Form Completion Sample Clauses

Form Completion. There will be a $25.00 fee for all insurance and disability forms needing to be filled out by the physician. Due to safety concerns, children are NOT permitted into the examination areas. Children must be accompanied and supervised by an adult at all times. NO EXCEPTIONS We reserve the right to reschedule your appointment if necessary. Date Injury Occurred: / / Time of Injury: Time Arrived at Clinic: Did your employer authorize your visit today? □ Yes □ No Name:

Form Completion. Enter the full legal name, physical address, telephone number and email address of the child care provider. Read the entire document.

Form Completion. There is a $10.00 fee for the completion of any form.

Form Completion. Forms needing completion outside of scheduled patient appointments may be dropped off at the practice. A practice representative will call when they are ready to be picked up, or we will send to appropriate designee. Fees for form completion are as follows: 1 page, $5.00 2 or more pages, $10.00 FMLA, $25.00

Form Completion. 1. The DSHS Representative completes the following information:

Form Completion. There may be a time when you are required to have your provider complete a form for you. This could be FMLA, disability, AFLAC, injury reports, etc. There is a charge for the completion of these forms, and that charge will be applied to your account. This charge is your responsibility, as insurance will not cover it. Also, we

Form Completion. FMLA and Disability forms require time and medical review therefore there is a $25.00 charge per form. Please allow 48-72 hours for completion.

Form Completion. This Practice charges a $20 fee for completion of any forms requested by patient including, but not limited to, supplemental insurance, disability and FMLA paperwork. This fee is due at the time disability forms are submitted.

Form Completion. Agreement Number: Enter the number of the Work Experience Agreement, DSHS 11-046, under which the referral is being made which is the same number as the Work Experience Agreement with the WEX Agency. Community Services Office (CSO) Number: Enter the CSO Number. Referral