LEOFF I Board Policy & Forms

  1. Policies and Procedures (PDF)
  2. Employees Statement (PDF)
  3. Employers Statement and Report on Application for Disability Retirement (PDF)
  4. List of Health Care Providers (PDF)
  5. Health Care Provider Statement (PDF)
  6. Health Care Provider Treatment Plan (PDF)
  7. Medical Expense Claim (PDF)
  8. Medical Expense Claims Procedures (PDF)
  9. Employer Statement Regarding Medical Expense Claim (PDF)
  10. Medical Request for Home Health Care (PDF)
  11. Reimbursement (Medicare) (PDF)
  12. Reimbursement (Non-Medicare) (PDF)
  13. Member Insurance Coverages (to Be Completed Annually) (PDF)
  14. Nomination Letter Firefighter Representative (PDF)
  15. Nomination Form Firefighter Representative (PDF)
  16. Nomination Certification Firefighter Representative (PDF)
  17. Ballot Form Firefighter Representative (PDF)
  18. Election Certification Firefighter Representative (PDF)
  19. Nomination Letter - Law Enforcement Officer Representative (PDF)
  20. Nomination Form Law Enforcement Officer Representative (PDF)
  21. Ballot Form Law Enforcement Officer Representative (PDF)
  22. Election Certification Law Enforcement Officer Representative (PDF)
  23. Nomination Certification Law Enforcement Officer Representative (PDF)
  24. HIPAA - Response to Access Health Information Record Letter (PDF)
  25. HIPAA - Revocation of Authorization for Use or Disclosure of Health Care Information-2 Pages (PDF)
  26. Amended Health Information (PDF)
  27. Amended Health Information (Page 2) (PDF)
  28. Approval Rejection of Claim Form Letter (PDF)
  29. Rejection of Claim Form Letter (PDF)
  30. HIPAA - PHI Disclosure Log (PDF)
  31. HIPAA - Acknowledgement (PDF)
  32. HIPAA - Sample Grievance Resolution Letter (PDF)
  33. HIPAA - Confidentiality Statement (PDF)
  34. HIPAA - Authorization to Release Private Information (Page 1) (PDF)
  35. HIPAA - Authorization to Release Private Information (Page 2) (PDF)
  36. HIPAA - Volunteer Service Provider Confidentiality Statement (PDF)