ColumbiaDoctors. Adult New Patient Intake Form
|
|
- Juliana Barker
- 6 years ago
- Views:
Transcription
1 Name: DOB: ColumbiaDoctors Adult New Patient Intake Form Page 1 of 4 Patient Information Last Name: First Name: DOB: Gender: Home Phone: Mobile Phone: Preferred Phone: Home or Mobile (circle one) Emergency Contact: Re I at ions hip: Emergency Contact Phone: Patient Marital Status: cc up at ion: Em p Io ye r: Primary Care Provider (PCP): PCP Phone: Referring Provider: Referring Phone: Preferred Pharmacy: Pharm Phone: Preferred Pharmacy Address: Please list ALL active treating physicians (i.e. pulmonologist, oncologist, internist, cardiologist, etc... ) Doctor's Doctor's Name: Specialty: Doctor's Name: Specialty: Doctor's Name: Specialty: Doctor's Name: Specialty: Collection of the following information is encouraged by federal health agencies. This information is used to monitor and improve the quality of care provided to all patients. Ethnicity: Race: o Decline Response o Decline Response o Hispanic or Latino o American-Indian or Alaska Native o Not Hispanic or Latino o Asian o Black or African American o Native Hawaiian or Pacific Islander D White D Other Preferred Language: o Decline Response Patient Financial Obligation Agreement I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible an,d make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to Columbia Doctors for services rendered. I authorize representatives of ColumbiaDoctors to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. Notice of Privacy Practices: Acknowledgement of Receipt I acknowledge that I was provided with a copy of the Columbia Doctors Notice of Privacy Practices (NOPP). o Received o N/A (only if you received the notice from ColumbiaDoctors previously) Information Disclosure and Consent Columbia Doctors will provide you with the health plans that your provider(s) accepts*. If you decide to be treated by a provider who does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider. I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information). Patient or Legal Guardian Name (Print): Patient or Legal Guardian Signature: Date: *Please refer to our website: columbiadoctors.org, for a list of insurances accepted by your provider. Version 1.9 Updated: 12/19/2017
2 Name: DOB: ColumbiaDoctors Page 2 of 4 Reason for today's visit: General Medical Questionnaire Have you EVER had any of the following? Asthma/Breathing Problems... o Y o N Arthritis... o Y o N Bleeding/Clotting Disorder... o Y o N Blood Pressure Disorder... o Y o N Blood Transfusion... o Y o N Bowel/Stomach Problems... o Y o N Cancer... o Y o N Cholesterol Disorder... o Y o N Diabetes... o Y o N Eye Disorder (i.e. Glaucoma, cataract)... o Y o N Women Only: Gynecological Issues... o Y o N Heart Disease/Disorder... o Y o N Lung Disorder... o Y o N Liver Disease... o Y o N Neurological Disorder/Chronic Headaches.. o Y o N Psychiatric Disorder/Illness... o Y o N Pulmonary Embolism/DVT... o Y o N Stroke... o Y o N Seizure or Epilepsy... o Y o N Thyroid Disorder... o Y o N Urinary/Kidney Disorder... o Y o N Please list any other medical illnesses or problems and provide details for any of the above conditions: Please list all past surgeries and hospitalizations and the approximate date. Procedure/ Hospitalization Date Complications Please indicate any major conditions/illnesses that your immediate family members have had: Relative Condition and description Living? If deceased, at what age? Mother oy on Father oy on Sibling oy on Other: oy on Do you currently smoke? o Y o N If no, previously? o Y o N Years smoked --- Packs/day --- Do you use other tobacco products? o Y o N Consume alcohol? o Y o N If yes, drinks/week: --- Women Only: Any past pregnancies? o Yo N How many? -- How many deliveries? --- Version 1.9 Updated: 12/19/2017
3 ColumbiaDoctors Page 3 of 4 Please list ALL of your current medications, including over the counter medications, supplements, and herbs: Medication Name Dose Medication Name Dose Review of Systems Please indicate ALL that you have experienced within the past 6-12 months. Constitutional DYDN Fever DYDN Fatigue DYDN Weight Gain(_ Lbs) DYDN Sleep Disturbances DYDN Chills DYDN Feeling Poorly DYDN Weight Loss(_ Lbs) DYDN Sweats Head, Eyes, Ears, Nose, and Throat DYDN Unexp. Weight Change DYDN Vision Problem DYDN Red Eye s DYDN Congestion DYDN Hoarseness DYDN Decreased Hearing DYDN Eye Pain DYDN Snoring DYDN Ringing in Ears DYDN Double Vision oyon Runny Nose DYDN Dry Mouth oyon Vertigo DYDN Light Sensitivity DYDN Neck Stiffness DYDN Flu-Like Symptoms OYDN Earache DYDN Itchy Eyes DYDN Nosebleed DYDN Sore Throat DYDN Other: Cardiovascular DYDN Chest Pain DYDN Cold Extremities DYDN Irregular Heart Rhythm DYDN Palpitations DYDN Cold Hands or Feet DYDN Other: DYDN Leg Swelling DYDN Leg Pain w/ Walking Respiratory DYDN Shortness of Breath DYDN Wheezing DYDN Coughing Up Blood D DYDN Cough DYDN Shortness of Breath DYDN Coughing Up Sputum DYDN Rapid Breathing DYDN Chest Congestion o Other: Gastro i ntesti na 1 DYDN Abdominal Pain DYDN Blood in Stool DYDN Vomiting DYDN Nausea oyon Diarrhea oyon Change in Bowels oyon Painful Swallowing DYDN Black/Ta1rry Stools DYDN Vomiting Blood o Other: DYDN Decreased Appetite DYDN Bowel Incontinence DYDN Yellow Skin DYDN Rectal Pain Version 1.9 Updated: 12/20/2017
4 Name: DYDN Constipation Neurological DYDN Headache DYDN Dizziness DYDN Decreased Strength DYDN Poor Coordination Musculoskeletal DYDN Joint Pain DYDN Neck Pain DYDN Back Pain DOB: ColumbiaDoctors Page 4 of 4 DYDN Trouble Swallowing DYDN Unsteady DYDN Disorientation OYDN Confusion OYDN Burning Sensation DYDN Limb Pain DYDN Joint Swelling OYDN Muscle Cramps DYDN Heartburn DYDN Numbness DYDN Tingling OYDN Seizures DYDN Fainting (Syncope) DYDN Muscle Pain oyon Muscle Weakness OYDN Leg Swelling DYDN Tremor DYDN Memory Lapses/Loss Genitourinary DYDN Frequent Urination DYDN Pelvic Pain DYDN Painful Intercourse DYDN Heavy Period Bleeding DYDN Incontinence DYDN Nocturia DYDN Discharge- Vaginal DYDN Urinary Urgency DYDN Painful Urination DYDN Itching- Genital DYDN Change in Libido DYDN Vaginal Bleeding DYDN lrreg. Monthly Cycles lntegumentary DYDN Rash DYDN Dry Skin DYDN Skin Wound DYDN Change in A Mole DYDN Unusual Growth DYDN Itching DYDN Skin Cancer Psychiatric OYDN Depression DYDN Anxiety oother: Hematologic/Lymphatic DYDN Easy Bruising DYDN Easy Bleeding DYDN Swollen Lymph Nodes Endocrine DYDN Excessive Thirst OYDN Heat Intolerance DYDN Changes- Skin DYDN Cold Intolerance DYDN Changes- Hair o Other: OFFICE USE ONLY: Provider Signature: Date: Version 1.9 Updated: 12/20/2017
5 Additional Ophthalmology Information Chief Complaint: What is the main or primary problem with your eye(s), and when did you first notice symptoms or were you told of diagnosis? Past History: Do you have or have you had any of the following problems or conditions? Pleas.e answer ALL questions-indicate YES or NO. If the answer is YES, please provide a brief explanation. Glaucoma DYES ono Cataract DYES ono Droopy Eyelids o YES ono Double Vision o YES ono Dry Eye o YES ono Tearing DYES ono Lazy Eye (Amblyopia) o YES ono Crossed Eyes (Strabismus) o YES ono Macular Degeneration DYES ono Retinal Detachment o YES ono Eye Injury o YES ono Eye Inflammation o YES ono Thyroid eye disease/ Graves' disease o YES ono Laser Surgery o YES D NO Other o YES o NO o Previous eye surgery? What kind(s) o Previous face, brow, eyelid, tear duct, or orbital surgery? What kind(s) D Previous cosmetic facial procedures? (Botox, fillers, peels, LASER, etc.) EXPLANATION Sensitive to soaps? o YES ono Do you ever take Aspirin, Plavix, Coumadin, Lovenox? Tapes? o YES o YES ono ono History of slow or poor wound healing o YES o NO History of Keloids History of cold sores, herpes, shingles o YES ono History of skin cancer o YES o NO Type: History of other cancer(s) o YES ono Type: DYES D NO Hepatitis Positive HIV Test o YES o NO When? 0 YES o NO When? Type: A B C Problems tolerating anesthesia: To local anesthetic o YES o NO To general aesthetic o YES o NO Family History: Glaucoma o YES o NO Macular Degeneration o YES o NO Thyroid Disease o YES o NO Other eye conditions Version 1.9 Updated 12/20/2017
6 AUTHORIZATION OF BENEFITS Name of Beneficiary: Health Insurance Claim#: 1 request that payment of authorized health insurance benefits, including Medicare and Medigap, be made either to me or on my behalf to Dr. for services furnished to me by this provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, any information needed to determine these benefits payable for related services. Signature of Responsible Party: Date: Commercial Insurance I hereby authorize direct payment of surgical/medical benefits to Dr. for services rendered by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance, including co-pays, deductibles, refractions, and differences between surgeon's charges and allowable. I hereby authorize Dr. to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits. Signature of Responsible Party: Date: Advance notice regarding Insurance Reimbursement and Beneficiary Agreement I have been informed that refraction ( the measurement of one's eyeglass prescription and the determination of the best visual sharpness ) is usually not considered by insurance companies, health maintenance organizations, and Medicare to be medically reasonable of necessary. Knowing this, I have instructed the doctor to proceed with the services. If insurance decides to reduce or even deny the fee or services, I agree to pay the doctor's fee in full. Signature of Responsible Party: Date:
7 Eye Glass and Contact Lens Prescription Policy ColumbiaDoctors Ophthalmology does not accept vision insurance. You are responsible for fees of any services not covered by your medical insurance. *A 25% fitting fee reduction if contact lens brand and prescription are not changed. I. Refraction A. What is a refraction? Refraction is a test done to determine the refractive error of your eyes, or the need for corrective glasses and/or contact lenses. B. When do I have to pay for a refraction? Refraction (CPT code 92015) is a non-covered service by Medicare. As a result, your healthcare provider is required by CMS (the department to the federal government that controls Medicare) to charge for this service. Most insurance plans follow Medicare's rules. All these plans consider refraction a "vision" service, and not a "medical" service. C. How much do I have to pay? You will only be charged a refraction fee if you receive a prescription for glasses or contact lenses. Our office fee for refraction is $80. This is collected at the time of service in addition to any co-payment your plan may require. Should your plan pay us for the refraction, we will refund you accordingly.
8 D. Suggestions When Filling Your Prescription Since refraction is an inexact art in which errors may arise at any step, including from the patient, the doctor, and the optician making the eyeglasses, we suggest the following: 1. Fill your prescription at an establishment that will give you a warranty. At the very least, choose an optical that agrees to make at least one adjustment at no charge to you. if you are uncomfortable with the new prescription for whatever reason, this will enable us to make changes as necessary at no cost to you. 2. Start with purchasing only one pair of new glasses with the new prescription to ensure you are happy with your vision before purchasing new pairs. 3. Please address any legibility issues regarding the written prescription with the prescribing doctor prior to filling the prescription. 4. Change as few parameters like lens size and shape, lens company/brand (especially with progressive add spectacles), as possible, with your new glasses to minimize the risk of being uncomfortable with newly prescribed glasses. II. Non-Medically Necessary Contact Lens Fitting Please be aware that most medical insurance do not cover the portion of the eye examination to evaluate you for elective contact lenses. This part of the examination requires a separate evaluation in addition to the medical examination. Contact lenses are medical or cosmetic devices placed on a vital organ in your body. An improper fit may cause a host of problems including infection, permanent scarring, new growth of blood vessels, contact lens rejection and ultimately decreased vision. Based on FDA regulation, contact lens prescriptions are only valid for 1 YEAR. An annual contact lens evaluation is required. If you are also being seen for an ocular complaint that requires a medical examination, your insurance will be billed for the medical portion. III. What if my glasses or contact lenses don't fit well? Our physician will re-evaluate you at no charge within 60 days of your initial refraction to change your prescription if necessary. However, our office does not pay for revision of glasses in which good faith efforts were made in measuring and writing the prescription. I understand that refraction and contact lens examination are not included in my eye exam and there will be an additional fee. Refraction and contact lens fitting fees are non-refundable. Any changes that need to be made to your prescription must be made within 60 days of your examination. I have been fully informed and accept full responsibility to pay. Patient Name Patient Signature Date
9 Pharmacy Information Update Form As of Mairch 27, 2016, NYS Public Health Law requires your doctor t,o electronically prescribe (eprescribe) all your prescription medications directly to your pharmacy. Prescriptions will no longer be handwritten or called in to your pharmacy, except in limited circumstances. Please use this form to tell your doctor where you want your prescriptions filled. Your Name Date of Birth Cell Phone Home Phone Pharmacy Name D Retail Pharmacy Telephone D Mail Order Pharmacy Address City State -- D Please make this my default pharmacy 2. Pharmacy Name D Retail Pharmacy Telephone D Mail Order Pharmacy Address City State NABP # (if known) D Please make this my default pharmacy Page 1 of 1
MEDICATION GUIDE RIBAVIRIN TABLETS Rx Only Read this Medication Guide carefully before you start taking ribavirin tablets and read the Medication
MEDICATION GUIDE RIBAVIRIN TABLETS Rx Only Read this Medication Guide carefully before you start taking ribavirin tablets and read the Medication Guide each time you get more ribavirin tablets. There may
More informationEnoxaparin (Lovenox )
What is enoxaparin (Lovenox )? Enoxaparin is also called Lovenox Enoxaparin is an anticoagulant, or blood thinner, that works to prevent blood clots from forming in your body or treat blood clots after
More informationMedical History Questionnaire
Medical History Questionnaire Name: DOB: : Referring Physician: Primary Complaint: Dizziness Blacking out/fainting Lightheadedness Imbalance Falling Vertigo (spinning) Blurred Vision Unsteadiness Hearing
More informationSummer Youth Musical Theatre Workshop Application Form
Office Use Only: Date Rec d Full payment Rec d 2016 Summer Youth Musical Theatre Workshop Application Form PLEASE READ THIS APPLICATION CAREFULLY Please complete the entire application and mail it along
More informationBritish Midland Regional Limited Cabin Crew Employment Application Form
British Midland Regional Limited Cabin Crew Employment Application Form Please complete this form clearly and accurately, giving as many details as possible of your skills and experience relating to this
More informationAVONEX. What is in this Leaflet. What AVONEX is used for. Before you use AVONEX. Interferon beta-1a. Consumer Medicine Information
Interferon beta-1a Consumer Medicine Information What is in this Leaflet This leaflet answers some common questions about AVONEX Solution for Injection (also known as 'Pre- Filled Syringe') and AVONEX
More informationGuidelines for the Medical Clearance of Designated Ebola Caregivers in US Hospitals
Guidelines for the Medical Clearance of Designated Ebola Caregivers in US Hospitals American College of Occupational and Environmental Medicine Medical Center Occupational Health Section Prepared by the
More informationLearn more about why severe RSV disease APPROVED USE
Learn more about why severe RSV disease can turn a welcome home into a welcome back to the hospital APPROVED USE SYNAGIS (palivizumab) is a prescription medication that is used to help prevent a serious
More informationAPPLICATION FOR EMPLOYMENT AS AN INTERIM MANAGER
PO Box 493 Concord NSW 2137 02 8765 1200 Email: admin@blackadderassoc.com.au APPLICATION FOR EMPLOYMENT AS AN INTERIM MANAGER Address: APPLICANT INFORMATION Date of Surname Given Name (s) Birth: dd/mm/yyyy
More informationTreatment: Nutrition and Medication
INFLAMMATORY BOWEL DISEASE (IBD): CROHN S DISEASE Treatment: Nutrition and Medication While there is no cure for Crohn s disease, there are a number of options to help treat it. The goals of treatment
More informationWelcome Back to the Framingham Heart Study
Framingham Heart Study Group 3 Exam 3 RESEARCH CONSENT FORM Welcome Back to the Framingham Heart Study Why is the research study being done? The Framingham Heart Study is a long term research study. The
More informationIllumina Clinical Services Laboratory
Illumina Clinical Services Laboratory CLIA Certificate No.: 05D1092911 Illumina Clinical Services Laboratory TruGenome Technical Sequence Data Test Requisition Form The Illumina Clinical Services Laboratory
More informationMERCY FLEET Phone: Fax:
MERCY considers all applications for all positions without regard to race, color, religion, creed, gender, national origin, age, sexual orientation, marital, veteran or any other legally protected status.
More informationCoordinated Primary Options Service. DVT Management Plan. Management options using Dabigatran or Warfarin
Coordinated Primary Options Service DVT Management Plan Management options using Dabigatran or Warfarin Name NHI DOB Ethnicity Gender Address Contact Information Mobile Home Treatment commenced date *CPO
More informationCITY OF EXETER. PHONE EXETER, CA PHONE URL (559)
An Equal Opportunity Employer CITY OF EXETER STREET P.O. BOX 237 100 CITY NORTH STATE C STREET PHONE EXETER, CA 93221 PHONE URL (559)592-9244 www.cityofexeter.com (Refer to the job announcement or job
More informationFAMILY AND MEDICAL LEAVE ACT OF 1993
Division of Administrative Services HUMAN RESOURCES FAMILY AND MEDICAL LEAVE ACT OF 1993 Employee Packet Division of Administrative Services HUMAN RESOURCES North End Center 300 Turner St. NW Suite 2300
More informationGBS Advantage HRA Group Agreement Please complete this form in its entirety and legibly
GBS Advantage HRA Group Agreement Please complete this form in its entirety and legibly Employer Information Employer Name: Contact Name: Title: Address: Phone Number: Email Address: Fax Number: Effective
More informationWelcome to Baylor Scott and White Health! New Hire Packet Central Division
Welcome to Baylor Scott and White Health! New Hire Packet Central Division New Hire Packet Details We are excited to have you start employment with us! Your next step is to complete the forms in this packet
More informationTEST REQUISITION, PATIENT INFORMATION, AND CONSENT HUDSONALPHA CLINICAL SERVICES LABORATORY
1. Patient Information Patient Name TEST REQUISITION, PATIENT INFORMATION, AND CONSENT HUDSONALPHA CLINICAL SERVICES LABORATORY HudsonAlpha Clinical Services Lab, LLC HUDSONALPHA CLINICAL SERVICES LABORATORY
More informationHUMAN RESOURCES DEPARTMENT 100 South Myrtle Avenue, P.O. Box 4748 Clearwater, FL
HUMAN RESOURCES DEPARTMENT 100 South Myrtle Avenue, P.O. Box 4748 Clearwater, FL 33756 727-562-4870 APPLICATION FOR EMPLOYMENT Apply on-line: www.myclearwater.com Date Recv'd: A City application is required
More informationLEARN. about. Please see Important Safety Information on pages 3-5 and enclosed full Prescribing Information.
LEARN about on pages 3-5 and enclosed 2 3? What is ZARXIO (filgrastim-sndz)? ZARXIO is a man-made form of granulocyte colony-stimulating factor (G-CSF) called filgrastim. G-CSF is a substance produced
More informationEMPLOYMENT APPLICATION
EMPLOYMENT APPLICATION 8364 Shawnee Road Ullin, IL 62992 www.shawneecc.edu POSITION: Full Time Part Time Temporary Date of Application: Salary Desired: PERSONAL DATA Name: Last First Middle Home Phone:
More informationSPECIMEN INFORMATION PATIENT INFORMATION REFERRING PROVIDER INFORMATION. Institution: Same as Referring Provider
The LMM is a satellite facility of Massachusetts General Hospital. CLIA # 22D1005307 Specimen (Refer to page 4 for Specimen and Shipping requirements): SPECIMEN INFORMATION Blood (5-7mL K 2 EDTA/K 3 EDTA)
More informationFor a full listing of nonmedicinal ingredients see Part 1 of the product monograph. PART III: CONSUMER INFORMATION
PART III: CONSUMER INFORMATION AVONEX PS (interferon beta-1a) prefilled syringe AVONEX PEN (interferon beta-1a) prefilled autoinjector This leaflet is part III of a three-part "Product Monograph" published
More informationTransitioning to Express Scripts
Transitioning to Express Scripts Welcome to Express Scripts. We re pleased to announce that, beginning January 1, 2017 the Michigan Tech prescription benefit will be managed by Express Scripts. Express
More informationYour Prescription Drug [ or 20%] Plan with Refill By Mail
Refill By Mail The Home Delivery Pharmacy sends drugs you take on a regular basis right to your door. And you get a larger supply of medicine for less money. 1 Your Prescription Drug [15-40-75 or 20%]
More informationYOUR HRA HANDBOOK FOR
YOUR HRA HANDBOOK FOR WELCOME TO Blue Options HRA is a new way to pay for health care. We ve taken our most popular plan design, the PPO, and paired it with an employer-funded health reimbursement account
More informationPackage leaflet: Information for the user. Remicade 100 mg powder for concentrate for solution for infusion Infliximab
Package leaflet: Information for the user Remicade 100 mg powder for concentrate for solution for infusion Infliximab Read all of this leaflet carefully before you start using this medicine because it
More informationPHYSICIAN OFFICE BILLING INFORMATION SHEET FOR IMLYGIC (talimogene laherparepvec)
PHYSICIAN OFFICE BILLING INFORMATION SHEET FOR IMLYGIC (talimogene laherparepvec) INDICATION IMLYGIC is a genetically modified oncolytic viral therapy indicated for the local treatment of unresectable
More informationSummary of the Family and Medical Leave Act of 1993
Summary of the Family and Medical Leave Act of 1993 The Family and Medical Leave Act of 1993 (FMLA) was enacted on August, 1993. It requires public agencies to provide up to twelve weeks (60 work days;
More informationSection 1 Material Identification Manufacturer: Bunting Bearings, LLC Emergency Telephone Number 200 Van Buren Street
BUNTING BEARINGS, LLC 200 Van Buren Street * Delta, Ohio 43515 * (419) 822-3483 * Fax: (419) 822-3372 Safety Data Sheet Bunting Continuous Cast Revised: August 1, 2015 Meets the Requirements of OSHA Standard
More informationA GUIDE TO THIS REFLECTIONS B RESEARCH STUDY IF YOU RE FIGHTING BREAST CANCER, YOU RE NOT ALONE
A GUIDE TO THIS REFLECTIONS B327-02 RESEARCH STUDY IF YOU RE FIGHTING BREAST CANCER, YOU RE NOT ALONE Do you have breast cancer that has spread to outside the breast? Has your tumor tested positive for
More informationMATERIAL SAFETY DATA SHEET =============================GENERAL INFORMATION===========================
MATERIAL SAFETY DATA SHEET =============================GENERAL INFORMATION=========================== Manufacturer: Creation Date: 02/93 Precision-Marshall Steel Co. Washington, PA Revision Date: 08/08
More informationUsing Complete Blood Cell Counts to Diagnose Disease
Physiology 2 Redwood High School Name Class Period Using Complete Blood Cell Counts to Diagnose Disease Background A healthy adult has about 4.5 to 5 million red blood cells and approximately 8,000 white
More informationNOTICE OF JOB OPENING. CUSTOMER SERVICE REPRESENTATIVE-OFFICE (Several Openings)
NOTICE OF JOB OPENING CUSTOMER SERVICE REPRESENTATIVE-OFFICE (Several Openings) Opening Date: September 18, 2017 Closing Date: 4:30 p.m. on September 18, 2017 Classification: Grade 5 Non-Exempt ($18.27
More informationAccessing your HRA. If you are a new or existing UnitedHealthcare member. Tracking your Healthy Rewards on myuhc.com. Dear Member,
Dear Member, Now that you have enrolled in the Health Reimbursement Medical Plan option, we wanted to provide you with important information about your Health Reimbursement Account (HRA). Accessing your
More informationROOSTER PRODUCTS INTERNATIONAL Application for Employment
ROOSTER PRODUCTS INTERNATIONAL Application for Employment In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to
More informationThe regular use of Moringa leaf powder shows fast and noticeable results. Moringa can be used for the following:
Information Why Moringa? There are numerous health benefits to Moringa. Moringa has been called The Tree of Life, The Miracle Tree and The Super Food that Beats ALL Superfoods. The regular use of Moringa
More informationPrevent unauthorised deductions Antenatal care. Failure to allow time off for trade union activities/safety rep duties
Fees and Remissions Although this form is not part of the ET1 it must be returned with the claim form if you are making your claim by post. This will assist our staff in confirming that the correct fee
More informationHITT 1211 Final Exam Review (Chap 1-12)
HITT 1211 Final Exam Review (Chap 1-12) This exam is a two-part exam consisting of a comprehensive, closed-book exam over lecture text chapters 1 12 and a closed-book skills exam demonstrating your skills
More informationNORTHAMPTON COUNTY LOCAL GOVERNMENT. Human Resources Department NORTHAMPTON COUNTY APPLICATION FOR EMPLOYMENT
NORTHAMPTON COUNTY LOCAL GOVERNMENT APPLICATION FOR EMPLOYMENT NORTHAMPTON COUNTY Human Resources Department 107 Thomas Bragg Drive Post Office Box 367 Jackson, NC 27845 (252) 574-0236 FAX: 534-4483 HR@NHCNC.NET
More informationAccessing Your HRA myuhc.com If You Are a New UnitedHealthcare Member myuhc.com myuhc.com Tracking Your Healthy Rewards on myuhc.
Dear Member, Now that you have enrolled in the Health Reimbursement Medical Plan option, we wanted to provide you with important information about your health reimbursement account (HRA). Accessing Your
More informationFIRST NAME MI LAST NAME BIRTH DATE (MM/DD/YYYY) GENDER. Specify countries: Name of person previously tested and relationship:
REQUEST FOR SITE SPECIFIC ANALYSIS [APC / MYH / TP53 / MLH1 / MSH2 / MSH6] Please provide the following information. We cannot perform your test without ALL of this information. PLEASE PRINT ALL ANSWERS
More informationLincoln s ChalleNGe Program
Lincoln s ChalleNGe Program Lincoln s Challenge Program Overview The Illinois National Guard Lincoln s ChalleNGe Program is a program for 16-18 year old at-risk youth. The ChalleNGe Program is designed
More informationNORTHAMPTON COUNTY LOCAL GOVERNMENT
NORTHAMPTON COUNTY LOCAL GOVERNMENT APPLICATION FOR EMPLOYMENT NORTHAMPTON COUNTY Human Resources Department 107 Thomas Bragg Drive Post Office Box 367 Jackson, NC 27845 (252) 574-0236 FAX: 534-4483 EMAIL:
More informationTexas Vendor Drug Program Fee-For-Service Medicaid Synagis Authorization Request
Form 1033 September 2017-E Texas Vendor Drug Program Fee-For-Service Medicaid Synagis Authorization Request About Human Respiratory Syncytial Virus (RSV) causes respiratory tract infections and serious
More informationNORTHAMPTON COUNTY LOCAL GOVERNMENT
NORTHAMPTON COUNTY LOCAL GOVERNMENT APPLICATION FOR EMPLOYMENT NORTHAMPTON COUNTY Human Resources Department 107 Thomas Bragg Drive Post Office Box 367 Jackson, NC 27845 (252) 574-0236 PLEASE NOTE: Northampton
More informationFRANCHE COMMUNITY PRIMARY SCHOOL & Policies & Procedures
Title: Storage and Administering of Medicines Method Statement & Policy 2018-19 DOCUMENT MANAGEMENT This document was adopted at the PAW Committee Meeting on 24 th January 2018 This document is subject
More informationHealth Effects Associated with Stack Chemical Emissions from NYS Natural Gas Compressor Stations:
Health Effects Associated with Stack Chemical Emissions from NYS Natural Gas Compressor Stations: 2008-2014 A Technical Report Prepared for the Southwest Pennsylvania Environmental Health Project D.O.
More informationPersonal Check Money Order Credit Card Visa MC Discover Amex LYMPHOCYTE TRANSFORMATION TESTING (LTT) AND/OR METAL ION TESTING SERVICE (ALL FIELDS REQUIRED) Patient Last, First Name, M.I. Mail or e-mail
More informationCity of Homestead 790 North Homestead Boulevard Homestead, Florida Application for Employment
City of Homestead 790 North Homestead Boulevard Homestead, Florida 33030 Application for Employment The City of Homestead is an Equal Opportunity Employer and considers applications for all positions without
More informationColumbia, SC Experienced Orientation
Columbia, SC Experienced Orientation Welcome! On behalf of the TMC Family, we are pleased that you have chosen to be a part of our company. You have been extended an offer of employment dependent upon
More informationCOLORADO MILITARY ACADEMY, INC.
Application for Employment Location of the School (being remodeled so please email application) 360 Command View Colorado Springs, CO (719)576-9838 OFFICE USE ONLY Position: Application Received: (Page
More informationGhana IUD Assessment Tools Frontiers in Reproductive Health Program-Population Council
Ghana IUD Assessment Tools Frontiers in Reproductive Health Program-Population Council The following instruments were developed as part of a comprehensive review of IUD services conducted by the Frontiers
More informationSection 1 APPLICANT INFORMATION: Please submit a resume with this Application for Employment. First Name Middle Name Last Name
Employment Application Utopian Academy for the Arts is an equal opportunity employer, dedicated to a policy of nondiscrimination in employment on any basis including age, sex, color, race, creed, national
More informationWEBCO INDUSTRIES, INC. P.O. Box 100 Sand Springs, OK Material Safety Data Sheet
WEBCO INDUSTRIES, INC. P.O. Box 100 Sand Springs, OK 74063 Material Safety Data Sheet Site: Sand Springs, OK. Approved MSDS: Date Prepared: 10/06/09 Replaces: 6/28/2004 MSDS : 1 Section 1: Product and
More informationEmployment Application
THE CITY OF LAKE FOREST Employment Application Human Resources Department 220 E. Deerpath Lake Forest, IL 60045 847-234-2600 FAX 847-615-4289 www.cityoflakeforest.com Please print all answers PERSONAL
More informationFIRST NAME MI LAST NAME BIRTH DATE (MM/DD/YYYY) GENDER. P70.4 Neonatal hypoglycemia Q79.59 Omphalocele P08.1 Large for gestational age
REQUEST FOR BECKWITH-WIEDEMANN SYNDROME (BWS) TESTING Please provide the following information. We cannot perform your test without ALL of this information. PLEASE PRINT ALL ANSWERS PATIENT INFORMATION*
More informationUnderstanding the roots of `electrical pollution`
Understanding the roots of `electrical pollution` protect your family Because you can... Because you care Understanding the roots of `electrical pollution` Until recently, people who suffer from electrical
More informationRelated Donor Informed Consent to Participate in Research
Related Donor Informed Consent to Participate in Research This is an informed consent document for a research study that your family member is participating in. This document will inform you about the
More informationSTREET/UNIT NUMBER CITY STATE ZIP PHONE NUMBER ALTERNATE OR MESSAGE PHONE NUMBER ADDRESS. Yes NO. OF YEARS ATTENDED
It is our policy to deal with all applicants and employees without regard to race, color, religion, sex, national origin, marital status, age, disability, or status as a Vietnam era or qualified disabled
More informationEMPLOYMENT APPLICATION
Transit Systems Sydney Bus Operations EMPLOYMENT APPLICATION Please return completed application to: Hoxton Park Depot Transit Systems (NSW) Lot 2 Airfield Drive Len Waters Estate Smithfield Depot Transit
More informationEMERGENCY PHONE: or (651) (24 hours) Ingredient C.A.S. No. % by Wt Quartz Silica
Material Safety Data Sheet Copyright, 2012, 3M Company All rights reserved. Copying and/or downloading of this information for the purpose of properly utilizing 3M Purification Inc. products is allowed
More informationMND Review of Molecular and Genomic Diagnostic Testing Services Questions & Answers
MND Review of Molecular and Genomic Diagnostic Testing Services Questions & Answers 1. What is the Molecular and Genomic Testing Program? Horizon Blue Cross Blue Shield of New Jersey has expanded its collaboration
More informationMSDS FOR ZINC METAL: PRIME WESTERN
SECTION I - GENERAL INFORMATION NAME: ZINC METAL MANUFACTURER: TRANSPORTATION EMERGENCY: HORSEHEAD CORPORATION CHEMTREC: 800-424-9300 300 Frankfort Road Monaca, PA 15061 724-774-1020 CHEMICAL FAMILY: Nonferrous
More informationAPPLICATION FOR EMPLOYMENT THIS APPLICATION WILL REMAIN ACTIVE FOR 90 DAYS FROM THE DATE OF APPLICATION
APPLICATION FOR EMPLOYMENT THIS APPLICATION WILL REMAIN ACTIVE FOR 90 DAYS FROM THE DATE OF APPLICATION Applicants are considered for all positions without regard to race, color, national origin, religion,
More informationKILWORTH HOUSE HOTEL AND THEATRE APPLICATION FOR EMPLOYMENT Please write clearly and in block capitals
KILWORTH HOUSE HOTEL AND THEATRE APPLICATION FOR EMPLOYMENT Please write clearly and in block capitals PERSONAL INFORMATION Mr/Mrs/Miss/Ms... Place of Birth Surname. N.I.Number First Names Home Tel No
More informationOHIO HISTORICAL SOCIETY APPLICATION FOR EMPLOYMENT
OHIO HISTORICAL SOCIETY APPLICATION FOR EMPLOYMENT Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application
More informationPackage leaflet: Information for the user. HUMAN ALBUMIN BAXALTA 200 g/l Solution for Infusion. Human albumin
Package leaflet: Information for the user HUMAN ALBUMIN BAXALTA 200 g/l Solution for Infusion Human albumin Read all of this leaflet carefully before you start using this medicine because it contains important
More informationEmployment Application
West River Electric Association, Inc. Home Office Branch Office 1200 W Fourth Ave 3250 E Hwy 44 PO Box 412 PO Box 3486 Wall, SD 57790 Rapid City, SD 57709-3486 (605) 279-2135 1-888-279-2135 (605) 393-1500
More informationWhen an employee requests a PFL, the Leave Administrator will determine whether the
1 Hello and welcome to this overview of the new Paid Family Leave benefit for Syracuse University staff that will be available starting January 1, 2018. This overview is intended for managers and supervisors
More informationKohler Distributing Company 150 Wagaraw Road Hawthorne, NJ 07506
Kohler Distributing Company 150 Wagaraw Road Hawthorne, NJ 07506 APPLICATION FOR EMPLOYMENT Kohler Distributing Company is an Equal Opportunity Employer Please fill in this application completely and truthfully.
More informationApplication for Employment
Application for Employment PLEASE USE BLACK INK AND COMPLETE IN BLOCK CAPITALS Optimo House 73 Liverpool Road Crosby Liverpool L23 5SE 0151 924 1999 Email: recruitment@warrencare.co.uk 1: PERSONAL DETAILS
More informationThe Los Angeles Child Guidance Clinic
The Los Angeles Child Guidance Clinic Today s Date: APPLICATION FOR EMPLOYMENT It is the policy of THE LOS ANGELES CHILD GUIDANCE CLINIC to provide equal employment opportunity to all qualified applicants
More informationLead is a metal that can have harmful
Lead Lead is a metal that can have harmful effects on the human body. It can be found in many products, including lead-based paints, lead solder, electrical fittings and conduits, tank linings, plumbing
More informationFIRE FIGHTER EMPLOYMENT APPLICATION
CITY OF SHAWNEE FIRE FIGHTER EMPLOYMENT APPLICATION REVISED MAY, 2012 THIS APPLICATION WILL REMAIN ON FILE CITY OF SHAWNEE FIRE DEPARTMENT ADMINISTRATION Dru Tischer, Interim Fire Chief 405-878-1538 16
More informationi AM THE BIG SISTER MENTORING PROGRAM Mentee Little Sister Application Process
i AM THE BIG SISTER MENTORING PROGRAM Mentee Little Sister Application Process Thank you for your interest in the i Am the Big Sister Mentoring Program! Attached is the application form for i Am the Big
More information1230 W. Boone Avenue, Spokane, Washington Phone: (509) FAX: (509)
1230 W. Boone Avenue, Spokane, Washington 99201 Phone: (509) 325-6000 FAX: (509) 325-6021 APPLICATION FOR EMPLOYMENT Thank you for your interest in working for Spokane Transit. All qualified applicants
More informationWEEKLY SAFETY MEETING All Euramax Subsidiaries STRESS. Safety Meeting Contents. Meeting Notice. Leaders Guide. Employee Handout.
Safety Meeting Contents Meeting Notice Leaders Guide Employee Handout Employee Quiz Meeting Sign-In Sheet Employee Puzzle PRIOR TO THE WEEKLY MEETING: - Post the meeting notice by the timeclock - Read
More informationannex 3. Template consent form for biobanking
annex 3. Template consent form for biobanking This template is based on Public Population Project in Genomics and Society (P3G) database resources. General considerations The information brochure and consent
More informationMailing Address Number and Street City and State Zip
SANTA BARBARA COUNTY SUPERIOR COURT EMPLOYMENT APPLICATION An Equal Opportunity Employer Human Resources, 118 E. Figueroa St., Santa Barbara, CA 93101 805-882-4739 Hours: 8am 5pm M-F http://www.sbcourts.org/gi/hr
More informationBeths Grammar School POLICY ON EYE & EYESIGHT TESTING (Display Screen Equipment)
Beths Grammar School POLICY ON EYE & EYESIGHT TESTING (Display Screen Equipment) 1. INTRODUCTION This policy is formulated to comply with the Health & Safety Display Screen (DSE) Equipment Regulations
More informationPart Time General Office Secretary 2017 Application for Employment
An Equal Opportunity Employer 325 N. O Plaine Road Gurnee, IL 60031 Phone: 847-599-7500 www.gurnee.il.us The Village of Gurnee Department accepts for employment and promotes its employees without regard
More informationApplication for Employment
Application for Employment Thank you for your interest in applying with MCCCU. Please answer all questions, print clearly, and attach a copy of your resume (if available). This application will remain
More informationWELLNESS PROGRAM AND WEBSITE GUIDE
L i f e C h a n g e s D i s e a s e M a n a g e m e n t LIVE well M a n a g i n g S t r e s s G o o d N u t r i t i o n L i f e s t y l e F i t n e s s H e a l t h y H a b i t s WELLNESS PROGRAM AND WEBSITE
More informationMATERIAL SAFETY DATA SHEET
Section 1. COMPANY AND PRODUCT IDENTIFICATION Name: TRAID VILLARROYA HNOS. S.L. Address: C/ Isabel de Santo Domingo 35 50014 Zaragoza SPAIN E-mail: info@traidvillarroya.com Website: Material Name: Copper
More informationClinical trial information leaflet and consent
Informed consent 1(7) Clinical trial information leaflet and consent General You must provide sufficient information on the rights of clinical trial subjects, the purpose and nature of the trial, the methodologies
More informationPropel PEO, Inc. ( Propel HR ) New Employee Onboarding Packet To Be Completed AFTER Employee Receives a Conditional Offer of Employment
Updated: 1/1/2016 Propel PEO, Inc. ( Propel HR ) New Employee Onboarding Packet To Be Completed AFTER Employee Receives a Conditional Offer of Employment ALL new hire paperwork must be completed (including
More informationUFCW & Employers Benefit Trust
UFCW & Employers Benefit Trust New PPO Medical Plan Features Page 2 The PPO Medical Plan For those members who are covered under the 2007 Collective Bargaining Agreement, there are significant improvements
More informationEbola Facts. October 14, 2014
Ebola Facts October 14, 2014 Symptoms of Ebola Initial symptoms are nonspecific - may include fever, chills, myalgias, and malaise. Patients can progress to develop gastrointestinal symptoms: severe watery
More informationREQUEST FOR RETINOBLASTOMA TESTING
PATIENT INFORMATION REQUEST FOR RETINOBLASTOMA TESTING Please provide the following information. We cannot perform your test without ALL of this information. PLEASE PRINT ALL ANSWERS FIRST NAME MI LAST
More informationGet well, stay well and save money
Get well, stay well and save money Aetna Discount Programs Save on gyms, eyewear, weight-loss programs and more. 00.02.333.1-TX C (8/10) Stay healthy with savings that come with your Aetna health plan
More informationApplication for Employment
30 Village Square Glendale, Ohio 45246 (513) 771-7200 glendale@glendaleohio.org Instructions: Please print and complete all questions. Application for Employment Applicant Identification: Date / / Name
More informationRainbow Room International
Rainbow Room International Modern Apprenticeship Application Pack Thank you for your interest in training with Rainbow Room International Academy of Hair. At Rainbow Room International, we are recruiting
More informationJackson Municipal Airport Authority Director of Business Development, Marketing & Communications
Jackson Municipal Airport Authority Director of Business Development, Marketing & Communications The Director of Business Development, Marketing & Communications is responsible for overseeing the development,
More informationMaterial Safety Data Sheet
Material Safety Data Sheet Terbinafine Hydrochloride MSDS 0 He a lt h Fir e Re a c t iv it y P e r s o n a l P r o t e c t io n 0 E Section : Chemical Product and Company Identification Product Name: Terbinafine
More informationEmployment Application
Employment Application Human Resources Department 122 First Avenue, 2nd Floor Fairbanks, AK 99701 Phone: 907-452-8251 x3155 Fax: 907-459-3956 www.tananachiefs.org Position applying for: Last Name: First
More informationSPECSAVERS CORPORATE EYECARE Guide to Display Screen Equipment regulations and eyecare
SPECSAVERS CORPORATE EYECARE Guide to Display Screen Equipment regulations and eyecare HOW TO USE THIS GUIDE This guide relates to the Health and Safety (Display Screen Equipment) Regulations 1992 as amended
More informationPACKAGE LEAFLET: INFORMATION FOR THE USER
PACKAGE LEAFLET: INFORMATION FOR THE USER Genotropin MiniQuick 0.2mg, 0.4mg, 0.6mg, 0.8mg, 1.0mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2.0mg powder and solvent for solution for injection somatropin Read all of
More information