FINANCIAL OPTIONS. 2. For non-insured patients, payment is due on the day of service.

Size: px
Start display at page:

Download "FINANCIAL OPTIONS. 2. For non-insured patients, payment is due on the day of service."

Transcription

1

2

3 FINANCIAL OPTIONS 1. Fr thse patients wh carry dental insurance, all c-payments are due n date f service. We will file yur claim as a service t yu, and will d ur very best t maximize yur benefits. We accept assignment t lwer yur immediate ut-f- pcket expenditures. 2. Fr nn-insured patients, payment is due n the day f service. 3. MasterCard, Visa, Discver Card and American Express cards are accepted. 4. Fr lng term payment plans, we ffer Care Credit. Care Credit is a financing prgram fr dentistry that allws yu t make mnthly payments, spreading thse payments ur ver a desired time perid. (Based n Care Credit apprval) 5. A $35.00 fee will be charged due t insufficient funds n all returned checks. These financial ptins will meet the needs f mst families in ur practice. We want t be flexible in changing times. We will d ur very best t wrk ut a financial slutin t yur particular situatin. We are here t help yu. There will be a $50.00 fee fr appintments brken with less than 48 hurs ntice. Fees may be applied if yur accunt is sent t cllectins. Yurs fr Better Dental Health, Dickinsn & Brann Dental Care Patient s Signature: Date:!

4 Billing Prcedure Dental insurance is a benefit frm yur emplyer that helps yu pay fr yur dental treatment. It generally des nt pay fr all f yur treatment. Ultimately, yu are respnsible fr paying fr the cst f yur dental treatment. We will try ur best t make the benefit yu receive g as smthly as pssible, but we need yur help. As a curtesy, we will file insurance claims n yur behalf. T d this we will need a cpy f yur dental insurance card and sme additinal infrmatin. Generally dental benefits are reimbursed at different rates, depending n the plicy that yur emplyer has purchased. The categries cvered are preventive, basic and majr and the reimbursement varies fr each emplyer s individual plicy. The insurance cmpanies have a yearly maximum fr the dental benefits and this als varies fr each emplyer s individual plicy. Dickinsn & Brann Dental Care is nt a prvider fr Blue Crss Blue Shield. As a curtesy, we file yur insurance fr yu but the Explanatin f Benefits (EOB) and payment g directly t the emplyee (yu). Payments are due n the day f service fr patients with Blue Crss dental benefits. In rder fr us t bill secndary insurance, we need yur help. Sme secndary insurance cmpanies will require a cpy f the Blue Crss Explanatin f Benefits s we need yu t frward this cpy frm Blue Crss Blue Shield prmptly t ur ffice. We can then submit the EOB fr Blue Crss and the secndary insurance claim t the secnd cmpany fr additinal payment. Failure t submit the Blue Crss Blue Shield Explanatin f Benefit cpy t us in a timely manner may result in finance charges. All insurance cmpanies send the Explanatin f Benefits t ur ffice and t the patient. Cpays frm the patient will be billed t the patient with ur mnthly billing statements. Statements will cntinue t be sent n a mnthly basis until the accunt is paid in full. Ultimately, yu are respnsible fr the payment f dental services frm ur ffice. PLEASE CONTACT US IF YOU HAVE ANY QUESTIONS ON PATIENT CO-PAYS, OR OTHER QUESTIONS ON YOUR DENTAL BENEFIT. WE ARE HERE TO HELP YOU.

5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **Yu May Refuse t Sign This Acknwledgement*** I have received a cpy f Dickinsn & Brann Dental Care Ntice f Privacy Practices. {Please Print Name} {Signature} {Date} UNLESS YOU REQUEST OTHERWISE, we may use r disclse health infrmatin t an immediate family member r legal guardian t the extent necessary t help with yur healthy care r with payment f yur healthy care. I request the fllwing t NOT have access t my dental/financial recrds. Fr Office Use Only We attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, but acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatins barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (Please Specify) 2002 American Dental Assciatin All Rights Reserved Reprductin and use f this frm by dentists and their staff is permitted. Any ther use, duplicatin r distributin f this frm by any ther party requires the prir written apprval f the American Dental Assciatin. This Frm is educatinal nly, des nt cnstitute legal advice, and cvers nly federal, nt state, law (August 14, 2002)

6 Dickinsn & Brann Dental Care NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law t maintain the privacy f yur health infrmatin. We are als required t give yu this Ntice abut ur privacy practices, ur legal duties, and yur rights cncerning yur health infrmatin. We must fllw the privacy practices that are described in this Ntice while it is in effect. This Ntice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right t change ur privacy practices and the terms f this Ntice at any time, prvided such changes are permitted by applicable law. We reserve the right t make the changes in ur privacy practices and the new terms f ur Ntice effective fr all health infrmatin that we maintain, including health infrmatin we created r received befre we made the changes. Befre we make a significant change in ur privacy practices, we will change this Ntice and make the new Ntice available upn request. Fr mre infrmatin abut ur privacy practices, r t request a cpy f ur Ntice, please cntact us using the infrmatin listed n this website. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclse health infrmatin abut yu fr treatment, payment, and healthcare peratins. Fr example: Treatment: We may use r disclse yur health infrmatin t a physician r ther healthcare prvider prviding treatment t yu. Payment: We may use and disclse yur health infrmatin t btain payment fr services we prvide t yu. Healthcare Operatins: We may use and disclse yur health infrmatin in cnnectin with ur healthcare peratins. Healthcare peratins include quality assessment and imprvement activities, reviewing the cmpetence r qualificatins f healthcare prfessinals, evaluating practitiner and prvider perfrmance, cnducting training prgrams, accreditatin, certificatin, licensing r credentialing activities. Yur Authrizatin: In additin t ur use f yur health infrmatin fr treatment, payment r healthcare peratins, yu may give us written authrizatin t use yur health infrmatin r t disclse it t anyne fr any purpse. If yu give us an authrizatin, yu may revke it in writing at any time. Yur revcatin will nt affect any use r disclsures permitted by yur authrizatin while it was in effect. Unless yu give us a written authrizatin, we cannt use r disclse yur health infrmatin fr any reasn except thse described in this Ntice. T Yur Family and Friends: We must disclse yur health infrmatin t yu as described in the Patient Rights sectin f this Ntice. We may disclse yur health infrmatin t a family member, friend, r ther persn t the extent necessary t help with yur healthcare r with payment fr yur healthcare; but nly if yu agree that we may d s. Persns Invlved In Care: We may use r disclse health infrmatin t ntify r assist in the ntificatin f (including identifying r lcating) a family member, yur persnal representative r anther persn respnsible fr yur care, f yur lcatin, yur general cnditin, r death. If yu are present, then prir t use r disclsure f yur health infrmatin, we will prvide yu with an pprtunity t bject t such uses r disclsures. In the event f yur incapacity r emergency circumstances, we will disclse health infrmatin based n a determinatin using ur prfessinal judgment disclsing nly health infrmatin that is directly relevant t the persn s invlvement in yur healthcare. We will als use ur prfessinal judgment and ur experience with cmmn practice t make reasnable inferences f yur best interest in allwing a persn t pick up filled prescriptins, medical supplies, x- rays, r ther similar frms f health infrmatin. Marketing Health-Related Services: We will nt use yur health infrmatin fr marketing cmmunicatins withut yur written authrizatin. Required by Law: We may use r disclse yur health infrmatin when we are required t d s by law. Abuse r Neglect: We may disclse yur health infrmatin t apprpriate authrities if we reasnably believe that yu are a pssible victim f abuse, neglect, dmestic vilence, r the pssible victim f ther crimes. We may disclse yur health infrmatin t the extent necessary t avert a serius threat t yur health r safety r the health r safety f thers.

7 Natinal Security: We may disclse t military authrities the health infrmatin f Armed Frces persnnel under certain circumstances. We may disclse t authrized federal fficials health infrmatin required fr lawful intelligence, cunterintelligence, and ther natinal security activities. We may disclse t crrectinal institutin r law enfrcement fficial having lawful custdy f prtected health infrmatin f inmate r patient under certain circumstances. Appintment Reminders: We may use r disclse yur health infrmatin t prvide yu with appintment reminders (such as vic messages, pstcards, r letters). PATIENT RIGHTS Access: Yu have the right t lk at r get cpies f yur health infrmatin, with limited exceptins. Yu may request that we prvide cpies in a frmat ther than phtcpies. We will use the frmat yu request unless we cannt practicably d s. Yu must make a request in writing t btain access t yur health infrmatin. We may charge yu a reasnable cst-based fee fr expenses such as cpies and staff time. If yu request an alternative frmat, we will charge a cst-based fee fr prviding yur health infrmatin in that frmat. Disclsure Accunting: Yu have the right t receive a list f instances in which we r ur business assciates disclsed yur health infrmatin fr purpses, ther than treatment, payment, healthcare peratins, and certain ther activities. If yu request this accunting mre than nce in a 12-mnth perid, we may charge yu a reasnable, cst-based fee fr respnding t these additinal requests. Restrictin: Yu have the right t request that we place additinal restrictins n ur use r disclsure f yur health infrmatin. We are nt required t agree t these additinal restrictins, but if we d, we will abide by ur agreement, except in an emergency. Alternative Cmmunicatin: Yu have the right t request that we cmmunicate with yu abut yur health infrmatin by alternative means r t alternative lcatins. {Yu must make yur request in writing.} Yur request must specify the alternative means r lcatin, and prvide satisfactry explanatin hw payments will be handled under the alternative means r lcatin yu request. Amendment: Yu have the right t request that we amend yur health infrmatin. Yur request must be in writing, and it must explain why the infrmatin shuld be amended. We may deny yur request under certain circumstances. Electrnic Ntice: If yu receive this Ntice n ur website r by electrnic mail ( ), yu are entitled t receive this Ntice in written frm. QUESTIONS AND COMPLAINTS If yu want mre infrmatin abut ur privacy practices r have questins r cncerns, please cntact us. If yu are cncerned that we may have vilated yur privacy rights, yu disagree with a decisin we made abut access t yur health infrmatin, r in respnse t a request yu made t amend r restrict the use r disclsure f yur health infrmatin, r t have us cmmunicate with yu by alternative means r at alternative lcatins, yu may cmplain t us using the cntact infrmatin listed n this website. Yu als may submit a written cmplaint t the U.S. Department f Health and Human Services. We will prvide yu with the address t file yur cmplaint with the U.S. Department f Health and Human Services upn request. We supprt yur right t the privacy f yur health infrmatin. We will nt retaliate in any way if yu chse t file a cmplaint with us r with the U.S. Department f Health and Human Services. Cntact Officer: Teresa Furnier/Office Administratr Telephne: Fax: Address: 12 Mapleville Dept, St. Albans, VT , 2009 American Dental Assciatin. All Rights Reserved Reprductin and use f this frm by dentists and their staff is permitted. Any ther use, duplicatin r distributin f this frm by any ther party, requires the prir written apprval f the American Dental Assciatin. This Frm is educatinal nly, des nt cnstitute legal advice, and cvers nly federal, nt state, law (August 14, 2002; April 30, 2009).

Hampton Roads Orthopaedics & Sports Medicine. Notice of Privacy Practices

Hampton Roads Orthopaedics & Sports Medicine. Notice of Privacy Practices This is being prvided t yu as a requirement f the privacy regulatins issued under the Health Insurance Prtability and Accuntability Act f 1996 (HIPAA). This ntice describes hw HROSM may use and disclse

More information

Project Open Hand Atlanta. Health Insurance Portability and Accountability Act (HIPAA) NOTICE OF PRIVACY PRACTICES

Project Open Hand Atlanta. Health Insurance Portability and Accountability Act (HIPAA) NOTICE OF PRIVACY PRACTICES Prject Open Hand Atlanta Effective Date: April 14, 2003 Health Insurance Prtability and Accuntability Act (HIPAA) The Health Insurance Prtability and Accuntability Act f 1996 (HIPAA) directs health care

More information

HIPAA Notice of Privacy Practices. Central Ohio Surgical Associates, Inc.

HIPAA Notice of Privacy Practices. Central Ohio Surgical Associates, Inc. HIPAA Ntice f Privacy Practices Central Ohi Surgical Assciates, Inc. THIS NOTICE OF PRIVACY PRACTICES (THE NOTICE ) DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

Texas Woman's University University Policy Manual

Texas Woman's University University Policy Manual Texas Wman's University University Plicy Manual Plicy Name: Plicy Number: 6.06 Date Passed: July 2004 Health Insurance Prtability& Accuntability Act (HIPAA) Date Reviewed: September 2008 Next Review: September

More information

GOVERNORS PHARMACY HIPAA NOTICE OF PRIVACY PRACTICES For Your Protected Health Information

GOVERNORS PHARMACY HIPAA NOTICE OF PRIVACY PRACTICES For Your Protected Health Information GOVERNORS PHARMACY HIPAA NOTICE OF PRIVACY PRACTICES Fr Yur Prtected Health Infrmatin THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

More information

THRIFTY DRUG STORES, INC. d/b/a THRIFTY WHITE DRUG / WHITE DRUG / BELL PHARMACY/VALLEY DRUG/ THRIFTY NYSTROM DRUG NOTICE OF PRIVACY PRACTICES

THRIFTY DRUG STORES, INC. d/b/a THRIFTY WHITE DRUG / WHITE DRUG / BELL PHARMACY/VALLEY DRUG/ THRIFTY NYSTROM DRUG NOTICE OF PRIVACY PRACTICES THRIFTY DRUG STORES, INC. d/b/a THRIFTY WHITE DRUG / WHITE DRUG / BELL PHARMACY/VALLEY DRUG/ THRIFTY NYSTROM DRUG NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY

More information

Notice of Privacy Practices for Protected Health Information Effective March 26, 2013

Notice of Privacy Practices for Protected Health Information Effective March 26, 2013 Ntice f Privacy Practices fr Prtected Health Infrmatin Effective March 26, 2013 This ntice describes hw medical infrmatin abut yu may be used and disclsed and hw yu can get access t this infrmatin. Please

More information

We will record and prepare documents based off the information presented

We will record and prepare documents based off the information presented Dear Client: We appreciate the pprtunity f wrking with yu regarding yur Payrll needs. T ensure a cmplete understanding between us, we are setting frth the pertinent infrmatin abut the services that we

More information

IMPORTANT INFORMATION ABOUT MEDICAL CARE FOR YOUR WORK-RELATED INJURY OR ILLNESS

IMPORTANT INFORMATION ABOUT MEDICAL CARE FOR YOUR WORK-RELATED INJURY OR ILLNESS IMPORTANT INFORMATION ABOUT MEDICAL CARE FOR YOUR WORK-RELATED INJURY OR ILLNESS MEDICAL PROVIDER NETWORK (MPN) NOTIFICATION If yu are injured at wrk, Califrnia Law requires yur emplyer t prvide and pay

More information

Potomac Region Medical Associates

Potomac Region Medical Associates Ptmac Regin Medical Assciates 14300 Gallant Fx Lane Ste.118 1600K Crystal Square Arcade Bwie, Maryland 20715 Arlingtn, VA 22202 Phne (301-805-4348 Phne: 703-418-1870 Patient Infrmatin Frm Scial Security

More information

Cell Phone & Data Access Policy Frequently Asked Questions

Cell Phone & Data Access Policy Frequently Asked Questions Cell Phne & Data Access Plicy Frequently Asked Questins 1. Wh is eligible fr a technlgy allwance? First and fremst, the technlgy allwance is fr the benefit f the University, rather than fr the cnvenience

More information

Key Steps for Organizations in Responding to Privacy Breaches

Key Steps for Organizations in Responding to Privacy Breaches Key Steps fr Organizatins in Respnding t Privacy Breaches Purpse The purpse f this dcument is t prvide guidance t private sectr rganizatins, bth small and large, when a privacy breach ccurs. Organizatins

More information

Letter of Engagement. as instructed from time to time in respect of your/the company/trusts affairs

Letter of Engagement. as instructed from time to time in respect of your/the company/trusts affairs We enclse material which sets ut: Letter f Engagement Infrmatin fr clients which lawyers are required by the New Zealand Law Sciety t prvide; and Our standard terms f engagement. Services t be prvided

More information

WHAT SHOULD I LOOK FOR WHEN I BUY HEALTH INSURANCE?

WHAT SHOULD I LOOK FOR WHEN I BUY HEALTH INSURANCE? WHAT SHOULD I LOOK FOR WHEN I BUY HEALTH INSURANCE? The Maine Bureau f Insurance 34 State Huse Statin Augusta, Maine 04333 207-624-8475 r 1-800-300-5000 (in Maine) http://www.maine.gv/pfr/insurance Paul

More information

The Family Cost Share system is designed so families with the ability to pay will share in the cost of services.

The Family Cost Share system is designed so families with the ability to pay will share in the cost of services. Paying fr Early Childhd Interventin Services What is ECI? Texas Early Childhd Interventin (ECI) prgrams serve families with children birth t 36 mnths with develpmental delays r disabilities. ECI prvides

More information

TUFTS MEDICAL CENTER AND AFFILIATED PROVIDERS* NOTICE OF PRIVACY PRACTICES

TUFTS MEDICAL CENTER AND AFFILIATED PROVIDERS* NOTICE OF PRIVACY PRACTICES TUFTS MEDICAL CENTER AND AFFILIATED PROVIDERS* NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 Revisin Date: February 18, 2010 Revisin Date: September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL

More information

Workers Compensation Employee Packet

Workers Compensation Employee Packet Wrkers Cmpensatin Emplyee Packet Cmplete the fllwing frms and return t Meagan Vrhies, Claims Crdinatr via fax (817) 735-0127, email at Meagan.Vrhies@untsystem.edu r in persn at Human Resurce Services (EAD-280).

More information

THE CITY UNIVERSITY OF NEW YORK IDENTITY THEFT PREVENTION PROGRAM

THE CITY UNIVERSITY OF NEW YORK IDENTITY THEFT PREVENTION PROGRAM THE CITY UNIVERSITY OF NEW YORK IDENTITY THEFT PREVENTION PROGRAM 1. Prgram Adptin The City University f New Yrk (the "University") develped this Identity Theft Preventin Prgram (the "Prgram") pursuant

More information

Bill Payment Agreement & Disclosures

Bill Payment Agreement & Disclosures Bill Payment Agreement & Disclsures Welcme t Online Banking Bill Payment Service. Use f the Bill Payment Service indicates acceptance f terms and cnditins set frth in the Online Banking Agreement & Disclsures

More information

University of Texas at Dallas Policy for Accepting Credit Card and Electronic Payments

University of Texas at Dallas Policy for Accepting Credit Card and Electronic Payments University f Texas at Dallas Plicy fr Accepting Credit Card and Electrnic Payments Cntents: Purpse Applicability Plicy Statement Respnsibilities f a Merchant Department Prcess t Becme a Merchant Department

More information

RQ10.06 AACo Share Trading Policy

RQ10.06 AACo Share Trading Policy Australian Agricultural Cmpany Limited ACN 010 892 270 RQ10.06 AAC Share Trading Plicy Versin 5 This plicy was apprved by the Bard f Australian Agricultural Cmpany Limited n 15 December 2010. This plicy

More information

Multi-Year Accessibility Policy and Plan for NSF Canada and NSF International Strategic Registrations Canada Company, 2014-2021

Multi-Year Accessibility Policy and Plan for NSF Canada and NSF International Strategic Registrations Canada Company, 2014-2021 Multi-Year Accessibility Plicy and Plan fr NSF Canada and NSF Internatinal Strategic Registratins Canada Cmpany, 2014-2021 This 2014-21 accessibility plan utlines the plicies and actins that NSF Canada

More information

MANUAL OF UNIVERSITY POLICIES PROCEDURES AND GUIDELINES. HIPAA: Use and Disclosure of Protected Health Information

MANUAL OF UNIVERSITY POLICIES PROCEDURES AND GUIDELINES. HIPAA: Use and Disclosure of Protected Health Information Page 1 f 23 HIPAA: Use and Disclsure f Prtected Health Infrmatin Applies t: faculty staff students student emplyees visitrs cntractrs clinicians Effective Date f This Revisin: Nvember 27, 2012 Cntact fr

More information

PATIENT LIABILITY STATEMENT

PATIENT LIABILITY STATEMENT PATIENT LIABILITY STATEMENT We will nt initiate therapeutic services until signed authrizatin is prvided. I understand that I am persnally respnsible fr charges incurred fr services rendered by the ffice

More information

IN-HOUSE OR OUTSOURCED BILLING

IN-HOUSE OR OUTSOURCED BILLING IN-HOUSE OR OUTSOURCED BILLING Medical billing is ne f the mst cmplicated aspects f running a medical practice. With thusands f pssible cdes fr diagnses and prcedures, and multiple payers, the ability

More information

FORM ADV (Paper Version) UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION AND REPORT FORM BY EXEMPT REPORTING ADVISERS

FORM ADV (Paper Version) UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION AND REPORT FORM BY EXEMPT REPORTING ADVISERS APPENDIX A FORM ADV (Paper Versin) UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION AND REPORT FORM BY EXEMPT REPORTING ADVISERS Frm ADV: General Instructins Read these instructins carefully befre

More information

Privacy Policy. The Central Equity Group understands how highly people value the protection of their privacy.

Privacy Policy. The Central Equity Group understands how highly people value the protection of their privacy. Privacy Plicy The Central Equity Grup understands hw highly peple value the prtectin f their privacy. Fr that reasn, the Central Equity Grup takes particular care in dealing with any persnal and sensitive

More information

Guidelines for Custodians

Guidelines for Custodians Guidelines fr Custdians t assess cmpliance with the Persnal Health Infrmatin Privacy and Access Act (PHIPAA) This dcument is designed t help custdians evaluate readiness fr cmpliance with PHIPAA and t

More information

Munising Memorial Hospital. Administrative/Financial Policy

Munising Memorial Hospital. Administrative/Financial Policy Munising Memrial Hspital Administrative/Financial Plicy SUBJECT: Credit and Cllectins & Financial Assistance POLICY NO. 100-072 REVISED: March 26, 2014 Authrized By: The credit and cllectin plicy f Munising

More information

Employer Phone Number City State ZIP Patient Relationship to Responsible Party. Name of Insured Date of Birth

Employer Phone Number City State ZIP Patient Relationship to Responsible Party. Name of Insured Date of Birth PATIENT INFORMATION Patient Registratin Frm (Please Print) Title (Mrs./Miss/Ms/Dr) Hw did yu hear abut us? Referral? Patient s Name (Last) (First) (Middle) Als Knwn As Name (Last) (First) Marital Status

More information

CORPORATE CREDIT CARD POLICY

CORPORATE CREDIT CARD POLICY TITLE: POLICY OWNERS: DATE INSTITUTED: May 1, 2008 CURRENT VERSION: Ver. 1.6 REVISION DATE: July 1, 2015 Crprate Credit Card Plicy Melissa Cluse, Vice President & Cntrller Cindy Klein, Accunts Payable

More information

Online Banking Agreement

Online Banking Agreement Online Banking Agreement 1. General This Online Banking Agreement, which may be amended frm time t time by us (this "Agreement"), fr accessing yur Clrad Federal Savings Bank accunt(s) via the Internet

More information

Personal Data Security Breach Management Policy

Personal Data Security Breach Management Policy Persnal Data Security Breach Management Plicy 1.0 Purpse The Data Prtectin Acts 1988 and 2003 impse bligatins n data cntrllers in Western Care Assciatin t prcess persnal data entrusted t them in a manner

More information

COMPREHENSIVE SAFETY ASSESSMENT INSTRUCTIONS for STUDY ABROAD PROGRAMS

COMPREHENSIVE SAFETY ASSESSMENT INSTRUCTIONS for STUDY ABROAD PROGRAMS COMPREHENSIVE SAFETY ASSESSMENT INSTRUCTIONS fr STUDY ABROAD PROGRAMS Belw is a list f items t address and questins that need t be addressed in the cmprehensive safety assessment. In additin t the safety

More information

Privacy Breach and Complaint Protocol

Privacy Breach and Complaint Protocol Privacy Breach and Cmplaint Prtcl Effective: December 31, 2012 Apprved by: Le McKenna, CFO 1.0 General Privacy breaches and privacy cmplaints will be handled in accrdance with this prtcl. This prtcl is

More information

Data Protection Policy & Procedure

Data Protection Policy & Procedure Data Prtectin Plicy & Prcedure Page 1 Prcnnect Marketing Data Prtectin Plicy V1.2 Data prtectin plicy Cntext and verview Key details Plicy prepared by: Adam Haycck Apprved by bard / management n: 01/01/2015

More information

First Global Data Corp.

First Global Data Corp. First Glbal Data Crp. Privacy Plicy As f February 23, 2015 Ding business with First Glbal Data Crp. ("First Glbal", First Glbal Mney, "we" r "us", which includes First Glbal Data Crp. s subsidiary, First

More information

Special Tax Notice Regarding 403(b) (TSA) Distributions

Special Tax Notice Regarding 403(b) (TSA) Distributions Special Tax Ntice Regarding 403(b) (TSA) Distributins P.O. Bx 7893 Madisn, WI 53707-7893 1-800-279-4030 Fax: (608) 237-2529 The IRS requires us t prvide yu with a cpy f the Explanatin f Direct Rllver,

More information

UNIVERSITY OF WINCHESTER

UNIVERSITY OF WINCHESTER UNIVERSITY OF WINCHESTER INTRODUCTION DEBT MANAGEMENT POLICY: STUDENTS ACADEMIC YEAR 15/16 This dcument sets ut the plicy f the University in relatin t student debt, alng with the debt management prcedures

More information

Internet Banking Agreement & Disclosure

Internet Banking Agreement & Disclosure Internet Banking Agreement & Disclsure Please read this agreement carefully befre cntinuing. Intrductin This Internet Banking Agreement and Disclsure gverns yur use f Internet Banking. Thrughut this web

More information

Symantec User Authentication Service Level Agreement

Symantec User Authentication Service Level Agreement Symantec User Authenticatin Service Level Agreement Overview and Scpe This Symantec User Authenticatin service level agreement ( SLA ) applies t Symantec User Authenticatin prducts/services, such as Managed

More information

Heythrop College Disciplinary Procedure for Support Staff

Heythrop College Disciplinary Procedure for Support Staff Heythrp Cllege Disciplinary Prcedure fr Supprt Staff Intrductin 1. This prcedural dcument des nt apply t thse academic-related staff wh are mentined in the Cllege s Ordinance, namely the Librarian and

More information

The Ohio Board of Regents Credit When It s Due process identifies students who

The Ohio Board of Regents Credit When It s Due process identifies students who Credit When It s Due/ Reverse Transfer FAQ fr students Ohi is participating in a natinal grant initiative, Credit When It s Due, designed t implement reverse-transfer, which is a prcess t award assciate

More information

MSB FINANCIAL CORP. MILLINGTON BANK AUDIT COMMITTEE CHARTER

MSB FINANCIAL CORP. MILLINGTON BANK AUDIT COMMITTEE CHARTER MSB FINANCIAL CORP. MILLINGTON BANK AUDIT COMMITTEE CHARTER This Audit Cmmittee Charter has been amended as f July 17, 2015. The Audit Cmmittee shall review and reassess this Charter annually and recmmend

More information

Transportation Allowance Program

Transportation Allowance Program Transprtatin Allwance Prgram Respnsibilities, Prcedures and Guidelines I. INTRODUCTION This manual describes respnsibilities, prcedures and guidelines (including vehicle specificatins and reimbursable

More information

LOUISIANA TECH UNIVERSITY Division of Student Financial Aid Post Office Box 7925 Ruston, LA 71272

LOUISIANA TECH UNIVERSITY Division of Student Financial Aid Post Office Box 7925 Ruston, LA 71272 LOUISIANA TECH UNIVERSITY Divisin f Student Financial Aid Pst Office Bx 7925 Rustn, LA 71272 Dear Financial Aid Applicant, Accrding t yur 2011-2012 Student Aid Reprt (SAR), yu did nt include any parental

More information

WHAT YOU NEED TO KNOW ABOUT. Protecting your Privacy

WHAT YOU NEED TO KNOW ABOUT. Protecting your Privacy WHAT YOU NEED TO KNOW ABOUT Prtecting yur Privacy YOUR PRIVACY IS OUR PRIORITY Credit unins have a histry f respecting the privacy f ur members and custmers. Yur Bard f Directrs has adpted the Credit Unin

More information

expertise hp services valupack consulting description security review service for Linux

expertise hp services valupack consulting description security review service for Linux expertise hp services valupack cnsulting descriptin security review service fr Linux Cpyright services prvided, infrmatin is prtected under cpyright by Hewlett-Packard Cmpany Unpublished Wrk -- ALL RIGHTS

More information

Frequently Asked Questions About I-9 Compliance

Frequently Asked Questions About I-9 Compliance Frequently Asked Questins Abut I-9 Cmpliance What is required t verify wrk authrizatin? The basic requirement t verify wrk authrizatin is the Frm I-9. This frm is available n the HR website: http://www.fit.edu/hr/dcuments/frms/i-9.pdf

More information

Accessible Service Policy

Accessible Service Policy Accessible Service Plicy Date Created Revisin Oct. 16, 2012 1 Gal This plicy is intended t meet the requirements f the Accessibility Standards fr Custmer Service, Ontari Regulatin 429/07 under the Accessibility

More information

OUR DISCIPLINARY POLICY

OUR DISCIPLINARY POLICY OUR DISCIPLINARY POLICY WHO is this plicy fr? Channel 4 emplyees wh ve passed their prbatinary perid Channel 4 managers This plicy des nt frm part f any emplyee s cntract f emplyment and we may amend it

More information

DATA REQUEST GUIDELINES

DATA REQUEST GUIDELINES DATA REQUEST GUIDELINES This dcument describes prcedures law enfrcement authrities and individuals invlved in civil litigatin shuld fllw t request data frm LinkedIn and its affiliated service prviders.

More information

o o 2) Program Rewards

o o 2) Program Rewards 1) T qualify fr the American Red Crss High Schl Leadership Prgram (referred t as Prgram), each student (referred t as Member) is asked t cmplete the fllwing requirements: a. Cmplete an nline prfile at

More information

True Blue Rx Option I (HMO)

True Blue Rx Option I (HMO) True Blue Rx Optin I (HMO) 2014 Evidence f Cverage January 1 December 31, 2014 Yur Medicare Health Benefits and Services and Prescriptin Drug Cverage as a Member f True Blue Rx Optin I (HMO) This bklet

More information

Information Services Hosting Arrangements

Information Services Hosting Arrangements Infrmatin Services Hsting Arrangements Purpse The purpse f this service is t prvide secure, supprted, and reasnably accessible cmputing envirnments fr departments at DePaul that are in need f server-based

More information

Norwood Public Schools Internet & Cell Phone Use Agreement School Year 2015-16

Norwood Public Schools Internet & Cell Phone Use Agreement School Year 2015-16 Yu must read and agree t fllw the netwrk rules belw t use yur netwrk accunt r access the internet. Nrwd Public Schls makes available t students access t cmputers and the Internet. Students are expected

More information

Purpose Statement. Objectives

Purpose Statement. Objectives Apprved by Academic Affairs Cuncil, June 24, 2014 Faculty Handbk Part VI: Other Plicies and Prcedures Sectin R. Intellectual Prperty Classified Emplyee Handbk Part VI: Other Plicies and Prcedures Sectin

More information

Johnston Public Schools Special Education Procedural Manual. IEP Overview

Johnston Public Schools Special Education Procedural Manual. IEP Overview Jhnstn Public Schls Special Educatin Prcedural Manual IEP Overview Definitin The Individualized Educatin Prgram (IEP) is a written plan fr the apprpriate educatin f students with disabilities. It is a

More information

General Records Authority 33. Accredited Training

General Records Authority 33. Accredited Training General Recrds Authrity 33 2012/00579704 Accredited Training February 2013 This is an accurate reprductin f the authrised recrds authrity cntent, created fr accessibility purpses CONTENTS INTRODUCTION

More information

Malpractice and Maladministration Policy

Malpractice and Maladministration Policy TR340 Malpractice and Maladministratin Plicy This plicy aims t: Define malpractice and maladministratin in the cntext f CIM/CAM studying members, Accredited study centres (ASCs), examinatin centres, invigilatrs

More information

Scotiabank Group Privacy Agreement

Scotiabank Group Privacy Agreement Sctiabank Grup Privacy Agreement Last revised Octber 2010 Yur privacy is imprtant t Sctiabank. This Agreement sets ut the infrmatin practices fr Sctiabank Grup Members in Canada, including what type f

More information

0820.02 Workers Disability Compensation Claims Procedures Issued: January 1, 1994 Revised: March 29, 2012

0820.02 Workers Disability Compensation Claims Procedures Issued: January 1, 1994 Revised: March 29, 2012 State f Michigan Administrative Guide t State Gvernment 0820.02 Wrkers Disability Cmpensatin Claims Prcedures Issued: January 1, 1994 Revised: March 29, 2012 SUBJECT: APPLICATION: PURPOSE: CONTACT AGENCY:

More information

An employer s Guide to engaging an occupational health physician

An employer s Guide to engaging an occupational health physician An emplyer s Guide t engaging an ccupatinal health physician When and why d emplyers need the services f ccupatinal physicians? Being in business invlves risk. Business pprtunities are inherently uncertain

More information

MAYFAIR INSURANCE & MORTGAGE CONSULTANTS LTD 11 Lurke Street, Bedford MK40 3HZ Telephone: 01234 242900

MAYFAIR INSURANCE & MORTGAGE CONSULTANTS LTD 11 Lurke Street, Bedford MK40 3HZ Telephone: 01234 242900 MAYFAIR INSURANCE & MORTGAGE CONSULTANTS LTD 11 Lurke Street, Bedfrd MK40 3HZ Telephne: 01234 242900 Please read this dcument carefully as it sets ut the terms n which we agree t act fr ur clients and

More information

67.50. Your child s health is our priority. Bupa schools scheme. bupa.co.uk ONLY PER TERM PER CHILD. Provided by

67.50. Your child s health is our priority. Bupa schools scheme. bupa.co.uk ONLY PER TERM PER CHILD. Provided by Prvided by Bupa schls scheme Yur child s health is ur pririty 67.50 PER TERM PER CHILD * ONLY bupa.c.uk *Thesubscriptinrateappliesfrmembershipyear1September2013 t31august2014.thissubscriptinrateincludesinsurancepremium

More information

NYU Langone Medical Center NYU Hospitals Center NYU School of Medicine

NYU Langone Medical Center NYU Hospitals Center NYU School of Medicine Title: Identity Theft Prgram Effective Date: July 2009 NYU Langne Medical Center NYU Hspitals Center NYU Schl f Medicine POLICY It is the plicy f the NYU Langne Medical Center t educate and train staff

More information

Systems Support - Extended

Systems Support - Extended 1 General Overview This is a Service Level Agreement ( SLA ) between and the Enterprise Windws Services t dcument: The technlgy services the Enterprise Windws Services prvides t the custmer. The targets

More information

Workers' Compensation Employee's Guide

Workers' Compensation Employee's Guide Wrkers' Cmpensatin Emplyee's Guide Intrductin What is Wrkers' Cmpensatin? What is a Wrk-Related Injury? Wh Is Cvered by the UCSD Wrkers' Cmpensatin Prgram and When? Where D Yu Receive Initial Medical Treatment?

More information

Medi-Pak Advantage MA-PD Option 1 (PFFS) is a Medicare Advantage organization with a Medicare contract.

Medi-Pak Advantage MA-PD Option 1 (PFFS) is a Medicare Advantage organization with a Medicare contract. January 1 December 31, 2011 Evidence f Cverage: Yur Medicare Health Benefits and Services and Prescriptin Drug Cverage as a Member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) This bklet gives yu the details

More information

UNIVERSITY OF CALIFORNIA MERCED PERFORMANCE MANAGEMENT GUIDELINES

UNIVERSITY OF CALIFORNIA MERCED PERFORMANCE MANAGEMENT GUIDELINES UNIVERSITY OF CALIFORNIA MERCED PERFORMANCE MANAGEMENT GUIDELINES REFERENCES AND RELATED POLICIES A. UC PPSM 2 -Definitin f Terms B. UC PPSM 12 -Nndiscriminatin in Emplyment C. UC PPSM 14 -Affirmative

More information

How to put together a Workforce Development Fund (WDF) claim 2015/16

How to put together a Workforce Development Fund (WDF) claim 2015/16 Index Page 2 Hw t put tgether a Wrkfrce Develpment Fund (WDF) claim 2015/16 Intrductin What eligibility criteria d my establishment/s need t meet? Natinal Minimum Data Set fr Scial Care (NMDS-SC) and WDF

More information

SEC Accommodation Procedures

SEC Accommodation Procedures SEC Accmmdatin Prcedures Office f Human Resurces SEC Disability Accmmdatin Prcess Accmmdatins enable peple with physical r mental disabilities t have access t emplyment pprtunities and public prgrams equivalent

More information

Dual Demonstration FAQs

Dual Demonstration FAQs Dual Demnstratin FAQs Benefits What benefits are available under the Dual Demnstratin? Individuals have access t a cmprehensive netwrk f acute and lng term care services prviders, and access t the same

More information

Plus500CY Ltd. Statement on Privacy and Cookie Policy

Plus500CY Ltd. Statement on Privacy and Cookie Policy Plus500CY Ltd. Statement n Privacy and Ckie Plicy Statement n Privacy and Ckie Plicy This website is perated by Plus500CY Ltd. ("we, us r ur"). It is ur plicy t respect the cnfidentiality f infrmatin and

More information

Service Request Form

Service Request Form New Prfessinal Services Order Frm Editable PDF Service Request Frm If yu have any questins while filling ut this frm, please cntact yur CDM, email Prfessinal Services at PS@swipeclck.cm, r call 888-223-3250

More information

Internet Banking Agreement and Disclosure Statement

Internet Banking Agreement and Disclosure Statement Internet Banking Agreement and Disclsure Statement This agreement cntains the terms and cnditins that gvern accessing r using Internet Banking (NetTeller), Bill Payment Services, Mbile Banking and On Demand

More information

FAFSA / DREAM ACT COMPLETION PROGRAM AGREEMENT

FAFSA / DREAM ACT COMPLETION PROGRAM AGREEMENT FAFSA / DREAM ACT COMPLETION PROGRAM AGREEMENT If using US Pstal Service, please return t: Califrnia Student Aid Cmmissin Prgram Administratin & Services Divisin ATTN: Institutinal Supprt P.O. Bx 419028

More information

State Fleet Card Oversight Usage and Responsibilities

State Fleet Card Oversight Usage and Responsibilities State Fleet Card Oversight Usage and Respnsibilities Intrductin The Department f General Services (DGS), Office f Fleet and Asset Management (OFAM) administers a statewide ne-prvider payment system cntract

More information

ES PROCEDURES FOR OVERPAYMENT RECOVERY

ES PROCEDURES FOR OVERPAYMENT RECOVERY ES PROCEDURES FOR OVERPAYMENT RECOVERY Effective: 7/1/2012 Respnsible Office: Emplyee Services (ES) Apprved: ES Directr Applicatin: All Emplyees f the University f Clrad Plicy The University f Clrad will

More information

UPREHS PRIME MEDICARE PART D PRESCRIPTION DRUG PLAN (EMPLOYER PDP) BENEFIT GUIDE

UPREHS PRIME MEDICARE PART D PRESCRIPTION DRUG PLAN (EMPLOYER PDP) BENEFIT GUIDE UPREHS PRIME MEDICARE PART D PRESCRIPTION DRUG PLAN (EMPLOYER PDP) BENEFIT GUIDE Yur Medicare Prescriptin Drug cverage as a Member f the UPREHS Prime Medicare Part D Plan 2016 A $9 cpayment gets yu a 90-day

More information

KIK s GUIDE FOR LAW ENFORCEMENT

KIK s GUIDE FOR LAW ENFORCEMENT Thanks fr checking ut ur law enfrcement guide. Kik takes the safety f ur users very seriusly, and we hpe this guide will be a useful tl fr yu. It includes infrmatin abut ur app; the features and functins

More information

Loan Application for Pre- Approval

Loan Application for Pre- Approval Lan Applicatin fr Pre- Apprval Get pre-apprved fr yur hme lan financing tday by cmpleting this applicatin. Please cmplete the entire applicatin and return with the dcumentatin requested n the attached

More information

Columbine Federal Credit Union ONLINE BANKING/ BILL PAYMENT AGREEMENT & DISCLOSURES AND PRIV ACY DISCLOSURE

Columbine Federal Credit Union ONLINE BANKING/ BILL PAYMENT AGREEMENT & DISCLOSURES AND PRIV ACY DISCLOSURE Clumbine Federal Credit Unin ONLINE BANKING/ BILL PAYMENT AGREEMENT & DISCLOSURES AND PRIV ACY DISCLOSURE 1. Online Banking/Bill Payment 2. Online Banking/ Bill Payment Limitatins 3. Online Bill Payment

More information

NAIC Replacement Requirements For Certain Life Insurance Policies And Annuity Contracts

NAIC Replacement Requirements For Certain Life Insurance Policies And Annuity Contracts NAIC Replacement Requirements Fr Certain Life Insurance Plicies And Annuity Cntracts Duties f Prducers If a transactin invlves a replacement, the prducer must leave with the applicant, at the time an applicatin

More information

Watlington and Chalgrove GP Practice - Patient Satisfaction Survey 2011

Watlington and Chalgrove GP Practice - Patient Satisfaction Survey 2011 Watlingtn and Chalgrve GP - Patient Satisfactin Survey 2011 Backgrund During ne week in Nvember last year patients attending either the Chalgrve r the Watlingtn surgeries were asked t cmplete a survey

More information

Enrollee Health Assessment Program Implementation Guide and Best Practices

Enrollee Health Assessment Program Implementation Guide and Best Practices Enrllee Health Assessment Prgram Implementatin Guide and Best Practices March 2015 033129 (03-2015) This guide will help yu answer these questins: What is the Enrllee Health Assessment (EHA) prgram and

More information

What payments will I need to make during the construction phase? Will the lender advance construction funds prior to the work being completed?

What payments will I need to make during the construction phase? Will the lender advance construction funds prior to the work being completed? Q&A What is a cnstructin lan? A cnstructin lan prvides the financing fr the cnstructin f yur new hme. Cnstructin lans may be structured as a single r tw-settlement transactin. Cnstructin lans culd include

More information

Pediatric Physical & Occupational Therapy Services, LLC Pacific Northwest Pediatric Therapy, LLC

Pediatric Physical & Occupational Therapy Services, LLC Pacific Northwest Pediatric Therapy, LLC , LLC, LLC The ffices f Rsemary White, OTR/L & Assciates Main Office Suth End Office Prtland Office Ped PT & OT Services Ped PT & OT Services Pacific NW Pediatric Therapy 20310 19 th Ave NE 6617 S 193

More information

If I am arrested, does this mean that I am considered guilty of a criminal offence?

If I am arrested, does this mean that I am considered guilty of a criminal offence? What is cnsidered a crime in Canada? Mst criminal acts in Canada are listed and defined in the Criminal Cde f Canada. Hwever, sme are als listed in ther laws, such as the Cntrlled Drugs and Substances

More information

FIREFIGHTER HEART AND CIRCULATORY MALFUNCTION BENEFITS PROGRAM STANDARD OPERATING GUIDELINES Approved by the DOLA Executive Director July 1, 2014

FIREFIGHTER HEART AND CIRCULATORY MALFUNCTION BENEFITS PROGRAM STANDARD OPERATING GUIDELINES Approved by the DOLA Executive Director July 1, 2014 FIREFIGHTER HEART AND CIRCULATORY MALFUNCTION BENEFITS PROGRAM STANDARD OPERATING GUIDELINES Apprved by the DOLA Executive Directr July 1, 2014 Prgram Overview: As f July 1, 2014, the Department f Lcal

More information

Consumer Guide to Health Insurance Appeals

Consumer Guide to Health Insurance Appeals Cnsumer Guide t Health Insurance Appeals Table f Cntents Intrductin Where t start Step 1: Identify the surce f yur cverage and the issue Where d yu get yur cverage? What kind f denial did yu receive? Is

More information

All Harvard University schools, tubs, local units, Affiliate Institutions, Allied Institutions and University-wide Initiatives.

All Harvard University schools, tubs, local units, Affiliate Institutions, Allied Institutions and University-wide Initiatives. HARVARD UNIVERSITY FINANCIAL POLICY INDEPENDENT CONTRACTOR CLASSIFICATION Plicy Title: Independent Cntractr Respnsible Office: ERP and UFS Effective Date: Octber 4, 2000 Revisin Date: May 12, 2009 Plicy

More information

INFORMATIONAL NOTICE MISCELLANEOUS TAX 2013-01. Issued: January 02, 2013

INFORMATIONAL NOTICE MISCELLANEOUS TAX 2013-01. Issued: January 02, 2013 INFORMATIONAL NOTICE MISCELLANEOUS TAX 2013-01 Issued: January 02, 2013 Pennsylvania Department f Revenue Guidelines fr Cllectin and Administrative Bank Attachment Required by Act 85 f 2012 Per the Tax

More information

Application Fee Schedule Please check the appropriate box below. See also Additional Information starting on page 6.

Application Fee Schedule Please check the appropriate box below. See also Additional Information starting on page 6. DRIVING SCHOOL LICENSE APPLICATION N. APPLICATION DMV USE ONLY N. LICENSE Received Fee Amunt Expiratin Fee Amunt PART 1 Schl Infrmatin: l READ VEHICLE AND TRAFFIC LAW SECTION 394 AND DMV COMMISSIONER S

More information

Audit Committee Charter

Audit Committee Charter Audit Cmmittee Charter Membership The Audit Cmmittee (the "Cmmittee") f the Bard f Directrs (the "Bard") f Philip Mrris Internatinal Inc. (the "Cmpany") shall cnsist f at least three directrs all f whm

More information

March 2016 Group A Payment Issues: Missing Information-Loss Calculation letters ( MILC ) - deficiency resolutions: Outstanding appeals:

March 2016 Group A Payment Issues: Missing Information-Loss Calculation letters ( MILC ) - deficiency resolutions: Outstanding appeals: The fllwing tpics were discussed in the March 24, 2016 meeting with law firms representing VCF claimants. Grup A Payment Issues: We cntinue t fcus n paying Grup A claims in full and are meeting the schedule

More information

ERISA Compliance FAQs: Fiduciary Responsibilities

ERISA Compliance FAQs: Fiduciary Responsibilities Brught t yu by Mrris & Reynlds Insurance ERISA Cmpliance FAQs: Fiduciary Respnsibilities The Emplyee Retirement Incme Security Act f 1974 (ERISA) is a federal law that sets minimum standards fr emplyee

More information

Maryland General Service (MGS) Area 29 Treatment Facilities Committee (TFC) TFC Instructions

Maryland General Service (MGS) Area 29 Treatment Facilities Committee (TFC) TFC Instructions Maryland General Service (MGS) Area 29 Treatment Facilities Cmmittee (TFC) TFC Instructins Lve And Service Facility Presentatin t Patients We are frm Alchlics Annymus (AA), fr AA, and ur service is fr

More information

Summary Plan Description Requirements for Group Health Plans

Summary Plan Description Requirements for Group Health Plans Summary Plan Descriptin Requirements fr Grup Health Plans September 2014 All grup health plans subject t the Emplyee Retirement Incme Security Act (ERISA) are required t prvide participants with a Summary

More information