Payment Authorization; Execution Clause Samples

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: ▇▇▇▇▇▇ ▇▇▇▇▇▇, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH ▇. ▇▇▇▇▇▇ ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE ▇. ACKNOWLEDGED AND AGREED INITIALS: ▇. 3RD MEMBER’S NAME B. DATE OF BIRTH ▇. ▇▇▇▇▇▇ ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE ▇. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH ▇. ▇▇▇▇▇▇ ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE ▇. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Enti...
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Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to ▇▇▇▇ one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: Cardholder Name Card Number Expiration Credit Card Zip Code Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. Signature Print Name Member Name from Member Agreement Acknowledged and Agreed (Initials) Member Name Date of Birth Email Address Home Phone Cell Phone Office Phone Fax Mailing Address City State Zip Code Member Name Date of Birth Email Address Home Phone Cell Phone Office Phone Fax Mailing Address City State Zip Code Member Name Date of Birth Email Address Home Phone Cell Phone Office Phone Fax Mailing Address City State Zip Code By signing this Authorization, I hereby authorize and direct the use or disclosure of certain information pertaining to me, my health or my health care that is maintained by ▇▇▇▇ ▇▇▇▇▇ COMMUNICATIONS LLC. 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the En...
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Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to ▇▇▇▇ oneVfourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: ▇▇▇▇▇ ▇. ▇▇▇▇▇▇, President
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Payment Authorization; Execution. Program Member tenders together with this Agreement the Member Amenities Fee and authorizes Personalized Care Practice's designee to bill the Member Amenities Fee per calendar year payable in advance to Program Member's: Visa MC Discover AMEX CVV ZIPCODE
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Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to ▇▇▇▇ one-­‐fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands and agrees to send checks for applicable Member Amenities Fees to: This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. LLE Holding PLLC d/b/a LEAMC Personalized Care, PLLC (Print Name) Name: ▇▇▇▇ ▇. ▇▇▇▇▇▇▇, M.D., F.A.C.P. Title: Member By signing this Authorization, I hereby authorize and direct the use or disclosure of certain information pertaining to me, my health or my health care that is maintained by ▇. ▇▇▇▇▇▇▇ & Associates Medical Clinic, PLLC (the “Entity”). 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity.
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Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: ▇▇▇▇▇▇ ▇. ▇▇▇▇▇, ▇▇., MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH ▇. ▇▇▇▇▇▇ ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE
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Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to ▇▇▇▇ oneVfourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARD NO. Program Member understands that credit card payments will be processed by ǍdŽnsYǍMD, Inc. and agrees to make payments by check payable to “ ÃdŽnsYÃMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: 'ǦŽdÖǦ >˙ ZǍǍEΣ DD * Signature MD, Inc., a California corporation doing business in the states of North Carolina and South Carolina as CarolinaMD, is not affiliated or associated in any way with the Charlotte-based concierge medical practice, Signature Healthcare, PLLC.
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Payment Authorization; Execution. In order for this Agreement to become effective, please return a signed copy of the Agreement along with the payment (please choose one):  Check for the amount of $1,100 payable to “Foundation for Better Healthcare” is attached; or  Please charge the annual Membership Fee of $1,100 to the following credit / debit / HSA account card Card Number Expiration (MM/YY) Cardholder’s Name as Printed on the Credit Card Verification code Billing address if different from the mailing address listed above Program Member Signature ▇▇▇▇ ▇▇▇▇▇▇▇, M.D., dba Foundation for Better Healthcare Date: Date: Please mail the signed Agreement and payment to: Foundation for Better Healthcare c/o First Internal Medicine ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇
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Payment Authorization; Execution. This Agreement becomes effective upon receipt from Program Member this signed Agreement and either (i) check payable to “Foundation for Better Healthcare” tendered together with this Agreement, or (ii) approved charge to the credit card provided herein to which Program Member hereby authorizes Foundation for Better Healthcare to ▇▇▇▇ the above Membership Fee:
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Related to Payment Authorization; Execution

  • Payment Authorization I authorize ▇▇▇▇▇ Management to collect payment of the application fee and application deposit in the amounts specified under paragraph 3 of the Disclosures.

  • AGENT AUTHORIZATION FORM I/We, (Print Bidder name) , Do hereby authorize (print agent’s name), , to act as my/our agent to execute any petitions or other documents necessary to affect the CONTRACT approval PROCESS more specifically described as follows, (IFB NUMBER AND TITLE) , and to appear on my/our behalf before any administrative or legislative body in the county considering this CONTRACT and to act in all respects as our agent in matters pertaining TO THIS CONTRACT. Signature of Bidder Date STATE OF FLORIDA ) COUNTY OF ) The foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 , by [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]. ☐Personally Known; OR ☐Produced Identification. Type of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public My Commission Expires: (Printed, typed or stamped commissioned name of Notary Public) I affirm that an employee leasing company provides my workers’ compensation coverage. I further understand that my contract with the employee leasing company limits my workers’ compensation coverage to enrolled worksite employees only. My leasing arrangement does not cover un-enrolled worksite employees, independent contractors, uninsured sub-contractors or casual labor exposure. I hereby certify that 100% of my workers are covered as worksite employees with the employee leasing company. I certify that I do not hire any casual or uninsured labor outside the employee leasing arrangement. I agree to notify the County in the event that I have any workers not covered by the employee leasing workers’ compensation policy. In the event that I have any workers not subject to the employee leasing arrangement, I agree to obtain a separate workers’ compensation policy to cover these workers. I further agree to provide the County with a certificate of insurance providing proof of workers’ compensation coverage prior to these workers entering any County jobsite. I further agree to notify the County if my employee leasing arrangement terminates with the employee leasing company and I understand that I am required to furnish proof of replacement workers’ compensation coverage prior to the termination of the employee leasing arrangement. I certify that I have workers’ compensation coverage for all of my workers through the employee leasing arrangement specified below: Workers’ Compensation Carrier: A.M. Best Rating of Carrier: Inception Date of Leasing Arrangement: I further agree to notify the County in the event that I switch employee-leasing companies. I recognize that I have an obligation to supply an updated workers’ compensation certificate to the County that documents the change of carrier. Signature of Owner/Officer: Title: Date: If the bidder is submitting as a joint venture, please be advised that this form MUST be completed and the REQUESTED written joint-venture agreement MUST be attached and submitted with this form.

  • Agent Authorization After the occurrence and during the continuance of any Default (including the commencement and continuation of any proceeding under any Bankruptcy Law relating to any other Loan Party), the Agent is authorized and empowered (but without any obligation to so do), in its discretion, (i) in the name of each Guarantor, to collect and enforce, and to submit claims in respect of, Subordinated Obligations and to apply any amounts received thereon to the Guaranteed Obligations (including any and all Post Petition Interest), and (ii) to require each Guarantor (A) to collect and enforce, and to submit claims in respect of, Subordinated Obligations and (B) to pay any amounts received on such obligations to the Agent for application to the Guaranteed Obligations (including any and all Post Petition Interest).

  • Appointment; Authorization Each Lender hereby irrevocably appoints, designates and authorizes Agent to take such action on its behalf under the provisions of this Agreement and each other Loan Document and to exercise such powers and perform such duties as are expressly delegated to it by the terms of this Agreement or any other Loan Document, together with such powers as are reasonably incidental thereto. Notwithstanding any provision to the contrary contained elsewhere in this Agreement or in any other Loan Document, Agent shall not have any duty or responsibility except those expressly set forth herein, nor shall Agent have or be deemed to have any fiduciary relationship with any Lender, and no implied covenants, functions, responsibilities, duties, obligations or liabilities shall be read into this Agreement or any other Loan Document or otherwise exist against Agent.

  • AGREEMENT AUTHORITY ‌ 5.1 PDL NPDL shall sell and PFLG shall purchase, on a used/not used basis, thirty percent (30%) of the space available on the vessel (or a maximum of 30% of the capacity of the vessel by weight) (including thirty percent (30%) of the available reefer plug capacity) on each sailing of PDL’s NPDL's vessel in the Trade. Additional slots may be sold/purchased on an ad 1 The inclusion of non-U.S. trades within the scope of this Agreement does not bring such trades within the scope of the U.S. Shipping Act or the jurisdiction of the Federal Maritime Commission ("FMC"). hoc basis, and such additional space shall not be unreasonably withheld. To determine the space allocation used by any breakbulk cargo loaded on the Vessel pursuant to this Agreement, the amount of any such breakbulk cargo shall be converted at a rate of 17 revenue tonnes per TEU. 5.2 The sale of slots under Article 5.1 shall be on such terms and such conditions as the Parties may agree from time to time. 5.3 PFLG shall not sub-charter slots made available to it hereunder to any third party, including PFLG affiliates, without the prior written consent of PDL NPDL. 5.4 Each party is responsible for the port charges attributed to its own cargo, but are authorized to discuss and agree on their respective responsibilities for port charges assessed to PDL NPDL as the vessel operator at island ports in the trade. 5.5 The Parties are authorized to discuss and agree upon routine operational and administrative matters including, but not limited to, procedures for allocating space, forecasting, stevedoring and terminal operations, recordkeeping, responsibility for loss, damage or injury (including provisions of bills of lading relating to same), the interchange of information and data regarding all matters within the scope of this Agreement, terms and conditions for force majeure relief, insurance, guarantees, indemnification, and compliance with customs, safety, security, documentation, and other regulatory requirements. 5.6 Each Party shall retain its separate identity and shall have separate sales, pricing and marketing functions. Each Party shall issue its own bills of lading and handle its own claims. 5.7 The Parties shall collectively implement this Agreement by meetings, writings, or other communications between them or within committees established by them, and make such other arrangements as may be necessary or appropriate to effectuate the purposes and provisions of this Agreement.