INFORMATION TO BE RELEASED Sample Clauses

The "INFORMATION TO BE RELEASED" clause defines what specific information a party is permitted or required to disclose under the agreement. Typically, this clause outlines the categories or types of information that may be shared, such as personal data, business records, or confidential materials, and may set conditions or limitations on such disclosures. Its core function is to ensure clarity and mutual understanding about the scope of information that can be released, thereby preventing unauthorized disclosures and protecting sensitive data.
INFORMATION TO BE RELEASED. Copies of chart notes.
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INFORMATION TO BE RELEASED. Complete Medical Record Including Billing Statement and Reports Billing Statements Laboratory Reports Dental Records
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INFORMATION TO BE RELEASED. This is a full disclosure authorization of health care information which includes health care maintenance records, and medical, surgical, sexually-transmitted disease, mental health, alcohol or other drug abuse care and treatment records, if any. This consent also authorizes the disclosure of HIV test results, if any. These records will be disclosed unless you specify information you wish excluded. Please initial below information you do not want released: NO Exclusions. Exclude: Exclude HIV test results INITIAL INITIAL Exclude Substance Abuse treatment information Exclude Mental Health treatment information _____ Exclude other information INITIAL This Authorization is effective immediately and will remain in effect for one year or until (date or event) Date Patient Signature SIGNATURE OF HOSPITAL STAFF WHEN REQUIRE Signature of Parent, Guardian, etc. Relationship EMPLOYEE NAME DATE LOCAL COURT FORM (MANDATORY) NEW, EFFECTIVE 11/1/19 MH-005 AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Attachment 5 Docket No. (rpt. period every 30 days) Treatment Provider: Contra Costa County Superior Court’s Mental Health Diversion Program requires monthly reports of participant’s progress in treatment. A separate form must be completed for every 30 days of treatment. Please reference the treatment plan when you complete the entire form and provide to the participant or his/her attorney of record. Please submit at the end of each month. The last month’s report in the progress period must be submitted at least two days before the next court date (noted above).
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INFORMATION TO BE RELEASED. (Check all that apply)
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INFORMATION TO BE RELEASED. Check one of the following boxes:
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INFORMATION TO BE RELEASED. Participant’s job title Job start date Hours worked per week Beginning wage Current employment status Current wage Job end date Benefits available to participant in current job This authorization expires on: / /
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Related to INFORMATION TO BE RELEASED

  • Information to be Furnished If Tenant desires at any time to Sublet the Premises or any portion thereof, it shall first notify Landlord of its desire to do so and shall submit in writing to Landlord: (i) the name of the proposed Subtenant; (ii) the nature of the proposed Subtenant's business to be carried on in the Premises; (iii) the terms and provisions of the proposed Sublet and a copy of the proposed Sublet form containing a description of the subject premises; and (iv) such financial information, including financial statements, as Landlord may reasonably request concerning the proposed Subtenant.

  • Additional Information to be Furnished The Master Servicer shall furnish to the Issuer and the Indenture Trustee from time to time such additional information regarding the Mortgage Loans and the Bonds as the Issuer and the Indenture Trustee shall reasonably request.

  • Information to be Supplied (a) The information supplied or to be supplied by the Company for inclusion or incorporation by reference in (i) the Registration Statement will, at the time the Registration Statement is filed with the SEC and at the time it becomes effective under the Securities Act, not contain any untrue statement of a material fact or omit to state any material fact required to be stated therein or necessary in order to make the statements therein not misleading and (ii) the Schedule 13E-3 will, at the time it is first filed with the SEC and at any time it is amended or supplemented, not contain any untrue statement of a material fact or omit to state any material fact required to be stated therein or necessary in order to make the statements therein not misleading. (b) The Proxy Statement will, at the time of the mailing thereof and at the time of the Company Stockholder Meeting, not contain any untrue statement of a material fact or omit to state any material fact required to be stated therein or necessary in order to make the statements therein, in light of the circumstances under which they are made, not misleading or omit to state any material fact necessary to correct any statement in any earlier communication with respect to the solicitation of proxies for the Company Stockholder Meeting which has become untrue or misleading. (c) The Registration Statement and the Schedule 13E-3 (in each case with respect to information provided by or incorporated by reference from, the Company) and the Proxy Statement will comply as to form in all material respects with the provisions of the Securities Act and the Exchange Act. (d) Notwithstanding the foregoing, the Company makes no representation or warranty with respect to any statements made or incorporated by reference in the Registration Statement, the Proxy Statement or the Schedule 13E-3 based on information supplied by Holding or Acquiror for inclusion or incorporation by reference therein.

  • POPULATION TO BE SERVED In accordance with the Contract, Contractor is required, within the limits of the Contractor’s service capacity, to serve individuals who meet the financial and clinical eligibility criteria for Seriously Emotionally Disturbed (SED) children and adolescents eligible for services as described in the DARHMA manual.

  • Additional Information to be Furnished to the Issuer The Administrator shall furnish to the Issuer from time to time such additional information regarding the Collateral as the Issuer shall reasonably request.