cnditins befre prceeding: As a subscriber t the TD Bank Mbile Depsit Service (the "Service")
More informationCORPORATE ONLINE BANKING SERVICE APPLICATION FORM(ENQUIRY ONLY) SECTION 1: ACCOUNT HOLDER S INFORMATION
BANK OF CHINA Singapre Branch www.bankfchina.cm/sg CORPORATE ONLINE BANKING SERVICE APPLICATION FORM(ENQUIRY ONLY) SECTION 1: ACCOUNT HOLDER S INFORMATION * f Accunt Hlder 1 *Mailing Address 1 Ntice Email
More informationCHARTER OF THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS OF PLURALSIGHT, INC. Adopted May 3, 2018
CHARTER OF THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS OF PLURALSIGHT, INC. Adpted May 3, 2018 PURPOSE The purpse f the Cmpensatin Cmmittee (the Cmpensatin Cmmittee ) f the Bard f Directrs (the
More information(FAMILY NAME) Qualified Small Employer Health Reimbursement Arrangement
(FAMILY NAME) Qualified Small Emplyer Health Reimbursement Arrangement Effective Date: Emplyer / Plan Administratr Emplyer Name: Address: Phne Number: ( ) - Federal Emplyer Identificatin Number: The emplyer
More informationELECTRONIC FILING INSTRUCTIONS LOGITECH FAIR FUND
ELECTRONIC FILING INSTRUCTIONS LOGITECH FAIR FUND I. Imprtant Ntes PLEASE READ Page 1 f 8 Electrnic claim submissin is available t institutins filing n their wn behalf r n behalf f thers as well as t claim
More informationREFERENCE NUMBER: PFS.PDS.115. TITLE: Patient Billing and Collections CURRENT EFFECTIVE DATE: 01/01/2018. PAGE 1 of 8 SCOPE:
PAGE 1 f 8 SCOPE: This Patient Billing and Cllectins Plicy applies t all Presbyterian Healthcare Services (Presbyterian) hspital facilities, including inpatient, utpatient, hme health care services and
More informationInformational Sheet- Application for Pension
33 Plaza La Prensa, Santa Fe, NM 87507 (505) 476-9401 Fax (505)476-9300 Vice (800) 342-3422 Tll-Free www.nmpera.rg Infrmatinal Sheet- Applicatin fr Pensin If yu are cnsidering retiring, PERA requests that
More informationPetition to Rezone Packet
Petitin t Rezne Packet Cntents Prcedure and Required Materials Petitin Applicatin Affidavit Permissin t Reprduce Cnfirmatin f Ownership by Owner; and Authrizatin fr Agent r Petitiner, when a different
More informationThe commission related to the dividend payment is supported by BVB.
ANNOUNCEMENT May 16, 2017 DIVIDEND ALLOCATION PROCEDURE BURSA DE VALORI BUCUREȘTI SA In accrdance with the reslutin f the Ordinary General Meeting f Sharehlders f April 12, 2017, Bursa de Valri București
More informationChecking and Savings Account Application
Checking and Savings Accunt Applicatin Please use the Checking and Savings Accunt Applicatin t: Open a FREE Checking r Dividend Checking and Opt-in r Out f DCU s Overdraft Payment Service including an
More informationPershing Financial Services Guide (FSG) including its Privacy Policy
Pershing Financial Services Guide (FSG) including its Privacy Plicy Issued by Pershing Securities Australia Pty Ltd ABN 60 136 184 962 Australian Financial Services License N. 338 264 Date FSG was prepared:
More informationThis financial planning agreement (the Agreement ) is made on this date: between the undersigned party, whose mailing address is
F I N A N C I A L P L A N N I N G A G R E E M E N T This financial planning agreement (the Agreement ) is made n this date: between the undersigned party, CLIENT(s): whse mailing address is (hereinafter
More informationThe Safety Net Foundation
The Safety Net Fundatin Instructins fr Kineret (anakinra) and Sensipar (cinacalcet HCl) Instructins The Safety Net Fundatin prvides temprary prduct assistance t financially needy patients wh meet predetermined
More informationVA Mortgage Lender License New Application Checklist (Company)
VA Mrtgage Lender License New Applicatin Checklist (Cmpany) CHECKLIST SECTIONS General Infrmatin License Fees Requirements Cmpleted in Requirements/Dcuments Upladed in Requirements Submitted Outside f
More informationThis policy outlines the Company s guidelines, expectations and requirements related to:
COMMUNICATION & RELEASE OF INFORMATION POLICY #77 Intrductin This plicy utlines the Cmpany s guidelines, expectatins and requirements related t: Use f devices t capture phtgraphs, vide and/r audi while
More informationFINANCIAL SERVICES GUIDE
PART N: iinvest Securities Financial Services Guide (FSG) FINANCIAL SERVICES GUIDE DATED: Octber 2017 Cntents f this FSG This Financial Services Guide ( FSG ) is an imprtant dcument that iinvest Securities
More informationRelocation/Moving Procedures for New Employees
Relcatin/Mving Prcedures fr New Emplyees Purpse T prvide guidelines and restrictins regarding thse cases where relcatin csts are necessary fr an individual t accept emplyment with the University and t
More informationSummary Plan Descriptions (SPD)
Descriptins (SPD) SPDs What Are They and Wh Needs Them? What is an SPD? The DOL defines the SPD as the Primary vehicle fr infrming participants and beneficiaries abut their plan and hw it perates. Must
More informationCertification of Beneficial Owner(s)
Certificatin f Beneficial Owner(s) GENERAL INSTRUCTIONS T help the gvernment fight financial crime, federal regulatin requires certain financial institutins t btain, verify, and recrd infrmatin abut the
More informationFAQS ON DEBT CONSOLIDATION PLAN
1. What is Debt Cnslidatin Plan (DCP)? Debt Cnslidatin is a debt refinancing prgram which ffers a custmer the ptin t cnslidate all his unsecured credit facilities (such as credit cards and sme types f
More informationBASHR Frequently Asked Questions
BASHR Frequently Asked Questins General What is BASHR Service? It is an integrated e-service granting investrs the ability t establish a business in UAE within a few minutes in a quick, easy and secure
More informationTWU OFFICE OF RESEARCH & SPONSORED PROGRAMS INSTRUCTIONS FOR USING THE TWU PROPOSAL APPROVAL ROUTING FORM
TWU OFFICE OF RESEARCH & SPONSORED PROGRAMS INSTRUCTIONS FOR USING THE TWU PROPOSAL APPROVAL ROUTING FORM Phne: (940) 898-3375 Website: http://www.twu.edu/research/ WHEN TO SUBMIT THROUGH RESEARCH & SPONSORED
More informationPrivacy Notice for Applicants and Tenants
Privacy Ntice fr Applicants and Tenants What we need Scttish Brders Husing Assciatin (SBHA) will be a "cntrller" f the persnal infrmatin that yu prvide t us thrugh yur cmpleted Husing Applicatin Frm, and
More informationResolving Frequently Asked Questions
Frm ADV Part 1A Updates Reslving Frequently Asked Questins Presented by: Stephen Gallett, Esq. Cary Kvitka, Esq. Max Schatzw, Esq. 609.219.7450 Prvide Backgrund n: Agenda New and Revised Questins in Item
More informationInstitute For Orthopaedic Surgery (IOS) Subject: Billing and Payments: General Guidelines
Institute Fr Orthpaedic Surgery (IOS) Plicy and Prcedure Manual Subject: Billing and Payment: General Statements Purpse: T prvide directin t staff members in their interactin with patients and guarantrs
More informationPrivacy & Data Protection Policy
Privacy & Data Prtectin Plicy Whitby & District Fishing Industry Training Schl Limited and 54 Nrth Maritime Training ("Whitby Fishing Schl", WDFITS, 54 Nrth Maritime "we" r "us") are cmmitted t prmting
More informationPROCESS FOR NATIONAL CAPITOL AREA GARDEN DISTRICTS, CLUBS AND COUNCILS CHOOSING TO FILE FOR 501(C)3 GROUP EXEMPTION
PROCESS FOR NATIONAL CAPITOL AREA GARDEN DISTRICTS, CLUBS AND COUNCILS CHOOSING TO FILE FOR 501(C)3 GROUP EXEMPTION What is a grup exemptin letter? The IRS smetimes recgnizes a grup f rganizatins as tax-exempt
More informationHawaii Division of Financial Institutions 2018 Renewal Checklist
Hawaii Divisin f Financial Institutins 2018 Renewal Checklist Instructins Renewal requests must be submitted thrugh by the date specified by yur state regulatr(s). Click here t review all renewal deadlines,
More information1. REIMBURSEMENTS FOR EXPENSES: 2. REQUESTING CHECKS:
Mnetary Plicies and Prcedures PTO funds are intended t benefit the students thrugh the enhancement f schl prgrams and activities. The PTO Officers are the guardians f these funds and have an bligatin t
More informationSubject Access Requests
Subject Access Requests The Data Prtectin Act 1998 gives rights t individuals in respect f the persnal data that rganisatins hld abut them. One f thse rights is the right t get a cpy f the infrmatin that
More informationMD Collection Agency License Amendment Checklist (Company)
MD Cllectin Agency License Amendment Checklist (Cmpany) CHECKLIST SECTIONS General Infrmatin Amendments GENERAL INFORMATION Instructins Maryland Cmmissiner f Financial Regulatin (MD) Agency des nt require
More informationSummit Asset Managers Limited
Irish Infrastructure Trust Privacy Ntice Intrductin This ntice sets ut details f hw and why Summit Asset Managers Limited, f Beresfrd Curt,, Dublin 1, Ireland, acting n behalf the Irish Infrastructure
More informationTERMS AND CONDITIONS FOR APPOINTMENT OF INDEPENDENT DIRECTOR
TERMS AND CONDITIONS FOR APPOINTMENT OF INDEPENDENT DIRECTOR 1 PRIVATE & CONFIDENTIAL Date: T, Independent Directrs, Subject: Appintment as an Independent Directr InfBeans Technlgies Limited Dear Sir/Madam,
More informationJoining SportsWareOnLine
Dear new MBU Student-Athletes, Prir t participating n an athletic team fr Missuri Baptist University (MBU), student-athletes must prvide the Athletic Training Department with lcal and permanent addresses,
More informationRegion 5 Student Paper Reimbursement Procedure
Regin 5 Student Paper Reimbursement Prcedure Prcedure fr student cmpetitin awards winners fr receptin f their prize mney frm Regin 5. This includes the prcedure fr Area student papers awards mnies receptin.
More informationDirect Entry Pre-Approval Requirements for Level II Technician Candidates
Direct Entry Pre-Apprval Requirements fr Level II Technician Candidates The Direct Entry prgram is intended t allw rpe access technicians wh have btained rpe access skills and experience n an industrial
More informationInstitute For Orthopaedic Surgery (IOS) Subject: Healthcare Financial Assistance Policy
Institute Fr Orthpaedic Surgery (IOS) Subject: Healthcare Financial Assistance Plicy Plicy and Prcedure Manual Subject: HealthCare Financial Assistance Plicy Purpse: T establish guidelines fr financial
More informationIRS 2016 FEDERAL TAX TRANSCRIPT INFORMATION
Financial Aid Office P.O. Bx 6905 Radfrd, VA 24142 Phne: (540) 831-5408 Fax: (540) 831-5138 finaid@radfrd.edu RU Financial Aid Website: http://www.radfrd.edu/finaid IRS 2016 FEDERAL TAX TRANSCRIPT INFORMATION
More informationLRR Energy Securities Litigation Settlement
Page 1 f 7 ELECTRONIC FILING INSTRUCTIONS I. Imprtant Ntes PLEASE READ In additin t these instructins, please review the details set frth in the claim frm and ntice prir t submitting claims. Electrnic
More informationInformation Package CAFETERIA 125 PLANS
Infrmatin Package CAFETERIA 125 PLANS Shaffer Insurance Services, Inc. Benefits Divisin 902 E. Ave Q-9 Palmdale Ca. 93550 Tll Free (866) 412-5872 Office Tel (661) 575 9331 Fax (661) 280 2016 Sectin 125
More informationWhat to Do Who How to Do It Purchasing Card Procedures: Purchase to Reconciliation
Purchasing Card Prcedures: Purchase t Recnciliatin Descriptin- These prcedures detail the department s required activities fr the Purchasing Card Prgram including purchase; transactin review and assignment
More informationMICRO GROUP EMPLOYER DOCUMENTATION REQUIREMENTS
Seattle, Washingtn 98101 MICRO GROUP EMPLOYER DOCUMENTATION REQUIREMENTS D nt cancel any existing plicies until yu receive cnfirmatin f final rates and/r acceptance f the grup by Regence BlueShield (Regence).
More informationWhat credit related information do we collect and hold and how do we collect it?
In this Credit Reprting Plicy, ORIX, we, us and ur mean ORIX Australia Crpratin Limited and ur related cmpanies. Thse related cmpanies may als have their wn privacy r credit reprting plicies which set
More informationNATCHITOCHES HISTORIC DISTRICT DEVELOPMENT COMMISSION STATE OF LOUISIANA
NATCHITOCHES HISTORIC DISTRICT DEVELOPMENT COMMISSION STATE OF LOUISIANA Independent Accuntants* Reprt n Applying Agreed-Upn Prcedures June 30, 2013 GRIFFIN & COAAPANY, LLC CERTIFIED PUBLIC ACCOUNTANTS
More informationISA CERTIFIED ARBORIST APPLICATION
ISA CERTIFIED ARBORIST APPLICATION This applicatin must be received at least 12 WORKING DAYS prir t the date f the chapter r assciate rganizatin exam fr which yu are applying. There is n deadline fr the
More informationSaba Software Inc. Settlement
Page 1 f 7 ELECTRONIC FILING INSTRUCTIONS I. Imprtant Ntes PLEASE READ In additin t these instructins, please review the details set frth in the claim frm and ntice prir t submitting claims. Electrnic
More informationapplication affiliate name address Website
applicatin Fr nrth american affilites year ($100 per year) new renewal affiliate name address Website designate the twn, state r prvince and cuntry that will be cnsidered the hme address f this affiliate.
More informationCharter Township of Oakland 4393 Collins Road, Rochester, MI Public Summary of FOIA Procedures and Guidelines
Charter Twnship f Oakland 4393 Cllins Rad, Rchester, MI 48306 248-651-4440 Public Summary f FOIA Prcedures and Guidelines Cnsistent with the Michigan Freedm f Infrmatin Act (FOIA), Public Act 442 f 1976,
More informationPLAN DOCUMENT TEMPORARY DISABILITY INSURANCE PROGRAM FOR LAY EMPLOYEES DIOCESE OF METUCHEN OFFICE OF HUMAN RESOURCES. Effective January 1, 2014
DIOCESE OF METUCHEN OFFICE OF HUMAN RESOURCES TEMPORARY DISABILITY INSURANCE PROGRAM FOR LAY EMPLOYEES PLAN DOCUMENT Effective January 1, 2014 (Replaces January 1, 2013 Plan Dcument) 1 CONTENTS OVERVIEW...
More informationAPPLICATION FOR RESIDENTIAL TENANCY
Head ffice: 7/29 Cllier Rad, Mrley WA 6062 (08) 9207 2088 Wangara ffice: 1/7 Prindiville Dr, Wangara WA 6065 (08) 9409 7577 admin@xceedre.cm.au 1. PROPERTY DETAILS APPLICATION FOR RESIDENTIAL TENANCY PROPERTY
More informationPreparing for Your Early Retirement
Preparing fr Yur Early Retirement Imprtant Infrmatin fr Railrad Emplyees Eligible fr GA-46000 Eligibility fr Railrad Annuity Railrad Retirement Bard https://secure.rrb.gv/ Call yur lcal Railrad Retirement
More informationJOHN L. LITTLE, D.D.S, P.A ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. May Refuse to Sign This Acknowledgement-
JOHN L. LITTLE, D.D.S, P.A ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES -Yu I, Privacy Practices. May Refuse t Sign This Acknwledgement- ---, have received a cpy f this ffice's Ntice f {Please
More informationClosing Out Award. The PI will work with ORA in obtaining the applicable resolution. Residuals
Clseut All spnsred prject awards must be frmally clsed-ut as sn as pssible after the prject end date t ensure that all expenses psted t this prject are allwable, n additinal charges are psted, all payments
More informationAgency Reorganization Process
Overview Definitins Respnsibilities This instructinal guide identifies the sequential steps that an agency must fllw when prcessing an agency rerganizatin in the Peple First system. Fllwing these steps
More informationGuide to Young Adult Dependent Coverage
Guide t Yung Adult Dependent Cverage The New Yrk State Legislature passed a law in 2009 which extends the availability f health insurance cverage t yung adults thrugh the age f 29. As a result, Freelancers
More informationHP DesignJet Cash In & Trade In (Canada)
HP DesignJet Cash In & Trade In (Canada) March 1, 2017 April 30, 2017 Prgram Terms and Cnditins Prgram Overview Effective March 1, 2017 t April 30, 2017, purchase r lease an eligible HP DesignJet Printer
More informationTRID Rule Purchase For Applications dated on or after 10/3/2015
Fr Applicatins dated n r after 10/3/2015 This dcument prvides a brief verview f the TRID Rule s requirements and specifies the purchase requirements fr CMG Mrtgage, Inc., dba CMG Financial, (CMG). CMG
More informationSRP Business Solutions: Electric Technology Rebates Forklift Rebate Application (Customer)
SRP Business Slutins: Electric Technlgy Rebates Frklift Rebate Applicatin (Custmer) Instructins: Fill ut this rebate applicatin cmpletely and sign. Attach required dcumentatin: all invices shwing dates
More informationSt. Paul s Lutheran Grade School Tuition Agreement Form
St. Paul s Lutheran Grade Schl Tuitin Agreement Frm Schl Year: 2017-2018 2017-18 tuitin schedule is listed n the bttm f this dcument. St. Paul s Lutheran Grade Schl strives t prvide an envirnment cnducive
More information