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LEOFF I Board
Members
Agendas
Policy & Forms
- Policies and Procedures (PDF)
- Employees Statement (PDF)
- Employers Statement and Report on Application for Disability Retirement (PDF)
- List of Health Care Providers (PDF)
- Health Care Provider Statement (PDF)
- Health Care Provider Treatment Plan (PDF)
- Medical Expense Claim (PDF)
- Medical Expense Claims Procedures (PDF)
- Employer Statement Regarding Medical Expense Claim (PDF)
- Medical Request for Home Health Care (PDF)
- Reimbursement (Medicare) (PDF)
- Reimbursement (Non-Medicare) (PDF)
- Member Insurance Coverages (to Be Completed Annually) (PDF)
- Nomination Letter Firefighter Representative (PDF)
- Nomination Form Firefighter Representative (PDF)
- Nomination Certification Firefighter Representative (PDF)
- Ballot Form Firefighter Representative (PDF)
- Election Certification Firefighter Representative (PDF)
- Nomination Letter - Law Enforcement Officer Representative (PDF)
- Nomination Form Law Enforcement Officer Representative (PDF)
- Ballot Form Law Enforcement Officer Representative (PDF)
- Election Certification Law Enforcement Officer Representative (PDF)
- Nomination Certification Law Enforcement Officer Representative (PDF)
- HIPAA - Response to Access Health Information Record Letter (PDF)
- HIPAA - Revocation of Authorization for Use or Disclosure of Health Care Information-2 Pages (PDF)
- Amended Health Information (PDF)
- Amended Health Information (Page 2) (PDF)
- Approval Rejection of Claim Form Letter (PDF)
- Rejection of Claim Form Letter (PDF)
- HIPAA - PHI Disclosure Log (PDF)
- HIPAA - Acknowledgement (PDF)
- HIPAA - Sample Grievance Resolution Letter (PDF)
- HIPAA - Confidentiality Statement (PDF)
- HIPAA - Authorization to Release Private Information (Page 1) (PDF)
- HIPAA - Authorization to Release Private Information (Page 2) (PDF)
- HIPAA - Volunteer Service Provider Confidentiality Statement (PDF)