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leoff

Whitman County

LEOFF I Board

Policies and Procedures

FORMS

#1        Employee's Statement

#2        Employer's Statement and Report on Application for Disability Retirement

#3        List of Health Care Providers

#4        Health Care Provider Statement

#5        Health Care Provider Treatment Plan

#6        Medical Expense Claim

#7        Medical Expense Claims Procedures

#8        Employer Statement Regarding Medical Expense Claim

#9        Medical Request for Home Health Care

#10       Approval/Rejection of Claim Form Letter

#11       Response to Request for Medical Payment/Reimbursement (Medicare)

#12       Response to Request for Medical Payment/Reimbursement (Non-Medicare)

#13       Member Insurance Coverages (to be completed annually)

#14-A   Nomination Letter 'Firefighter Representative

#14-B   Nomination Form ' Firefighter Representative

#14-C   Nomination Certification ' Firefighter Representative

#14-D   Ballot Form ' Firefighter Representative

#14-E   Election Certification ' Firefighter Representative

#15-A   Nomination Letter - Law Enforcement Officer Representative

#15-B   Nomination Form ' Law Enforcement Officer Representative

#15-C   Ballot Form ' Law Enforcement Officer Representative

#15-D   Election Certification ' Law Enforcement Officer Representative

#15-E   Nomination Certification ' Law Enforcement Officer Representative

#17       HIPAA - Response to Access Health Information Record Letter

#18       HIPAA - Revocation of Authorization for Use or Disclosure of Health Care Information-2 Pages

#19-A       HIPAA - Request for Corrected/Amended Health Information

#19-B       HIPAA - Request for Corrected/Amended Health Information, Page 2

#20       HIPAA - Response to Request for Corrected/Amended Health Information

#21       HIPAA - PHI Disclosure Log

#22       HIPAA - Acknowledgement

#23       HIPAA - Sample Grievance Resolution Letter

#24       HIPAA - Confidentiality Statement

#25       HIPAA - Authorization to Release Private Information (Page 1)

#25       HIPAA - Authorization to Release Private Information (Page 2)

#26       HIPAA - Volunteer/Service Provider Confidentiality Statement
     
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