Purpose of Sliding Scale Policy and Procedure Disclaimer Policy

Tamaño: px
Comenzar la demostración a partir de la página:

Download "Purpose of Sliding Scale Policy and Procedure Disclaimer Policy"

Transcripción

1 San Luis Valley Health s Behavioral Health department offers a sliding fee discount program to eligible patients. If you would like more information, please call , or ask one of our Admitting Clerks at the front desk. Departamento de salud mental de San Luis Valley Health ofrece un programa de descuento de cuota deslizante a pacientes elegibles. Si desea más información, por favor llame al , o pedir a uno de nuestros empleados de admisión en la recepción. Purpose of Sliding Scale Policy and Procedure To provide financial assistance to behavioral health patients who meet the criteria for the sliding fee discount program. Applicants must have annual incomes and family size at or below two hundred percent of the most current Federal Poverty Level (FPL). Disclaimer SLV Health provides care to all patients and does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities. Policy As a non-profit, charitable, community-based healthcare provider, SLV Health will provide discounts to patients who meet the income criteria and demonstrate the need for behavioral health counseling. This sliding scale discount program will not be used in combination with Medicaid, CICP or Medicare. Valley-Wide Health Systems patients who qualify for their Sliding Fee program will be deemed eligible for SLV Health Behavioral Health Sliding Scale.

2 Discounts are offered based upon family/household size and annual income. A sliding fee and co-payment schedule is used to calculate the basic discount and is updated each year using the Federal Poverty Guidelines as issued each spring by the U.S. Department of Health and Human Services (Attachment A). Once approved, the discount will be honored for 12 months, after which the patient must reapply. Patients who are determined to be ineligible may reapply in three months or file an appeal with the Director of the Business Revenue Cycle. SLV Health will inform patients of the sliding fee program by displaying notices in the Stuart Avenue Clinic and SLV Health website in English and Spanish. Scope of Coverage: Eligible patients must meet with an eligibility advocate to be approved before being seen by Behavioral Health Specialist at the Stuart Street Clinic. Exceptions may be made on a caseby-case basis. After determining the slide, co-pays will be expected at the time of service. Service will not be denied if patient is unable to pay at the time of service. See the Co-pay Guideline, Attachment B. Ineligible Services This policy does not apply to charges for services incurred from other providers whose services are coincident to those provided by SLV Health Behavioral Health.

3 SLV Behavioral Health Application SLV Health VISIT ID # It is the policy of San Luis Valley Health to provide essential services regardless of the patient s ability to pay. Discounts are offered based upon family/household size and annual income. Please complete the following information and return to the Patient Financial Counselors to determine if you or members of your family are eligible for a discount. One application per household. The discount will not apply to those services which are purchased from outside. This is not considered insurance. This form must be completed every 12 months or if your financial situation changes. VWHS Rating: or Verified with VWHS Case Manager: Number of related persons living* in your taxable household: Household Member Household Income (complete one column) Annual Monthly Bi-Weekly Self Spouse TOTAL I certify that the family size and income information shown above is correct. Copies of tax returns, pay stubs, or other information verifying income is required before a discount is approved. Print Patient Name Patient Signature DOB Date *If supporting family members not in the household, list all names and DOBS of each (financial support must be 50% or more of their living expenses): Name Name Name DOB DOB DOB

4 SLV Salud Caridad Cuidado Programa Aplicación SLV Salud Visite ID # Es la política de San Luis Valle de salud para proporcionar servicios esenciales independientemente de la capacidad del paciente para pagar. Los descuentos se ofrecen basándose en el tamaño de la familia/hogar y renta anual. Por favor complete la siguiente información y volver a los asesores Financieros de la Paciente para determinar si usted o los miembros de su familia son elegibles para un descuento. Una solicitud por hogar. El descuento no se aplicará a los servicios que se compran de afuera. Esto no se considera seguro y no se puede utilizar conjuntamente con cualquier otro seguro de salud. Este formulario debe ser completado cada 12 meses o si su situación financiera cambia. VWHS calificación: or verificado con el administrador de caso VWHS: Número de vida personas relacionadas * en su casa sujetos: Miembro Masculino Ingreso de los hogares (una columna) Anual Mensual Bismenual Yo Cónyuge TOTAL Certifico que la información de tamaño y renta familiar que se muestra arriba es correcta. Copias de declaraciones de impuestos, talones de pago u otra información de verificación de ingresos se requiere antes de aprobar un descuento. Escribir Nombre de Paciente Firma de Paciente Fecha de Nacimiento Fecha * Si no en el hogar apoyo a miembros de la familia, lista todos los nombres y fecha de nacimiento de cada uno (apoyo financiero debe ser 50% o más de sus gastos): Nombre Nombre Nombre Fecha de Nacimento Fecha de Nacimento Fecha de Nacimento

5 Effective

6

2015 16 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program

2015 16 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program 2015 16 Student Eligibility Verification Advanced Placement (AP) and/or International Baccalaureate (IB) Exams AP Exam IB Exam AP and IB Exams I. Student Information Last Name First Name MI Grade High

Más detalles

Required Documentation for Charity Care

Required Documentation for Charity Care Patchogue, New York 11772 Required Documentation for Charity Care The completed signed application listing all family members, must be filled out and returned to the Patient Financial Services Department

Más detalles

2014 15 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program

2014 15 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program 2014 15 Student Eligibility Verification Advanced Placement (AP) and/or International Baccalaureate (IB) Exams þ AP Exam IB Exam AP and IB Exams I. Student Information Last Name First Name MI Grade High

Más detalles

Guide to Health Insurance Part II: How to access your benefits and services.

Guide to Health Insurance Part II: How to access your benefits and services. Guide to Health Insurance Part II: How to access your benefits and services. 1. I applied for health insurance, now what? Medi-Cal Applicants If you applied for Medi-Cal it will take up to 45 days to find

Más detalles

Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387

Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387 Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387 January 27, 2009 Courtesy_Title Full_Name 1 Mail_Address_2 Mail_Address_1

Más detalles

News Flash! Primary & Specialty Care Providers. Sharp Health Plan. Date: February 17, 2012. Subject: Member Grievance Forms

News Flash! Primary & Specialty Care Providers. Sharp Health Plan. Date: February 17, 2012. Subject: Member Grievance Forms I M P O R T A N T News Flash! A FAX Publication for Providers of Sharp Health Plan To: From: Primary & Specialty Care Providers Sharp Health Plan Date: February 17, 2012 Subject: Member Grievance Forms

Más detalles

ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights

ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights ODJFS Bureau of Civil Rights I NEED AN INTERPRETER, PLEASE. Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of national origin. If you do not speak English well, social services,

Más detalles

APLICACION de HONORARIO de ESCALA MOVIL

APLICACION de HONORARIO de ESCALA MOVIL APLICACION de HONORARIO de ESCALA MOVIL Nombre de Paciente: Fecha de Naciemento: Direccion de Correo: Telephono: Ciudad,Estado,Codigo: NSS#: Total en la Unidad Familiar: Number de Adultos: Numbero de Menores:

Más detalles

TITLE VI COMPLAINT FORM

TITLE VI COMPLAINT FORM TITLE VI COMPLAINT FORM Before filling out this form, please read the Arcata and Mad River Transit System Title VI Complaint Procedures located on our website or by visiting our office. The following information

Más detalles

TITLE VI COMPLAINT FORM

TITLE VI COMPLAINT FORM [CITY SEAL/EMBLEM] The Capital City of the Palm Beaches TITLE VI COMPLAINT FORM Title VI of the 1964 Civil Rights Act requires that "No person in the United States shall, on the ground of race, color or

Más detalles

Screener for Peer Supporters

Screener for Peer Supporters Screener for Peer Supporters Primary Recruiter: Secondary Recruiter: Potential Peer Supporter Name: Phone #1: Home/Cell Phone #2: Home/Cell Address: City: Zip: Contact 1: Date: / / Contact 2: Date: / /

Más detalles

El Estado de Nevada le prestará ayuda con el costo de medicamentos recetados si califica:

El Estado de Nevada le prestará ayuda con el costo de medicamentos recetados si califica: Necesita ayuda para pagar sus medicamentos recetados? SeniorRx puede ser la solución! El Estado de Nevada le prestará ayuda con el costo de medicamentos recetados si califica: - Edad 62 años o más -Residentes

Más detalles

Affordable Care Act Informative Sessions and Open Enrollment Event

Affordable Care Act Informative Sessions and Open Enrollment Event 2600 Cedar Ave., P.O. Box 2337, Laredo, TX 78044 Hector F. Gonzalez, M.D., M.P.H Tel. (956) 795-4901 Fax. (956) 726-2632 Director of Health News Release. Date: February 9, 2015 FOR IMMEDIATE RELEASE To:

Más detalles

Identity and Statement of Educational Purpose (To Be Signed in the Presence of a Notary)

Identity and Statement of Educational Purpose (To Be Signed in the Presence of a Notary) Identity and Statement of Educational Purpose (To Be Signed in the Presence of a Notary) If the student is unable to appear in person at (Name of Postsecondary Educational Institution) to verify his or

Más detalles

Asistencia para alimentos de Iowa (Iowa Food Assistance Program) SCRIPT

Asistencia para alimentos de Iowa (Iowa Food Assistance Program) SCRIPT Asistencia para alimentos de Iowa (Iowa Food Assistance Program) http://video.extension.iastate.edu/2011/12/14/asistencia para alimentos de iowa/ Six minute video in Spanish explaining what Food Assistance

Más detalles

EMPLOYER & EMPLOYEE RETIREMENT PLAN TAX CREDITS

EMPLOYER & EMPLOYEE RETIREMENT PLAN TAX CREDITS EMPLOYER & EMPLOYEE RETIREMENT PLAN TAX CREDITS For employers who set up and maintain retirement plans, the setup costs, annual administrative costs, and retirement-related employee education costs are

Más detalles

DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS

DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS DAVID L. LAKEY, M.D. DIRECTOR P.O. Box 149347 Austin, Texas 78714-9347 1-888-963-7111 TTY (teletipo): 1-800-735-2989 www.dshs.state.tx.us 1 de marzo,

Más detalles

Janssen Prescription Assistance. www.janssenprescriptionassistance.com

Janssen Prescription Assistance. www.janssenprescriptionassistance.com Janssen Prescription Assistance www.janssenprescriptionassistance.com Janssen Prescription Assistance What is Prescription Assistance? Prescription assistance programs provide financial help to people

Más detalles

www.deltadentalins.com/language_survey.html

www.deltadentalins.com/language_survey.html Survey Code: Survey 1 February 6, 2008 Dear Delta Dental Enrollee: Recent changes in California law will require that all health care plans provide language assistance to their plan enrollees beginning

Más detalles

CNS Paragraph Form Date: 09.02.11

CNS Paragraph Form Date: 09.02.11 CNS Paragraph Form Date: 09.02.11 Program Area 03 (01=PA, 02=FS, 03=MA, 04=HP) Paragraph Number U0223 Version Number 00001 Effective Date 2011 Title Administrative Renewal for Aged, Blind and Disabled,

Más detalles

IMPORTANT NOTICE FOR SPONSORS READ THIS BEFORE SUBMITTING FORM I-864

IMPORTANT NOTICE FOR SPONSORS READ THIS BEFORE SUBMITTING FORM I-864 IMMIGRANT VISAS AMERICAN CONSULATE GENERAL, AVE. LOPEZ MATEOS #924 NTE. CD. JUAREZ, CHIHUAHUA, MEXICO TEL. 1-900-476-1212 USA, CHARGE OF US$1.25 (ONE DOLLAR & TWENTY FIVE CTS) PER MINUTE. TEL. 01-900-849-4949

Más detalles

Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts?

Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts? Albany Housing Authority RESIDENT COMMISSIONER ELECTION Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts? RUN FOR RESIDENT COMMISSIONER

Más detalles

Q. What is the 1095-B form and why does it matter to me?

Q. What is the 1095-B form and why does it matter to me? FAQ This tax season, certain Medicaid members will receive Form 1095-B from the Georgia Medicaid/ PeachCare for Kids program. Select members who receive their healthcare coverage through Fee-for-Service

Más detalles

Creating your Single Sign-On Account for the PowerSchool Parent Portal

Creating your Single Sign-On Account for the PowerSchool Parent Portal Creating your Single Sign-On Account for the PowerSchool Parent Portal Welcome to the Parent Single Sign-On. What does that mean? Parent Single Sign-On offers a number of benefits, including access to

Más detalles

A los niños que tienen Medicaid (Asistencia Médica) Jamás debe. cobrárseles unacantidad por las recetas médicas aún cuando tengan

A los niños que tienen Medicaid (Asistencia Médica) Jamás debe. cobrárseles unacantidad por las recetas médicas aún cuando tengan Disability Rights Network of Pennsylvania 1414 N. Cameron Street Second Floor Harrisburg, PA 17103-1049 (800) 692-7443 (Voice) (877) 375-7139 (TDD) www.drnpa.org A los niños que tienen Medicaid (Asistencia

Más detalles

SFGH FHC Healthy Children Vaccination Program Frequently Asked Questions

SFGH FHC Healthy Children Vaccination Program Frequently Asked Questions SFGH FHC Healthy Children Vaccination Program Frequently Asked Questions The Family Health Center (FHC) Healthy Children Vaccination Program at SF General Hospital (SFGH) provides immunization services

Más detalles

ALERT. Customers inquiring about the letter must be asked if he/she has filed 2014 tax return and:

ALERT. Customers inquiring about the letter must be asked if he/she has filed 2014 tax return and: ALERT Customers who received a premium tax credit in 2014 and are preparing to renew his/her health coverage for 2016 are required to have filed his/her 2014 taxes in order to continue receiving his/her

Más detalles

UNIVERSIDAD GABRIELA MISTRAL Departamento de Relaciones Internacionales. Formulario de Postulación (Aplication For Admission/Exchange Student)

UNIVERSIDAD GABRIELA MISTRAL Departamento de Relaciones Internacionales. Formulario de Postulación (Aplication For Admission/Exchange Student) Personal Data Nombre/First Name Apellidos/Last Name Dirección/Permanent Address Numbers/Street Ciudad City/Province País Country Teléfono Local Phone Number (with area codes) E-mail Fecha de Nacimiento

Más detalles

IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR

IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR Subject: Important Updates Needed for Your FAFSA Dear [Applicant], When you completed your 2012-2013 Free Application for Federal Student Aid

Más detalles

Nombre de la persona completando esta forma

Nombre de la persona completando esta forma mbre de Paciente mbre de la persona completando esta forma Fecha Relación del paciente / / Sexo Masculino Raza Numero de Seguro Social Fecha de Nacimiento Femenino / / / / POR FAVOR LISTE TODA LA GENTE

Más detalles

Solicitud para Licencia de matrimonio (Marriage License Request)

Solicitud para Licencia de matrimonio (Marriage License Request) Solicitud para Licencia de matrimonio (Marriage License Request) Este documento contiene una traducción de la solicitud en línea para obtener una Licencia o permiso de matrimonio (o Marriage License, en

Más detalles

\RESOURCE\ELECTION.S\PROXY.CSP

\RESOURCE\ELECTION.S\PROXY.CSP The following is an explanation of the procedures for calling a special meeting of the shareholders. Enclosed are copies of documents, which you can use for your meeting. If you have any questions about

Más detalles

New Health Insurance Marketplace Coverage Options and Your Health Coverage

New Health Insurance Marketplace Coverage Options and Your Health Coverage New Health Insurance Marketplace Coverage Options and Your Health Coverage Form Approved OMB No. 1210-0149 (expires 11-30-2013) PART A: General Information When key parts of the health care law take effect

Más detalles

INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN

INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN Informacion importante de saber: Una guarderia de niños para familias consite de un niño hasta 6 niños. Una

Más detalles

New Health Insurance Marketplace Coverage Options and Your Health Coverage

New Health Insurance Marketplace Coverage Options and Your Health Coverage New Health Insurance Marketplace Coverage Options and Your Health Coverage Form Approved OMB No. PART A: General Information When key parts of the health care law take effect in 2014, there will be a new

Más detalles

Child Care Assistance Program Búsqueda de Trabajo

Child Care Assistance Program Búsqueda de Trabajo Child Care Assistance Program Búsqueda de Trabajo Usted ha pedido cuidado para sus niños mientras busca trabajo a través del programa de CCAP. Este programa ofrece un total de 30 días mientras busca trabajo.

Más detalles

MISSISSIPPI EMPLOYEES

MISSISSIPPI EMPLOYEES 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone (757) 460-6308 Fax (757) 457-9345 MISSISSIPPI EMPLOYEES MANCON Employees, Included in this packet is the following information: 1. Job Insurance

Más detalles

Title VI Complaint Form Horizon Cross Cultural Center (HORIZON) (formerly St. Anselm s Cross-Cultural Community Center) Office of Civil Rights

Title VI Complaint Form Horizon Cross Cultural Center (HORIZON) (formerly St. Anselm s Cross-Cultural Community Center) Office of Civil Rights Title VI Complaint Form Horizon Cross Cultural Center (HORIZON) (formerly St. Anselm s Cross-Cultural Community Center) Title VI of the Civil Rights Act of 1964 provides that no person in the United States

Más detalles

Saturday, June 22. Don t put it off any longer! It is vital that 100% of those eligible for DACA submit an application.

Saturday, June 22. Don t put it off any longer! It is vital that 100% of those eligible for DACA submit an application. NO-COST ASSISTANCE WITH YOUR APPLICATION FOR DEFERRED ACTION Don t put it off any longer! It is vital that 100% of those eligible for DACA submit an application. If you or a family member arrived in the

Más detalles

Formulario de Postulación Estudiante de Intercambio Application Form / Exchange Student

Formulario de Postulación Estudiante de Intercambio Application Form / Exchange Student Formulario de Postulación Estudiante de Intercambio Application Form / Exchange Student Información Personal Personal Information Nombres First Name Apellidos Last Name Dirección permanente Permanent Address

Más detalles

Health Plan of Nevada, Inc.

Health Plan of Nevada, Inc. HMO Option 1 Lifetime Maximum Benefit $1,000,000 Annual Copayment Maximum $2,000 per Member / $4,000 per Family Covered Services Physician Services - Office Visit/Consultation Hospital Services - Elective

Más detalles

Administración de ingresos. Voluntaria

Administración de ingresos. Voluntaria Administración de ingresos Voluntaria Qué es Administración de ingresos (Income Management)? La Administración de ingresos (Income Management) es una manera de ayudarle a administrar su dinero a fin de

Más detalles

Guide to Health Insurance Part I: What you need to know before you apply.

Guide to Health Insurance Part I: What you need to know before you apply. Guide to Health Insurance Part I: What you need to know before you apply. 1. What is health insurance and how does it help? Having health insurance protects you in the case of an emergency or sudden illness

Más detalles

El Abecedario Financiero

El Abecedario Financiero El Abecedario Financiero Unidad 4 National PASS Center 2013 Lección 5 Préstamos Vocabulario: préstamo riesgocrediticio interés obligadosolidario A lgunavezpidesdineroprestado? Dóndepuedespedirdinero prestado?

Más detalles

Down Payment Assistance Application Packet

Down Payment Assistance Application Packet Down Payment Assistance Application Packet Please assure that all needed items are attached and complete. Please note that your application will not be considered until all documents are received. 1. Down

Más detalles

Student Violence, Bullying, Intimidation, Harassment

Student Violence, Bullying, Intimidation, Harassment Case 4:74-cv-00090-DCB Document 1690-6 Filed 10/01/14 Page 159 of 229 Student Violence, Bullying, Intimidation, Harassment COMPLAINT FORM (To be filed with any School District employee who will forward

Más detalles

Financial Affidavit for Child Support, DC 6:5(2) Declaración Jurada de Finanzas para Manutención de Menores, DC 6:5(2).

Financial Affidavit for Child Support, DC 6:5(2) Declaración Jurada de Finanzas para Manutención de Menores, DC 6:5(2). IN THE DISTRICT CURT F CUNTY, NEBRASKA (county where Complaint filed) EN LA CRTE DE DISTRIT DEL CNDAD DE, NEBRASKA (condado donde se entabló la Demanda), ) (your full name) (su nombre completo) ) Plaintiff,/

Más detalles

PROOF MUST BE PROVIDED!

PROOF MUST BE PROVIDED! 2014-2015 Athletic Waiver of School Sports Fees Application You automatically qualify for a school fee waiver, BU T M UST C O MPL E T E T H IS F O R M if you can provide verification that you: Are eligible

Más detalles

OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal.

OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal. OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal. For Clerk s Use Only (Para uso de la Secretaria solamente)

Más detalles

Solicitud de Licencia de matrimonio (Marriage License Request)

Solicitud de Licencia de matrimonio (Marriage License Request) Solicitud de Licencia de matrimonio (Marriage License Request) Este documento contiene una traducción de la Solicitud en línea para obtener una Licencia o permiso de matrimonio. Si necesita ayuda técnica,

Más detalles

Passaic County Technical Institute 45 Reinhardt Road Wayne, New Jersey 07470

Passaic County Technical Institute 45 Reinhardt Road Wayne, New Jersey 07470 Note: Instructions in Spanish immediately follow instructions in English (Instrucciones en español inmediatamente siguen las instrucciónes en Inglés) Passaic County Technical Institute 45 Reinhardt Road

Más detalles

FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner

FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner

Más detalles

Asistencia para cuidado infantil

Asistencia para cuidado infantil SPANISH Asistencia para cuidado infantil El Gobierno Australiano ofrece una gama de pagos y servicios para ayudar a las familias con los costes de cuidado infantil incluyendo: Child Care Benefit para cuidado

Más detalles

Are You Eligible for a FREE Mammogram? Es Usted Elegible Para una Mamografía GRATIS? C OLUMBIA U NIVERSITY B REAST C ANCER S CREENING P ARTNERSHIP

Are You Eligible for a FREE Mammogram? Es Usted Elegible Para una Mamografía GRATIS? C OLUMBIA U NIVERSITY B REAST C ANCER S CREENING P ARTNERSHIP C OLUMBIA U NIVERSITY B REAST C ANCER S CREENING P ARTNERSHIP Are You Eligible for a FREE Mammogram? Es Usted Elegible Para una Mamografía GRATIS? Columbia Presbyterian Center NewYork-Presbyterian Hospital

Más detalles

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION FORM 16-1 AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Completion of this document authorizes the disclosure and use of health information about you. Failure to provide all information requested

Más detalles

LAC-2009-09 Modificación 2.3.3.3. DIRECT ALLOCATIONS TO ISPs DISTRIBUCIONES INICIALES A ISPs

LAC-2009-09 Modificación 2.3.3.3. DIRECT ALLOCATIONS TO ISPs DISTRIBUCIONES INICIALES A ISPs LAC-2009-09 Modificación 2.3.3.3 DIRECT ALLOCATIONS TO ISPs DISTRIBUCIONES INICIALES A ISPs Current Policy 2.3.3.3. Direct Allocations to Internet Service Providers LACNIC may grant this type of allocation

Más detalles

Your HUSKY Health Coverage Category is Changing

Your HUSKY Health Coverage Category is Changing Connecticut s Official Health Insurance Marketplace Person ID: , Mailed: Your HUSKY Health Coverage

Más detalles

Adobe Acrobat Reader X: Manual to Verify the Digital Certification of a Document

Adobe Acrobat Reader X: Manual to Verify the Digital Certification of a Document dobe crobat Reader X: Manual de verificación de Certificación Digital de un documento dobe crobat Reader X: Manual to Verify the Digital Certification of a Document support@bioesign.com Desarrollado por:

Más detalles

PROCEDIMIENTO PARA LA ADMISIÓN DE ESTUDIANTES DE INTERCAMBIO EN LA UNIVERSIDAD EUROPEA 2015/16

PROCEDIMIENTO PARA LA ADMISIÓN DE ESTUDIANTES DE INTERCAMBIO EN LA UNIVERSIDAD EUROPEA 2015/16 *English text below PROCEDIMIENTO PARA LA ADMISIÓN DE ESTUDIANTES DE INTERCAMBIO EN LA UNIVERSIDAD EUROPEA 2015/16 El presente procedimiento describe los pasos a seguir para solicitar la admisión como

Más detalles

CO148SPA.1206 PAGE 1 OF 3

CO148SPA.1206 PAGE 1 OF 3 Assurance of Support Algunos inmigrantes necesitan obtener una Assurance of Support (AoS) (Garantía de mantenimiento) antes de que se les pueda conceder su visado para vivir en Australia. El Department

Más detalles

Person ID:
, Mailed:

Person ID: <MPI_ID> <Primary Applicant/AREP FMLNS> <Address Line 1> <Address Line 2> <City>, <State> <Zip> Mailed: <Current Date> Person ID: , Mailed: Your HUSKY Health Coverage is Scheduled to End on August 31st Dear

Más detalles

Puede pagar facturas y gastos periódicos como el alquiler, el gas, la electricidad, el agua y el teléfono y también otros gastos del hogar.

Puede pagar facturas y gastos periódicos como el alquiler, el gas, la electricidad, el agua y el teléfono y también otros gastos del hogar. SPANISH Centrepay Qué es Centrepay? Centrepay es la manera sencilla de pagar sus facturas y gastos. Centrepay es un servicio de pago de facturas voluntario y gratuito para clientes de Centrelink. Utilice

Más detalles

MajestaCare Healthy Baby Program

MajestaCare Healthy Baby Program MajestaCare Healthy Baby Program Helping you have a healthy baby Para que tenga un bebé saludable Your baby s provider After your baby becomes a member of MajestaCare health plan, you will get a letter

Más detalles

LAC-2009-09 Modificación 2.3.3.3. DIRECT ALLOCATIONS TO ISPs DISTRIBUCIONES DIRECTAS A ISPs

LAC-2009-09 Modificación 2.3.3.3. DIRECT ALLOCATIONS TO ISPs DISTRIBUCIONES DIRECTAS A ISPs LAC-2009-09 Modificación 2.3.3.3 DIRECT ALLOCATIONS TO ISPs DISTRIBUCIONES DIRECTAS A ISPs Current Policy Política Actual 2.3.3.3. Direct Allocations to Internet Service Providers LACNIC may grant this

Más detalles

Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form

Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form The Program can: 1. Provide a discount off your monthly telephone bill. 2. Provide a discount on your electric bill if you

Más detalles

UNIVERSIDAD DE MONTEVIDEO

UNIVERSIDAD DE MONTEVIDEO UNIVERSIDAD DE MONTEVIDEO Formulario de admisión para estudiantes internacionales Application form for International Students PHOTO Semestre 1 (marzo-julio) / Semester 1 (March-July) Año/ Year Semestre

Más detalles

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

TEXAS DEPARTMENT OF STATE HEALTH SERVICES TEXAS DEPARTMENT OF STATE HEALTH SERVICES DAVID L. LAKEY, M.D. COMMISSIONER P.O. Box 149347 Austin, Texas 78714-9347 1-888-963-7111 TTY: 1-800-735-2989 www.dshs.state.tx.us August 15, 2013 Dear Birthing

Más detalles

Solicitud para Certificado de soltería (Certificate of Non-Impediment Request)

Solicitud para Certificado de soltería (Certificate of Non-Impediment Request) Solicitud para Certificado de soltería (Certificate of Non-Impediment Request) Este documento contiene una traducción de la solicitud en línea para obtener un Certificado de soltería (o Certificate of

Más detalles

We look forward to hearing from you soon!

We look forward to hearing from you soon! Larry Meredith, Ph.D., Director DIVISION OF SOCIAL SERVICES Public Assistance Branch CHILDRENS HEALTH INITIATIVE is LOW-COST HEALTH INSURANCE FOR KIDS IN MARIN under 19 years of age! The goal of the Children

Más detalles

PB #11-111-OPE. Attachment: Please use Print on M-687r Referral to Treatment Program (Rev. 11/30/11) (Rev. 11/30/11)

PB #11-111-OPE. Attachment: Please use Print on M-687r Referral to Treatment Program (Rev. 11/30/11) (Rev. 11/30/11) FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Stephen Fisher, Assistant Deputy Commissioner Office

Más detalles

SIHI México, S. de R.L. de C.V. Pricing Guide

SIHI México, S. de R.L. de C.V. Pricing Guide Pricing Guide Rates effective as of: October 1, 2016 Note: Rates are subject to change without prior notice. Rates are stated in Mexican Pesos unless otherwise specified. page 1 of 5 Table Of Contents

Más detalles

Workers Compensation Non-Subscriber Form

Workers Compensation Non-Subscriber Form Workers Compensation Non-Subscriber Form Texas is unique in one very important respect: It s the only state in which employers have the choice to carry workers compensation insurance or not. There are

Más detalles

Verificación de ingresos:

Verificación de ingresos: INSTRUCCIONES DE SOLICITUD PARA AYUDA FINANCIERA Instrucciones: Como parte de su compromiso de servir a la comunidad, MacNeal Hospital decide proporcionar ayuda financiera a personas que son económica

Más detalles

Cómo comprar en la tienda en línea de UDP y cómo inscribirse a los módulos UDP

Cómo comprar en la tienda en línea de UDP y cómo inscribirse a los módulos UDP Cómo comprar en la tienda en línea de UDP y cómo inscribirse a los módulos UDP Sistema de registro y pago Este sistema está dividido en dos etapas diferentes*. Por favor, haga clic en la liga de la etapa

Más detalles

EL PASO ELECTRIC COMPANY THIRD REVISED SAMPLE FORM NO. 22 CANCELLING SECOND REVISED SAMPLE FORM NO. 22

EL PASO ELECTRIC COMPANY THIRD REVISED SAMPLE FORM NO. 22 CANCELLING SECOND REVISED SAMPLE FORM NO. 22 'FILED IN OFFICE OF WMPUBLIC REG. COMM. EL PASO ELECTRIC COMPANY JAN 17 lu14 THIRD REVISED SAMPLE FORM NO. 22 CANCELLING SECOND REVISED SAMPLE FORM NO. 22 NOTIFY FOR DELINQUENT AMOUNT (IVR OUTBOUND CALL

Más detalles

Important! Action Required before November 29, 2013. Medical Plan Dependent Eligibility Verification & Instructions

Important! Action Required before November 29, 2013. Medical Plan Dependent Eligibility Verification & Instructions Dear Eligible Employee Partner: Important! Action Required before November 29, 2013 Medical Plan Dependent Eligibility Verification & Instructions During this year s open enrollment, any new dependent

Más detalles

IMMIGRATION Canada. Temporary Resident Visa. Mexico City Visa Office Instructions. Table of Contents IMM 5878 E (10-2015)

IMMIGRATION Canada. Temporary Resident Visa. Mexico City Visa Office Instructions. Table of Contents IMM 5878 E (10-2015) IMMIGRATION Canada Table of Contents Document Checklist Temporary resident visa (available in Spanish) Emergency Processing Request Form Temporary Resident Visa Mexico City Visa Office Instructions This

Más detalles

Chattanooga Motors - Solicitud de Credito

Chattanooga Motors - Solicitud de Credito Chattanooga Motors - Solicitud de Credito Completa o llena la solicitud y regresala en persona o por fax. sotros mantenemos tus datos en confidencialidad. Completar una aplicacion para el comprador y otra

Más detalles

Title VI Complaint Procedures

Title VI Complaint Procedures Title VI Complaint Procedures As a recipient of federal dollars, HELP of Ojai, Inc. is required to comply with Title VI of the Civil Rights Act of 1964 and ensure that services and benefits are provided

Más detalles

2015 Legal Assistance Income Guidelines ~ Pautas sobre ingreso para recibir asistencia jurídica en 2015 GRATUITA. Estados Unidos PRO BONO

2015 Legal Assistance Income Guidelines ~ Pautas sobre ingreso para recibir asistencia jurídica en 2015 GRATUITA. Estados Unidos PRO BONO Legal Assistance Request, 2015 ~ Solicitud de Asistencia Jurídica, 2015 Sírvase examinar el cuadro Pautas sobre ingreso para recibir asistencia jurídica en 2015 para determinar elegibilidad para solicitar

Más detalles

School Food and Nutrition Services - 703.791.7314 Facilities Management Services - 703.791.7221

School Food and Nutrition Services - 703.791.7314 Facilities Management Services - 703.791.7221 SUPPORT SERVICES To: All Principals All Food Service Managers Approved by: Dave Cline Contact Person: Serena Suthers SUPPORT SERVICES Spring Break Refrigerator/Freezer Checks This notice remains in effect

Más detalles

GOOD NEWS!!! HOUSING AUTHORITY HAS INCREASED ITS PAYMENT STANDARDS FREQUENTLY ASKED QUESTIONS (FAQs) FOR TENANTS

GOOD NEWS!!! HOUSING AUTHORITY HAS INCREASED ITS PAYMENT STANDARDS FREQUENTLY ASKED QUESTIONS (FAQs) FOR TENANTS GOOD NEWS!!! HOUSING AUTHORITY HAS INCREASED ITS PAYMENT STANDARDS FREQUENTLY ASKED QUESTIONS (FAQs) FOR TENANTS 1. WHAT IS THE GOOD NEWS? Effective February 1, 2016, the Housing Authority has increased

Más detalles

Dana-Farber Cancer Institute Patient Care and Administrative Policy Manual

Dana-Farber Cancer Institute Patient Care and Administrative Policy Manual Dana-Farber Cancer Institute Patient Care and Administrative Policy Manual POLÍTICA DE ASISTENCIA FINANCIERA AL PACIENTE PROPÓSITO: Esta política establece el compromiso del Dana-Farber Cancer Institute

Más detalles

Welcome to the CU at School Savings Program!

Welcome to the CU at School Savings Program! Welcome to the CU at School Savings Program! Thank you for your interest in Yolo Federal Credit Union s CU at School savings program. This packet of information has everything you need to sign your child

Más detalles

Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form

Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form The LITE-UP Texas Program can: 1. Provide a discount off your monthly telephone bill. 2. Provide a discount on your electric

Más detalles

UNIVERSIDAD CATOLICA ARGENTINA DIRECCION DE RELACIONES INTERNACIONALES Y COOPERACION ACADEMICA

UNIVERSIDAD CATOLICA ARGENTINA DIRECCION DE RELACIONES INTERNACIONALES Y COOPERACION ACADEMICA UNIVERSIDAD CATOLICA ARGENTINA DIRECCION DE RELACIONES INTERNACIONALES Y COOPERACION ACADEMICA FORMULARIO DE APLICACION / APPLICATION FORM foto 4x4 photo (passport size) Este formulario se debe completar

Más detalles

Historic Architectural

Historic Architectural Historic Architectural Rehabilitation Grant Program 50/50 GRANT PROGRAM 75/25 GRANT PROGRAM EXTERIOR PAINT PROGRAM CITY OF Elgin PLANNING & NEIGHBORHOOD SERVICES CITY OF Elgin Historic Architectural Rehabilitation

Más detalles

Family Health Source Medical Center FORMULARIO DE REGISTRO DEL PACIENTE -Toda la información es requerida y confidencial-

Family Health Source Medical Center FORMULARIO DE REGISTRO DEL PACIENTE -Toda la información es requerida y confidencial- FORMULARIO DE REGISTRO DEL PACIENTE -Toda la información es requerida y confidencial- Número de la Cuenta: Fecha: Alergias: APELLIDO: NOMBRE: INICIAL SEGUNDO NOMBRE: Dirección de Correo: Dirección Actual:

Más detalles

SAN BERNARDINO & RIVERSIDE COUNTIES. Catholic Charities. Moreno Valley Regional Center. 23623 Sunnymead Blvd., Ste. E Moreno Valley, CA 92553

SAN BERNARDINO & RIVERSIDE COUNTIES. Catholic Charities. Moreno Valley Regional Center. 23623 Sunnymead Blvd., Ste. E Moreno Valley, CA 92553 SAN BERNARDINO & COUNTIES Catholic Charities Moreno Valley Regional Center 23623 Sunnymead Blvd., Ste. E Family and Community Assistance Programs Information & Referral, Case Management Basic Needs, Emergency

Más detalles

Southern California Lumber Industry Retirement Fund

Southern California Lumber Industry Retirement Fund Southern California Lumber Industry Retirement Fund Established Jointly by Employers and Local Unions Telephone (562) 463-5080 (800) 824-4427 Facsimile (562) 463-5894 www.lumberfund.org January 9, 2015

Más detalles

PROCEDIMIENTOS: QUÉ HACER CON EL PEDIMENTO UNA VEZ QUE SE HA COMPLETADO

PROCEDIMIENTOS: QUÉ HACER CON EL PEDIMENTO UNA VEZ QUE SE HA COMPLETADO CENTRO DE AUTOSERVICIO PROCEDIMIENTOS: QUÉ HACER CON EL PEDIMENTO UNA VEZ QUE SE HA COMPLETADO PASO 1: COPIAS Y SOBRES. Haga tres (3) copias de las páginas siguientes del pedimento; Haga dos (2) copias

Más detalles

OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal.

OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal. OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal. Person Filing: (Nombre de persona:) Address (if not

Más detalles

Tarjetas de crédito Visa y Mastercard a través de la pagina de inscripción al curso. (En Argentina no se acepta Amex)

Tarjetas de crédito Visa y Mastercard a través de la pagina de inscripción al curso. (En Argentina no se acepta Amex) Terminos y Condiciones PAGOS El pago del curso deberá en todos los casos efectivizado como mínimo - 72 horas antes del comienzo del mismo. La vacante será confirmada contra el pago del curso, hasta ese

Más detalles

El límite mínimo para las cuentas comerciales grandes es de $2,000/mes por el uso del servicio.

El límite mínimo para las cuentas comerciales grandes es de $2,000/mes por el uso del servicio. ONNETIUT OBERTURA DEL FORMULARIO DE FAX PARA: XOOM Energy lientes omerciales No. FAX: 866.452.0053 FEHA: NOMBRE DE EMPRESARIO INDEPENDIENTE: # IDENTIFIAIÓN DE NEGOIO: ORREO ELETRÓNIO: # DE PÁGINAS: TELÉFONO:

Más detalles

Canutillo Middle School 7311 Bosque, P.O. Box 100 Canutillo, Texas 79835 (915) 877-7900 Fax (915) 877-7919

Canutillo Middle School 7311 Bosque, P.O. Box 100 Canutillo, Texas 79835 (915) 877-7900 Fax (915) 877-7919 Mark Paz August 24, 2015 Dear Parents/Legal Guardian, I would like to start by thanking each and every single one of you for the tremendous help and support we have been receiving. Thank You! Next school

Más detalles

Bienvenidos a Primer Grado Welcome to first grade

Bienvenidos a Primer Grado Welcome to first grade Bienvenidos a Primer Grado Welcome to first grade Mrs. Pulido Mrs. Howard Mrs. Escamilla Maestras del programa doble sendero Dual Language Teachers En la mañana Morning Procedures El desayuno se sirve

Más detalles

Registro de Semilla y Material de Plantación

Registro de Semilla y Material de Plantación Registro de Semilla y Material de Plantación Este registro es para documentar la semilla y material de plantación que usa, y su estatus. Mantenga las facturas y otra documentación pertinente con sus registros.

Más detalles

Daly Elementary. Family Back to School Questionnaire

Daly Elementary. Family Back to School Questionnaire Daly Elementary Family Back to School Questionnaire Dear Parent(s)/Guardian(s), As I stated in the welcome letter you received before the beginning of the school year, I would be sending a questionnaire

Más detalles

Mi Futuro esta en Carreras de Salud

Mi Futuro esta en Carreras de Salud Mi Futuro esta en Carreras de Salud Friday, January 27, 2017 8:30am - 2:10pm Santa Rosa, CA Latino Service Providers & the, in cooperation with community sponsors, invite you to a Spring Health Career

Más detalles

Lump Sum Final Check Contribution to Deferred Compensation

Lump Sum Final Check Contribution to Deferred Compensation Memo To: ERF Members The Employees Retirement Fund has been asked by Deferred Compensation to provide everyone that has signed up to retire with the attached information. Please read the information from

Más detalles