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[IP] [DEPLOY_ID]
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holla
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_____________________________________________________________________________
________________________________________ Cardinal Station Newburg Center for
Primary Care 215 Central Avenue, Suite 100 1941 Bishop Lane, Suite 900 215
Central Avenue, Suite 205 Louisville, KY 40208 Louisville, KY 40218
Louisville, Ky 40208 I:\FCM\Phyllis Harris\Forms\New Patient Pkg Components UofL Department of Family & Geriatric Medicine Dear New Patient, Welcome to your University of Louisville Physicians Family practice! We are
offering patient-centered medical care and are enthusiastic about our relationships with our patients. In order to better serve your needs, we
are enclosing several forms and ask that you completely fill each form out. The first sheet will help us learn more about you; please completely fill out
this form about your family history. The next sheet is titled, �Authorization
for the use and/or Disclosure of Protected Health Information�, and you will
need to completely fill that out for our doctors to treat you to the best of
their ability; it gives us permission to review your medical records from your
previous primary medical facilities. Following, please completely fill
out the Registration, Social Services & Consent Form. Next, you will find our
Privacy Notice, followed by an acknowledgement that you have received and
understand our Privacy Policies. Finally, the last form is the Office
Acknowledgements and Policies form. Please read carefully and sign your name
at the bottom of the letter. Please make sure to bring all of these forms with
you to your first office visit. Do not mail them back to the office. Also,
please remember to always bring your picture ID, current insurance cards and
your co-payment. If your health insurance requires you to select a primary
care doctor please do so prior to your office visit. Please bring in any and
all medication you take, in their original bottles, to your appointment. If the patient is under 18 years of age he or she must be accompanied by an adult and will need to bring a copy of their current immunization certificate. Please arrive 15 minutes ahead of your scheduled appointment time so that
if you have questions about these forms or we need more information, we can address it all prior to your appointment. We look forward to seeing you!
 University of Louisville Physicians UofL Family and Geriatric
Medicine
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 AMENDMENT OF

SOLICITATION/MODIFICATION OF CONTRACT 1. CONTRACT ID
CODE PAGE 1 of 1 PAGES 2.
AMENDMENT/MODIFICATION NO. A001 3. EFFECTIVE DATE 05/30/2017 4. REQUISITION/PURCHASE REQ. NO. 5. PROJECT NO. (If applicable) 6.
ISSUED BY CODE 7. ADMINISTERED BY (If other than Item 6) CODE American Embassy Cotonou Marina
Avenue Cotonou, Republic of Benin 8. NAME AND
ADDRESS OF CONTRACTOR (NO., street,city,county,State,and ZIP Code) 9a. AMENDMENT OF SOLICITATION NO. SBN150-17-
Q-0007 X 9b. DATED (SEE ITEM 11) 05/05/2017 10a. MODIFICATION OF
CONTRACT/ORDER NO. 10b. DATED (SEE ITEM 13) 11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS
 [ X] The above numbered solicitation is amended as set
forth in Item 14. The hour and date specified for receipt of Offers [X]
is extended, [ ] is not extended Offers must acknowledge receipt of
this amendment prior to the hour and date specified in the solicitation or as
amended, by one of the following methods: (a) By completing Items 8 and
15, and returning __1__ copies of the amendment;(b) By acknowledging receipt of
this amendment on each copy of the offer submitted; or(c) By separate
letter or telegram, which includes a reference to the solicitation and amendment
numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE
DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY
RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you
desire to change an offer already submitted, such change may be made by telegram or
letter, provided each telegram Or letter makes reference to the
solicitation and this amendment, and is received prior to the opening hour and date
specified. 12. ACCOUNTING AND APPROPRIATION DATA (If required) 13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS, IT
MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14. A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify
authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT
ORDER NO. IN ITEM 10A. B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED
TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying Office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY
OF FAR 43.103(b) C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO
PURSUANT TO AUTHORITY OF: D. OTHER (Specify type of
modification and authority) E. IMPORTANT: Contractor [ X]
is not, [ ] is required to sign this document and return 1 original copies to the
issuing office. 14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by
UCF section headings, including solicitation/contract subject matter where
feasible.) The purpose of this amendment is to extend the
period of submission of the quotations from May 30, 2017 to thru June
6, 2017 no later than 10:00AM. Except as provided herein, all
terms and conditions of the document referenced in Item 9A or 10A, as heretofore
changed, remains unchanged and in full force and effect. 15A. NAME AND
TITLE OF SIGNER (Type or print) 16A. NAME OF
CONTRACTING OFFICER Sarah E Kahnt 15B. NAME OF
CONTRACTOR/OFFEROR SIGNED BY (Signature of person authorized to
sign) 15C.DATE SIGNED 16B. UNITED
STATES OF AMERICA BY (Signature of Contracting Officer) 16C.DATE SIGNED May 30, 2017 
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Page 1 of 3 For Completion and Submission by Health Care Provider Request for Documentation of Medical Need for Housing/Dining Accommodation Dear Health Care Provider, Your patient is a student at Salem College and
has indicated that the student has a condition which rises to the level of a
disability and will require accommodation to participate in a program or activity
(i.e., housing or dining) at Salem College. For the purpose of receiving
consideration for reasonable accommodations at Salem College, the student must
have an impairment that substantially limits one or more major life
activities. In order to consider this request for accommodation related to a
specific diagnosis or chronic health condition, Salem College requires
documentation of the student�s current medical condition from the treating and
licensed clinical professional or health care provider who is thoroughly
familiar with the student�s condition and functional limitations or
restrictions. The information you provide will be used to determine the nature
and severity of the student�s condition and the appropriateness of the
requested accommodation. Please take the time to fill out this form in its
entirety, as it must be completed and returned before any accommodation can be
considered or provided. Please return the completed form to: Health
Services Salem College 601 S. Church Street Winston-Salem, NC
27101 Fax: 336-917-5582 All information obtained in response to this
request will be maintained and used in accordance with applicable confidentiality requirements. A signed consent for release of the requested
information should be completed by the student prior to the release of this
form to Salem College. Thank you for your assistance. General Information
about Salem College Facilities and Dining Options ? Salem College has
residential facilities on campus that are of varying configurations and
construction ranging from a typical residence hall room with a community
bathroom to suites and apartments which contain private or limited access
bathrooms and kitchens. Not all residence halls at Salem College are
airconditioned. ? Students who are eligible for dining accommodations are
required to meet with the registered dietician who provides support to Salem
College and educates eligible students on available food options through on-
campus dining. Page 2 of 3 Physician Information First Name:
______________________________ Last Name: ______________________________ Address: _________________________________ Specialty:
________________________________ License/certification #:
______________________ State of license/certification: _________________ Phone
#: _________________________________ Fax #:
___________________________________ If you are related to this student, what
is your relationship? _________________________________________ Student
Information First Name: ______________________________ Last Name:
______________________________ Diagnosis: _______________________________ Date
of diagnosis: _________________________ Date of last visit for condition:
_______________ Duration of time treating patient: ______________ Identify the
procedures/assessments used to diagnose student�s condition (if applicable, attach
a copy of test results; e.g. pulmonary function testing, blood tests, allergy
testing): __________________________________ _________________________________________________________________________________
________ _________________________________________________________________________________
________ Identify the severity of the condition (check one): ___
Mild ___ Moderate ___ Severe ___ In Remission Does the student
take prescription medication for this condition? ___ Yes, specific
medications, doses, and frequency: ________________________________________ ___ No Has the student been treated in any emergency room or hospital for
this condition within the last year? ___ Yes, total number of hospitalizations
and date of last hospitalization: _________________________ ___ No Page 3
of 3 Describe the environmental factors (if any) that exacerbate this
condition: ______________________________ _________________________________________________________________________________
________ _________________________________________________________________________________
________ If the diagnosis is a food allergy, describe the reaction/potential
reaction if exposed to allergen: _____________ _________________________________________________________________________________
________ _________________________________________________________________________________
________ Describe how this condition substantially limits a major life
activity. Major life activities include, but are not limited to, caring for
oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking,
standing, sitting, reaching, lifting, bending, speaking, breathing, learning,
reading, concentrating, thinking, communicating, interacting with others, and
working; and the operation of a major bodily function, including functions of
the immune system, special sense organs and skin; normal cell growth; and
digestive, genitourinary, bowel, bladder, neurological, brain, respiratory,
circulatory, cardiovascular, endocrine, hemic, lymphatic, musculoskeletal, and
reproductive functions (29 C.F.R. 1630.2):
______________________________________ _________________________________________________________________________________
_________ _________________________________________________________________________________
_________ Describe the recommended accommodation(s) linked to functional
limitations: __________________________ _________________________________________________________________________________
_________ _________________________________________________________________________________
_________ Describe the reasoning for the recommended accommodation:
_______________________________________ _________________________________________________________________________________
_________ _________________________________________________________________________________
_________ Identify the anticipated duration of medical need for the
recommended accommodation: __________________ _________________________________________________________________________________
_________ Affix business card or apply business stamp below: Physician
Signature: ______________________________ Date:
________________________________
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(1) Sample Cover Letters for Student reference (to seek industrial placement)
(a) <Date> <Name of Contact Person> <Designation> <Name of Company> <Address of
Company> Dear Sir / Madam, Ref: Application for Industrial Training Attachment I am
a year # student pursuing the (Name of Course> at Universiti Tunku Abdul Rahman,
and wish to apply as a trainee for Industrial Training in your company. Your
company is very suitable to me in terms of my area of interest and your location.
It is a requirement that I spend three months in an industry prior to the final
year programme. As your company is not among those contacted by the University, I
have obtained permission from the Dean to submit my application to you directly. I
enclose herewith the letters from the University and my particulars. I shall be
most grateful if my application is considered favourably. Thank you. Yours
faithfully, Student's name (b) <Date> <Name of Company> <Address of Company> To
Whom It May Concern: Dear Sir/Madam, Dear [Sir/Madam], Application for Industrial
Training Placement At [name of company] I would like to apply for the position of
Industrial Trainee at your company. [provide reasons why the company should accept
your application] [provide the duration of attachment] I enclose my resume for your
consideration. Thank You. Yours truly, [name of applicant] [address of applicant]
Encl. Resume and Copies of Transcript (c) <Date> <Name of Contact Person>
<Designation> <Name of Company> <Address of Company> Dear Sir/Madam, As a student
doing Bachelor of <course> at <Name of Faculty>, Universiti Tunku Abdul Rahman, I
am seeking for opportunity to do my industrial training in the area related to my
course of study. From the research I have conducted on � [Name of Company] �, I am
interested in pursuing � [ name of position] � intern position. � [Briefly describe
your interest in this company]� [Highlights two or three key experiences and/or
academic achievements that directly relate to the qualifications the employer is
seeking]. [Show proves that you have some of the key skills for the position].
Attached is my resume for your review. I would like the opportunity to further
discuss with you the �[name of job]� internship and my qualifications. Please let
me know if I can call your office to see if we might arrange a convenient time to
meet. I look forward to talking with you. Thank you for your consideration. Yours
sincerely, Student�s signature Name (2) Sample Resume format (You are advised to
use your own format) RESUME Full name (you may use prefix to indicate gender e.g.
Ms. or Mr.) Date of birth (attach your recent photo) Address Telephone Email
Academic achievements Course : Major : Minor : CGPA : STPM : Grade Aggregate
SPM : Grade Aggregate Language spoken and written (indicate level of proficiency)
Computer skills (indicate level of proficiency) Extra curricular activities
(indicate level of participation) Working experience (indicate salary if
significant) Resume dated (3) Sample letter for Acceptance of Offer Student�s Name
Address E-mail Date: Contact Person Name of Company Address Dear [Name of Contact
Person] Re: Acceptance of Offer for Industrial TrainingThank you for your
offer of employment as an Industrial Trainee at your company �.[Name of
Company]�. . As we discussed on the phone this �.[morning/afternoon]�., I am
delighted to accept your offer and look forward to working with �.[Name of
Company]�. . You indicated that I will be receiving an allowance of RM �.[Amount of
Allowance]�. per month, and will have initial duties reporting to �.[Name of
Supervisor]�. . As your offer stated, my training will be from �.[Start Date]� to
�.[End Date]�. . I will call you before I start my Industrial Training to see what
information or materials I may need. In the meantime, please let me know if I can
provide you with any information. Again, thank you for offering me this exciting
opportunity. Sincerely, Student�s Signature Name Address (4) Sample letter for
Rejection of Offer Student�s Name Address E-mail Date: Name of Contact Person
Address Dear �.[Name of Contact Person]�. : Re: Rejection of Offer for Industrial
Training I wish to express my sincerest appreciation to you for including me in the
interview process as you seek candidates for your Industrial Trainees position. It
was a privilege and a pleasure to meet with you and the members of your staff. I
believe that training at your company is a great opportunity and would be an
excellent experience. However, with all due respect, as I explained when we spoke
this �.. [morning/afternoon]�.., I am unable to accept your industrial training
placement offer. I have decided to accept another offer which I believe very
closely matches my training interest at this point in time. Thank you so much for
the time and effort you have given to me. I wish you and the staff of �.[Name of
Company]�. the best of success.
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<p class="text"><br /><br /><br /><br /><br />AMENDMENT OF

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