LEOFF 1 - Documents
LEOFF 1 Documents are listed below. Questions can be directed to the Clerk of the Whitman County LEOFF I BOARD at (509) 397-6202 and should be returned to: Whitman County LEOFF 1 Board 400 N Main St., Colfax WA 99111
LEOFF 1 Documents
- #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 Nomination Certification – Law Enforcement Officer Representative
- #15-D Ballot Form – Law Enforcement Officer Representative
- #15-E Election 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 HIPAA - Request for Corrected/Amended Health Information
- #19-B HIPAA - Request for Corrected/Amended Health Information (Page 2, to be completed by Whitman County)
- #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-A HIPAA - Authorization to Release Private Information (1 of 2-Pages)
- #25-B HIPAA - Authorization to Release Private Information (2 of 2-Pages)
- #26 HIPAA - Volunteer/Service Provider Confidentiality Statement