IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy Use and Disclosure of PHI With Authorization 10120

Size: px
Start display at page:

Download "IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy Use and Disclosure of PHI With Authorization 10120"

Transcription

1 IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy Use and Disclosure of PHI With Authorization POLICY INFORMATION Major Functional Area (MFA): MFA X - Office of General Counsel & Compliance Policy Title: Use and Disclosure of PHI With Authorization Responsible Executive (RE): General Counsel Sponsoring Organization (SO): Office of General Counsel Dates: Effective Date: Revised: Annual Review: I. POLICY STATEMENT: In accordance with 45 CFR ISU adopts and implements this policy in order to: A. Describe the uses and disclosures of protected health information (PHI) that require written authorization prior to the use or disclosure; B. Establish guidelines for obtaining and properly documenting an individual s written authorization for any use and/or disclosure of PHI that requires prior authorization; and C. Identify the elements of a valid authorization. II. AUTHORITY AND RESPONSIBILITIES: ISU is a hybrid entity in accordance with ISU s HIPPA Privacy Policy Only the health care component (i.e., the covered functions) of ISU must comply with this policy. All references in this policy to ISU shall be construed to refer only to the health care component of ISU. III. DEFINITIONS: See HIPAA Privacy Policy IV. PROCEDURES TO IMPLEMENT ISU may not use or disclose PHI without a valid authorization signed by the patient or his/her personal representative unless this Policy, in compliance with then-current HIPAA privacy regulations, permits such use or disclosure of PHI without written authorization. See the Special Considerations section below for references to other Policies related to use and disclosure of PHI. A. Authorization Requirements: 1. A valid authorization to release PHI must include all of the following core elements and required statements: HIPAA Privacy Use and Disclosure of PHI With Authorization Page 1 of 7

2 a. Description of PHI Disclosed Every authorization must contain a description of the information to be used or disclosed that identifies the information in a specific and meaningful manner. b. Name of Person(s)/Class Permitted to Send PHI The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure. c. Name of Person(s)/Class Permitted to Receive PHI The name or other specific identification of the person(s), or class of persons, to whom the covered entity may make the requested use or disclosure. d. Purpose for Disclosure A description of each purpose of the requested use of disclosure. The statement at the request of the individual is a sufficient description of the purpose when an individual initiates the authorization and does not, or elects not to, provide a statement of the purpose. e. Expiration Date An expiration date or an expiration event that relates to the patient or the purpose of the use or disclosure. The statement end of the research study, none, or similar language is sufficient if the authorization is for a use or disclosure of PHI for research, including the creation and maintenance of a research database or research repository (see HIPAA Privacy Policy Use and Disclosure of PHI for Research). f. Statement Regarding Right to Revoke A statement of the individual s right to revoke the authorization in writing and either: i. The exceptions to the right to revoke, together with a description of how the individual may revoke the authorization; or ii. To the extent that the information regarding the right to revoke the authorization is included in the ISU Notice of Privacy Practices, a reference to the Notice of Privacy Practices. g. Statement Regarding Conditions to Authorization The authorization must contain a statement concerning the ability or inability of the covered entity seeking the authorization to condition treatment, payment, enrollment or eligibility for benefits on the authorization, by stating either: i. The covered entity may not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs the authorization when the conditioning is prohibited by HIPAA as discussed in the section below entitled Prohibition on Conditioning of Authorizations; or ii. The consequences to the patient of a refusal to sign the authorization when, in accordance with the section below entitled Prohibition on Conditioning of Authorizations, the covered entity can condition treatment, enrollment, in the health plan, or eligibility for benefits on failure to obtain such authorization. h. Redisclosure of PHI The authorization must contain a statement that information disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected by HIPAA. i. Signed by Patient or Patient Representative The authorization must be signed and dated by the patient, or where appropriate, the patient s personal representative. j. Description of Representative s Authority If the authorization is signed by a personal representative of the patient, the authorization must contain a description of the representative right or authority under state law to act for the patient. 2. In addition to the above core elements and required statements, the authorization must be written in plain language HIPAA Privacy Use and Disclosure of PHI With Authorization Page 2 of 7

3 3. If ISU seeks an authorization from an individual for a use or disclosure of PHI, ISU must provide the individual with a copy of the signed authorization. 4. A valid authorization (See Attachment A Authorization for Use and/or Disclosure of Protected Health Information) must be written and delivered to ISU in person via U.S. mail, courier, facsimile, or via electronic method which meets the requirements of ISU s HIPAA Security Policies. 5. The signature and all other information on the authorization must be legible (if written), capable of being authenticated (if electronic), and verifiable in accordance with ISU s verification procedures. 6. The ISU Privacy Officer or his/her designee must review all authorizations and determine whether the authorization and the identity of the requestor are valid. a. If the ISU Privacy Officer or his/her designee has any reason to doubt the truthfulness or accuracy of the authorization, he or she may further investigate the matter prior to the disclosure of PHI. 7. An authorization is invalid or defective and will not be acted upon if any of the following are true: a. The expiration date has passed, or the expiration event is known by the covered entity to have occurred; b. The authorization has not been filled out completely, with respect to any element described above (this includes illegible authorizations); c. The covered entity knows the authorization has been revoked by the individual; d. The covered entity knows material information in the authorization is false; e. The authorization is combined with any other type of document, such as a Notice of Privacy Practices or a written voluntary consent; or f. The ISU Privacy Officer or his/her designee believes the authorization, in whole or in part, is false or fraudulent, or otherwise not properly executed. 8. If an invalid authorization is received, ISU must identify why it is invalid and return it to the requestor for completion. 9. If the authorization is valid, ISU must disclose PHI in accordance with the authorization, unless ISU is prevented from doing so by state or federal law. 10. Transition Provisions ISU may use or disclose PHI that is created or received prior to April 14, 2003, pursuant to an authorization or other express legal permission obtained from the individual, regardless of whether such authorization satisfies the requirements of this policy, provided that the authorization or other express legal permission specifically permits such use and disclosure and there is no agreed to restriction in effect. 11. Compound Authorizations Prohibited; Exceptions Generally, HIPAA authorizations may not be combined in a document with any other legal permission, except as described below. a. Examples of prohibited combined authorizations: i. A patient s informed consent to undergo a surgical procedure (unless for research as described below) may not be combined with a HIPAA authorization; ii. A patient s acknowledgment of the Notice of Privacy Practices may not be combined with a HIPAA authorization; and HIPAA Privacy Use and Disclosure of PHI With Authorization Page 3 of 7

4 iii. An authorization on which a covered entity has conditioned the provision of treatment, payment, enrollment in a health plan or eligibility for benefits may not be combined with an authorization that does not have such conditions. An authorization for use or disclosure of PHI may not be combined with any other document to create a compound authorization except as follows: b. Research Studies An authorization for the use or disclosure of PHI for a research study may be combined with any type of written permission - HIPAA authorization may be combined) (See HIPAA Privacy Policy Use and Disclosure of PHI for Research). c. Psychotherapy Notes An authorization for use or disclosure of psychotherapy notes (as defined by HIPAA) may only be combined with another authorization for the use or disclosure of psychotherapy notes (See HIPAA Privacy Policy Use and Disclosure of Psychotherapy Notes). B. Prohibition Conditioning of Authorizations; Exceptions: 1. ISU may not condition the provision of treatment, payment, enrollment in a health plan or eligibility for benefits on the provision of an authorization from the patient, except that ISU may condition the provision of research-related treatment on the provision of an authorization for the use or disclosure of PHI for research. a. ISU may condition the provision of health care that is solely for the purpose of creating PHI for disclosure to a third party on the patient signing an authorization for the disclosure of PHI to such third party. C. Who May Request Release of PHI: 1. A patient may request use and/or disclosure of his/her PHI (Note: a HIPAA authorization is not required for ISU to use and/or disclose PHI for those activities described in HIPAA Privacy Policy Use and Disclosure of PHI for Treatment, Payment and Health Care Operations and HIPAA Privacy Policy Use and Disclosure of PHI Without Authorization). 2. The individual s personal representative, as determined under state law, may authorize the use and/or disclosure of and individual s PHI. Proof of the personal representative s authority to act on behalf of the individual must be provided and verified. 3. The identity of the person signing the authorization must be validated. Methods of validation include reference to a picture ID, such as a driver s license or passport, or comparison of signatures documented in the patient s PHI records. D. Revocation of Authorizations: 1. An individual may revoke an authorization at any time. The revocation must be in writing, submitted to the ISU Privacy Officer or his/her designee, and specify which authorization is revoked. 2. The ISU Privacy Officer or his/her designee receiving the request to revoke an authorization must discontinue any further release of the patient s PHI as permitted by HIPAA Privacy Use and Disclosure of PHI With Authorization Page 4 of 7

5 the initial authorization, but the revocation does not apply to actions previously taken by ISU in reliance on the initial authorization. 3. For insurance purposes, the revocation is not effective if the authorization was obtained as a condition of obtaining insurance coverage, and other law provides the insurer with the right to contest a claim under the policy or the policy itself. 4. As appropriate, the ISU Privacy Officer or his/her designee must notify other Clinics that may have relied upon the authorization of the individual s revocation. E. Who May Receive an Authorization and Release PHI: 1. The ISU Privacy Officer or his/her designee may receive and validate an individual s authorization to release PHI. 2. The ISU Privacy Officer or his/her designee may release PHI after receipt of a valid authorization. F. Retention of Authorizations and Revocations and Tracking of Disclosures: 1. Authorizations and revocations of authorization must be maintained for six (6) years from their last effective date, or longer if required by state law. 2. Authorizations and revocations of authorization must be filed in the patient s records. G. Special Considerations: 1. Research See HIPAA Privacy Policy Use and Disclosure of PHI for Research. 2. Marketing See HIPAA Privacy Policy Use and Disclosure of PHI for Marketing. 3. Use and Disclosure of PHI Without Authorization a. HIPAA Privacy Policy Use and Disclosure of PHI Without Authorization, for circumstances when the patient s authorization is not required; and b. HIPAA Privacy Policy Use and Disclosure of PHI for Treatment, Payment and Health Care Operations. 4. Personal Representatives A covered entity must treat a personal representative of an adult or unemancipated minor as the individual per applicable state laws. V. REFERENCES HIPAA Privacy Policies 10020, 10100, 10110, 10130, 10150, HIPAA Regulations, 45 CFR , , VI. ATTACHMENTS Attachment A Authorization for Use and/or Disclosure of Protected Health Information HIPAA Privacy Use and Disclosure of PHI With Authorization Page 5 of 7

6 PRESIDENTIAL CERTIFICATION Approved by Arthur C. Vailas President, Idaho State University Date: OGC use only: Received by OGC on by (initial). Published to ISUPP on by (initial) HIPAA Privacy Use and Disclosure of PHI With Authorization Page 6 of 7

7 Attachment A Idaho State University Authorization for Use and/or Disclosure of Protected Health Information Patient Identification Printed Name: Date of Birth: Address: Social Security #: Telephone: Information To Be Released Covering the Periods of Health Care From (date) to (date) From (date) to (date) Please check type of information to be released: Entire medical record Pathology report Discharge summary History and physical exam Consultation reports Progress notes Laboratory test results/reports X ray reports X ray films / images Operative report Emergency room record Itemized bill Other, (specify) Purpose of Request Treatment or consultation At the request of the patient Billing or claims payment Other, (specify) Person Authorized to Receive Information Name: Address: Drug and/or Alcohol Abuse and/or Psychiatric, and/or HIV/AIDS Records Release I understand that if my medical or billing record contains information in reference to drug and/or alcohol abuse, psychiatric care, sexually transmitted disease, Hepatitis B or C testing, and/or other sensitive information, I agree to its release. Check One: Yes No Initials I understand that if my medical or billing record contains information in reference to HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome) testing and/or treatment, I agree to its release. Check One: Yes No Initials HIPAA Privacy Use and Disclosure of PHI With Authorization Page 7 of 7

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy Use and Disclosure of Psychotherapy Notes 10130

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy Use and Disclosure of Psychotherapy Notes 10130 IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy Use and Disclosure of Psychotherapy Notes 10130 POLICY INFORMATION Major Functional Area (MFA): MFA X - Office of General Counsel &

More information

4. No accounting of disclosures is required with respect to disclosures of PHI within a Limited Data Set.

4. No accounting of disclosures is required with respect to disclosures of PHI within a Limited Data Set. IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Limited Data Sets and Data Use Agreements 10200 POLICY INFORMATION Major Functional Area (MFA): MFA X - Office of General Counsel

More information

Releasing Information

Releasing Information Releasing Information There are 3 kinds of release situations now: our original Release of Information and it s uses under Colorado Law and Professional Ethical Standards; HPAA s Consent to release information

More information

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - De-identification of PHI 10030

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - De-identification of PHI 10030 IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - De-identification of PHI 10030 POLICY INFORMATION Major Functional Area (MFA): MFA X - Office of General Counsel & Compliance Policy

More information

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Business Associates 10230

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Business Associates 10230 IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Business Associates 10230 POLICY INFORMATION Major Functional Area (MFA): MFA X - Office of General Counsel & Compliance Policy Title:

More information

Winthrop-University Hospital

Winthrop-University Hospital Winthrop-University Hospital Use of Patient Information in the Conduct of Research Activities In accordance with 45 CFR 164.512(i), 164.512(a-c) and in connection with the implementation of the HIPAA Compliance

More information

Authorization for Release of Information

Authorization for Release of Information Authorization for Release of Information Section I. Date: Student Name: Date of Birth: / / (mm/dd/yy) ID: Grade: School: Section II: Name: authorizes District # to release the specific information identified

More information

acknowledgment of health center privacy policy, privacy practices, and privacy procedures PATIENT PRIVACY

acknowledgment of health center privacy policy, privacy practices, and privacy procedures PATIENT PRIVACY LAST NAME FIRST NAME OF BIRTH 001 acknowledgment of health center privacy policy, privacy practices, and privacy procedures PATIENT PRIVACY! HOPE s PRIVACY ACKNOWLEDGMENT PAGE 1 OF 1 HOPE s Statement of

More information

MEDICAL BENEFITS CLASS ACTION SETTLEMENT NOTICE OF INTENT TO SUE

MEDICAL BENEFITS CLASS ACTION SETTLEMENT NOTICE OF INTENT TO SUE MEDICAL BENEFITS CLASS ACTION SETTLEMENT NOTICE OF INTENT TO SUE Complete this form if you are a MEDICAL BENEFITS SETTLEMENT CLASS MEMBER seeking to exercise a BACK END LITIGATION OPTION. In addition to

More information

University of Mississippi Medical Center Office of Integrity and Compliance

University of Mississippi Medical Center Office of Integrity and Compliance Office of Integrity and Effective Date: 2005 By: Committee 1.0 PURPOSE The purpose of this policy is to guide (UMMC) employees, who are involved with research, in obtaining an authorization for the use

More information

HIPAA Templates. Health Plan Privacy Edition Version 2.4. Policy and Procedure Templates

HIPAA Templates. Health Plan Privacy Edition Version 2.4. Policy and Procedure Templates SAMPLE CLAYTON - MACBAIN HIPAA Templates Health Plan Privacy Edition Version 2.4 Policy and Procedure Templates Reflects modifications published in the August 14, 2002, Federal Register William A. MacBain,

More information

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Minimum Necessary Standard for Use and Disclosure of PHI 10190

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Minimum Necessary Standard for Use and Disclosure of PHI 10190 IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Minimum Necessary Standard for Use and Disclosure of PHI 10190 POLICY INFORMATION Major Functional Area (MFA): MFA X - Office of General

More information

Authorization to Use and Disclose Protected Health Information Form

Authorization to Use and Disclose Protected Health Information Form Authorization to Use and Disclose Protected Health Information Form Under the HIPAA Privacy Rule, an individual may authorize the release of his or her protected health information (PHI) to a specific

More information

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy & Security - Sanctions 10210

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy & Security - Sanctions 10210 IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy & Security - Sanctions 10210 POLICY INFORMATION Major Functional Area (MFA): MFA X - Office of General Counsel & Compliance Policy Title:

More information

HIPAA COMPLIANCE. What is HIPAA?

HIPAA COMPLIANCE. What is HIPAA? HIPAA COMPLIANCE What is HIPAA? The Health Insurance Portability and Accountability Act (HIPAA) also known as the Privacy Rule specifies the conditions under which protected health information may be used

More information

Life Insurance Policy Information. Policyowner(s)

Life Insurance Policy Information. Policyowner(s) L I F E S E T T L E M E N T A P P L I C A T I O N Life Insurance Policy Information insurance policy number issue face amount total policy loan cash surrender value annual premium payment next premium

More information

Life Insurance Policy Information. Policyowner(s) (please print clearly) insurance company policy number issue date (00/00/0000)

Life Insurance Policy Information. Policyowner(s) (please print clearly) insurance company policy number issue date (00/00/0000) L I F E S E T T L E M E N T Q U E S T I O N N A I R E (please print clearly) Life Insurance Policy Information insurance company policy number issue date (00/00/0000) face amount total policy loan cash

More information

Arizona Life Settlement Qualification Form

Arizona Life Settlement Qualification Form PERSONAL INFORMATION Arizona Life Settlement Qualification Form First Insured Name: SS # Current Address: City: State: Zip: Date of Birth: Driver s License Number: State: Expiration: Second Insured Name:

More information

Technical Assistance Document 5

Technical Assistance Document 5 Technical Assistance Document 5 Information Sharing with Family Members of Adult Behavioral Health Recipients Developed by the Arizona Department of Health Services Division of Behavioral Health Services

More information

PRELIMINARY LIFE INSURANCE APPRAISAL REQUEST

PRELIMINARY LIFE INSURANCE APPRAISAL REQUEST PRELIMINARY LIFE INSURANCE APPRAISAL REQUEST INSURED INFORMATION (If more than one insured, please duplicate this page and complete for each insured.) Name SSN Current Address Date of Birth Day Telephone

More information

Southwest Healthcare System Instructions to Request Copies of Your Medical Records

Southwest Healthcare System Instructions to Request Copies of Your Medical Records Southwest Healthcare System Instructions to Request Copies of Your Medical Records CA Health and Safety Code Section 123110 allows a 15-day timeframe to process a patient's request for copies of their

More information

Attachment B HIPAA-P03 Instructions for Completing IU s Authorization for Research Purposes

Attachment B HIPAA-P03 Instructions for Completing IU s Authorization for Research Purposes Attachment B HIPAA-P03 Instructions for Completing IU s Authorization for Research Purposes The HIPAA Privacy Rule generally prohibits health care providers from using or releasing protected health information

More information

PATIENT RECORDS PRIVACY POLICIES AND PROCEDURES FOR HIPAA COMPLIANCE (4/03)

PATIENT RECORDS PRIVACY POLICIES AND PROCEDURES FOR HIPAA COMPLIANCE (4/03) PATIENT RECORDS PRIVACY POLICIES AND PROCEDURES FOR HIPAA COMPLIANCE (4/03) Use and Disclosure of PHI: Protected Health Information ( PHI ) may not be used or disclosed in violation of the Health Insurance

More information

Conroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment.

Conroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment. Conroe Physician Associates Patient Consent Form Please Read and Sign I, undersigned, hereby consent to the following: Administration and performance of all treatments Administration of any needed anesthetics

More information

I. Individual (Name and information of person whose protected health information is being disclosed): Jane Doe 05-10-1962

I. Individual (Name and information of person whose protected health information is being disclosed): Jane Doe 05-10-1962 Instructions for Completing Standard Authorization Form To Complete Form go to Page 4 of 5 Use this form to authorize Blue Cross Blue Shield of Texas to disclose your protected health information (PHI)

More information

APPENDIX 1: Frequently Asked Questions

APPENDIX 1: Frequently Asked Questions APPENDIX 1: Frequently Asked Questions Practice Name Q: What is the HIPAA Privacy Rule? A: The HIPAA Privacy Rule controls the use and disclosure of what is known as Protected Health Information (PHI).

More information

insurance company policy number issue date (00/00/0000) face amount total policy loan cash surrender value amount paid

insurance company policy number issue date (00/00/0000) face amount total policy loan cash surrender value amount paid LIFE SETTLEMENT QUESTIONNAIRE (please print clearly) Life Insurance Policy Information policy number issue date (00/00/0000) face amount total policy loan cash surrender value annual premium payment next

More information

Inland Valley Medical Center Rancho Springs Medical Center Requesting Copies of Your Medical Record

Inland Valley Medical Center Rancho Springs Medical Center Requesting Copies of Your Medical Record Inland Valley Medical Center Rancho Springs Medical Center Requesting Copies of Your Medical Record Per Federal and State laws and regulations, patient information is kept in strict confidence and only

More information

Authorization/Informed Consent for Use and Disclosure of Health Care Information Grid Wisconsin Statutes and the Federal Privacy Law

Authorization/Informed Consent for Use and Disclosure of Health Care Information Grid Wisconsin Statutes and the Federal Privacy Law Disclaimer: This Document is. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may August 27, 2010 Grid updated to correct the omission of "general"

More information

HIPAA Privacy Rule Primer for the College or University Administrator

HIPAA Privacy Rule Primer for the College or University Administrator HIPAA Privacy Rule Primer for the College or University Administrator On August 14, 2002, the Department of Health and Human Services ( HHS ) issued final medical privacy regulations (the Privacy Rule

More information

Neera Agarwal-Antal, M.D. HIPAA Policies and Procedures

Neera Agarwal-Antal, M.D. HIPAA Policies and Procedures Neera Agarwal-Antal, M.D. HIPAA Policies and Procedures HIPAA POLICIES & PROCEDURES This packet includes the following HIPAA policies, procedures and model forms: HIPAA General Operating Policy...1 Authorization

More information

ACCIDENTAL DEATH -NEW BUSINESS MEMO WHOLE LIFE PROTECTOR APPLICATION

ACCIDENTAL DEATH -NEW BUSINESS MEMO WHOLE LIFE PROTECTOR APPLICATION Telephone: 800-428-3001 ACCIDENTAL DEATH -NEW BUSINESS MEMO WHOLE LIFE PROTECTOR APPLICATION Regular Mail: Overnight Mail: P.O. Box 7192 225 South East St Indianapolis, IN 46207-7192 Indianapolis, IN 46202

More information

California Life Settlement Qualification Form

California Life Settlement Qualification Form PERSONAL INFORMATION California Life Settlement Qualification Form First Insured Name: SS # Current Address: City: State: Zip: Date of Birth: Driver s License Number: State: Expiration: Second Insured

More information

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION Page 1 of 5 When you complete and sign this form, health information about you will be released as you describe in the form. Please read

More information

www.attorneygeneral.gov

www.attorneygeneral.gov Required fields are marked with an asterisk* Your information: Are you a veteran? Yes No Are you on active duty? Yes No Age Group: Under 18 18-34 35-59 60-64 65 and older Mr. Mrs. Address* Ms. Dr. Name*

More information

HIPAA AUTHORIZATION FORM FOR RELEASE OF PROTECTED HEALTH INFORMATION

HIPAA AUTHORIZATION FORM FOR RELEASE OF PROTECTED HEALTH INFORMATION HIPAA AUTHORIZATION FORM FOR RELEASE OF PROTECTED HEALTH INFORMATION SECTION A: Individual Authorizing Use and/or Disclosure. Member Name: Member ID #: Address: Date of Birth: Phone Number: SECTION B:

More information

MEDICAL RECORDS ACCESS GUIDE IOWA

MEDICAL RECORDS ACCESS GUIDE IOWA MEDICAL RECORDS ACCESS GUIDE IOWA Parsonage Vandenack Williams LLC Attorneys at Law Parsonage Vandenack Williams LLC 2008 For more information, contact info@pvwlaw.com TABLE OF CONTENTS Iowa...1 Patient

More information

Strategies for Electronic Exchange of Substance Abuse Treatment Records

Strategies for Electronic Exchange of Substance Abuse Treatment Records Strategies for Electronic Exchange of Substance Abuse Treatment Records Patricia Gray, J. D., LL. M. Prepared for the Texas Health and Human Services Commission and the Texas Health Services Authority

More information

Policy Evaluation and Application Form

Policy Evaluation and Application Form 1507 Park Center Drive, Unit 1B Orlando, FL 32835 888-335-4769 Fax: 321-400-1084 www.assetlifesettlements.com Personal Data Policy Evaluation and Application Form First Insured Name: SS #: Current Address:

More information

For the purposes of this Policy and Procedure, the following definitions apply:

For the purposes of this Policy and Procedure, the following definitions apply: Policies and Procedures TOPIC: Patient Opt-Out Choice and Meaningful Disclosure Policy #: TBD Effective Date: TBD I. BACKGROUND AND PURPOSE The purpose of this policy is to describe how the participation

More information

University of California Policy

University of California Policy University of California Policy HIPAA Uses and Disclosures Responsible Officer: Senior Vice President/Chief Compliance and Audit Officer Responsible Office: Ethics, Compliance and Audit Services Effective

More information

BILLING INFORMATION AND ASSIGNMENT OF BENEFITS

BILLING INFORMATION AND ASSIGNMENT OF BENEFITS BILLING INFORMATION AND ASSIGNMENT OF BENEFITS Facility: Northpoint Radiation Center Pro Physicians Clinic PA Physician: Timothy D. Nichols, M.D. PA, Board Certified Radiation Oncology Wilhelm J. Lubbe,

More information

MEDICAL RECORDS ACCESS GUIDE MICHIGAN

MEDICAL RECORDS ACCESS GUIDE MICHIGAN MEDICAL RECORDS ACCESS GUIDE MICHIGAN Parsonage Vandenack Williams LLC Attorneys at Law Parsonage Vandenack Williams LLC 2008 For more information, contact info@pvwlaw.com TABLE OF CONTENTS Michigan...1

More information

REGISTRATION FORM (Please print)

REGISTRATION FORM (Please print) REGISTRATION FORM (Please print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not so,

More information

Practice Name: Brief overview of your intended scope of practice at Anna Jaques Hospital:

Practice Name: Brief overview of your intended scope of practice at Anna Jaques Hospital: Medical Staff Application for Initial Appointment Supplemental Page Introduction (to be presented to the Credential Committee): Practice Name: Brief overview of your intended scope of practice at Anna

More information

Temecula Valley Hospital Requesting Copies of Your Medical Records

Temecula Valley Hospital Requesting Copies of Your Medical Records Temecula Valley Hospital Requesting Copies of Your Medical Records A medical record for every patient at Temecula Valley Hospital is maintained by the Health Information Management Department. Per Federal

More information

Health Insurance Portability and Accountability Policy 1.8.4

Health Insurance Portability and Accountability Policy 1.8.4 Health Insurance Portability and Accountability Policy 1.8.4 Appendix C Uses and Disclosures of PHI Procedures This Appendix covers procedures related to Uses and Disclosures of PHI. Disclosures to Law

More information

2015 Annual Patient Paperwork Update for Existing Patients

2015 Annual Patient Paperwork Update for Existing Patients 2015 Annual Patient Paperwork Update for Existing Patients DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě

More information

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) Information Technology Services Information Security Policy #2500

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) Information Technology Services Information Security Policy #2500 IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) Information Technology Services Information Security Policy #2500 POLICY INFORMATION Major Functional Area (MFA): Finance and Administration Policy

More information

Continued Dependent Life Insurance for a Disabled Child Instructions

Continued Dependent Life Insurance for a Disabled Child Instructions Continued Dependent Life Insurance Instructions Your application for consists of four forms. Every space should be filled in to avoid delay in processing your application. If a section does not apply,

More information

HIPAA (The Health Insurance Portability and Accountability Act)

HIPAA (The Health Insurance Portability and Accountability Act) Section 16. HIPAA Requirements and Information HIPAA (The Health Insurance Portability and Accountability Act) Molina Healthcare s Commitment to Patient Privacy Protecting the privacy of members personal

More information

UNIVERSITY OF WYOMING HIPAA POLICY 4.2 REQUEST FOR AMENDMENT OF PROTECTED HEALTH INFORMATION

UNIVERSITY OF WYOMING HIPAA POLICY 4.2 REQUEST FOR AMENDMENT OF PROTECTED HEALTH INFORMATION UNIVERSITY OF WYOMING HIPAA POLICY 4.2 REQUEST FOR AMENDMENT OF PROTECTED HEALTH INFORMATION I. PURPOSE: Patients may request amendments to their medical records, i.e. protected health information ( PHI

More information

Robert Stark Life Settlement Data Request Form Connecticut

Robert Stark Life Settlement Data Request Form Connecticut Robert Stark CT Life Settlement Data Request Form Life Settlement Data Request Form Connecticut Life Settlement Data Request Form LIFE INSURANCE POLICY INFORMATION Name of Insurance Company Face Amount

More information

Nursing Home Facility Implementation Overview

Nursing Home Facility Implementation Overview DrConnect Improved Communication; Improved Care Nursing Home Facility Implementation Overview clevelandclinic.org/drconnect Cleveland Clinic 1995-2013. All Rights Reserved. Table of Contents Table of Contents...2

More information

AMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502

AMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502 P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 DISABILITY CLAIM FORM INSTRUCTIONS Enclosed is a claim form required in order to process disability payments on your loan. It is important that all questions

More information

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. The Standard Benefit Administrators. How To Apply For Benefits

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. The Standard Benefit Administrators. How To Apply For Benefits Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. How To Apply For Benefits

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. How To Apply For Benefits Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

The Health Insurance Portability and Accountability Act (HIPAA) Excerpted from the UTC IRB Policy

The Health Insurance Portability and Accountability Act (HIPAA) Excerpted from the UTC IRB Policy The Health Insurance Portability and Accountability Act (HIPAA) Excerpted from the UTC IRB Policy June 2008 Table of Contents PART V: The Health Insurance Portability and Accountability Act (HIPAA)...

More information

SDC-League Health Fund

SDC-League Health Fund SDC-League Health Fund 1501 Broadway, 17 th Floor New York, NY 10036 Tel: 212-869-8129 Fax: 212-302-6195 E-mail: health@sdcweb.org NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION

More information

Parsonage Vandenack Williams LLC Attorneys at Law

Parsonage Vandenack Williams LLC Attorneys at Law MEDICAL RECORDS ACCESS GUIDE NEBRASKA Parsonage Vandenack Williams LLC Attorneys at Law Parsonage Vandenack Williams LLC 2008 For more information, contact info@pvwlaw.com TABLE OF CONTENTS RESPONDING

More information

MEDICAL RECORDS GUIDE. Mary E. Vandenack Parsonage Vandenack Williams LLC 402-504-1300

MEDICAL RECORDS GUIDE. Mary E. Vandenack Parsonage Vandenack Williams LLC  402-504-1300 MEDICAL RECORDS GUIDE Mary E. Vandenack Parsonage Vandenack Williams LLC www.pvwlaw.com 402-504-1300 TABLE OF CONTENTS I. Responding to Subpoenas, Court Orders, and Other Requests for Medical Records for

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM 201 N. Park Ave Suite 201 Apopka, FL 32703 Office (407)228-3180 Fax: (407)-228-3725 PATIENT REGISTRATION FORM Last Name: First Name: Middle Initial Male Female Date of Birth: Marital Status: Single Married

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This Agreement ( Agreement ) is made and entered into this day of [Month], [Year] by and between [Business Name] ( Covered Entity ), [Type of Entity], whose business address

More information

We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act ("HIPAA")

We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act (HIPAA) PRIVACY NOTICE We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act ("HIPAA") THIS NOTICE DESCRIBES HOW PERSONAL AND MEDICAL INFORMATION ABOUT YOU MAY

More information

ADA-Sponsored Disability Income Protection Plan Application for Insurance

ADA-Sponsored Disability Income Protection Plan Application for Insurance Members Insurance Plans ADA-Sponsored Disability Income Protection Plan Application for Insurance IPWS15 Read all forms Complete sections 1 thru 9 Mail or Fax ALL completed forms Questions? 866.607.5334

More information

TORT CLAIM FORM PACKET

TORT CLAIM FORM PACKET TORT CLAIM FORM PACKET Please carefully read all of the information in this packet before completing and presenting your Tort Claim Form. Documents Contained in the Tort Claim Form Packet Instructions

More information

AMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502

AMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502 P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 CREDIT LIFE CLAIM FORM INSTRUCTIONS Enclosed is a form required to process a claim for credit life benefits. It is important that all questions be fully

More information

SI 2047-643383 1 of 6 (12/04)

SI 2047-643383 1 of 6 (12/04) Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

Standard Tort Claim Form Packet

Standard Tort Claim Form Packet Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Standard Tort Claim. Presenting a Standard Tort Claim Form RCW 4.96.020

More information

Present in Person or Mail the Standard Tort Claim Form and Supporting Documents to:

Present in Person or Mail the Standard Tort Claim Form and Supporting Documents to: Standard Tort Claim Form Washington State law (Chapter 4.96 RCW) requires a Standard Tort Claim Form to be submitted when filing a tort claim against the Bellevue School District. Standard Tort Claim forms

More information

INSTRUCTIONS FOR COMPLETING A TORT CLAIM FORM. General Liability Claim Form #SF 210

INSTRUCTIONS FOR COMPLETING A TORT CLAIM FORM. General Liability Claim Form #SF 210 Standard Tort Claim Form Packet Washington State law (Chapter 4.96 RCW) requires a Standard Tort Claim Form to be submitted when filing a tort claim against the Franklin Pierce School District. Standard

More information

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information.

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Page 1 of 5 HIPAA Notification Policies and Practices to Protect the Privacy of Your Heath Information This notice describes how psychological and medical information about you may be used and disclosed

More information

WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future.

WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future. Phone: 717-234-2561 Franklyn J. Myers, III, M.D., F.C.C.P. Alexis B. Aaronson, M.S.N, C.R.N.P. Michele M. Knepper, C.R.N.P. WELCOME TO PCCMA Welcome to our practice. We are specialists in the treatment

More information

Blood & Marrow Transplant Group of Georgia Patient Demographic Form PLEASE FILL OUT FRONT AND BACK OF THIS FORM

Blood & Marrow Transplant Group of Georgia Patient Demographic Form PLEASE FILL OUT FRONT AND BACK OF THIS FORM Blood & Marrow Transplant Group of Georgia Patient Demographic Form ***Please complete entire form---do not leave any blanks*** BLOOD MARROW TRANSPLANT GROUP OF GEORGIA DEMOGRAPHIC FORM H. Kent Holland,

More information

Business Associate Agreement

Business Associate Agreement Business Associate Agreement This Business Associate Contract (Agreement) is entered into by and between, as a Covered Entity as defined in relevant federal and state law, and HMS Agency, Inc., as their

More information

POLICY REGARDING THE USE OR DISCLOSURE OF MENTAL HEALTH RECORDS, INCLUDING PSYCHOTHERAPY NOTES

POLICY REGARDING THE USE OR DISCLOSURE OF MENTAL HEALTH RECORDS, INCLUDING PSYCHOTHERAPY NOTES Purpose: To set forth the policy and procedures of WVU Physicians of Charleston (WVUPC) regarding the use or disclosure of mental health records, including psychotherapy notes. Standard: 1. Subject to

More information

Life Insurance Claim Requirements

Life Insurance Claim Requirements Life, AD&D, Living/Accelerated Benefit Claim Form Instructions Section A: Section B: Section C: Section D: Section E: Section F: General Information to be completed by the employer s authorized representative.

More information

HIPAA & The Medical Practice

HIPAA & The Medical Practice HIPAA & The Medical Practice Requirements for Privacy, Security and Breach Notification Presented by: Gina L. Campanella, JD, MHA Rules that Control Privacy A collection of laws and regulations including:

More information

Protecting Personal Health Information in Research: Understanding the HIPAA Privacy Rule

Protecting Personal Health Information in Research: Understanding the HIPAA Privacy Rule AA Privacy RuleP DEPARTMENT OF HE ALTH & HUMAN SERVICES USA Protecting Personal Health Information in Research: Understanding the HIPAA Privacy Rule NIH Publication Number 03-5388 The HI Protecting Personal

More information

City of Los Angeles Disability Insurance Claim Packet Instructions

City of Los Angeles Disability Insurance Claim Packet Instructions Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

HIPAA Basics for Clinical Research

HIPAA Basics for Clinical Research HIPAA Basics for Clinical Research Audio options: Built-in audio on your computer OR Separate audio dial-in: 415-930-5229 Toll-free: 1-877-309-2074 Access Code: 960-353-248 Audio PIN: Shown after joining

More information

CRITICAL ILLNESS CLAIM FORM

CRITICAL ILLNESS CLAIM FORM Send all claims to: Continental American Insurance Company Critical Illness Claims Processing Unit Post Office Box 427 Columbia, South Carolina 29202 Phone: (800)-433-3036 Fax: (866)-849-2970 CRITICAL

More information

Chimacum School District. Standard Tort Claim Form Packet

Chimacum School District. Standard Tort Claim Form Packet Chimacum School District Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Standard Tort Claim. A New Law that Impacts Presenting

More information

BUSINESS ASSOCIATE AGREEMENT FOR ATTORNEYS

BUSINESS ASSOCIATE AGREEMENT FOR ATTORNEYS BUSINESS ASSOCIATE AGREEMENT FOR ATTORNEYS This Business Associate Agreement (this Agreement ), is made as of the day of, 20 (the Effective Date ), by and between ( Business Associate ) and ( Covered Entity

More information

DETAILED NOTICE OF PRIVACY AND SECURITY PRACTICES OF THE Trustees of the Stevens Institute of Technology Health & Welfare Plan

DETAILED NOTICE OF PRIVACY AND SECURITY PRACTICES OF THE Trustees of the Stevens Institute of Technology Health & Welfare Plan DETAILED NOTICE OF PRIVACY AND SECURITY PRACTICES OF THE Trustees of the Stevens Institute of Technology Health & Welfare Plan THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

More information

Pacific Medical Centers HIPAA Training for Residents, Fellows and Others

Pacific Medical Centers HIPAA Training for Residents, Fellows and Others Pacific Medical Centers HIPAA Training for Residents, Fellows and Others Summary of Critical Pacific Medical Centers (PMC) HIPAA Policies and Procedures For additional information or questions, please

More information

Florida Health Information Exchange Subscription Agreement for Patient Look-Up and Delivery Services

Florida Health Information Exchange Subscription Agreement for Patient Look-Up and Delivery Services Florida Health Information Exchange Subscription Agreement for Patient Look-Up and Delivery Services This Florida Health Information Exchange Subscription Agreement for Patient Look-Up and Delivery Services

More information

Anxiety & OCD Treatment Center of Philadelphia

Anxiety & OCD Treatment Center of Philadelphia Anxiety & OCD Treatment Center of Philadelphia th 1845 Walnut Street, 15 Floor Philadelphia, PA 19103 Phone: (215) 735-7588 Website: www.ocdphiladelphia.com Authorization to Receive & Release Protected

More information

HIPAA COMPLIANCE INFORMATION. HIPAA Policy

HIPAA COMPLIANCE INFORMATION. HIPAA Policy HIPAA COMPLIANCE INFORMATION HIPAA Policy Use of Protected Health Information for Research Policy University of North Texas Health Science Center at Fort Worth Applicability: All University of North Texas

More information

SARASOTA COUNTY GOVERNMENT EMPLOYEE MEDICAL BENEFIT PLAN HIPAA PRIVACY POLICY

SARASOTA COUNTY GOVERNMENT EMPLOYEE MEDICAL BENEFIT PLAN HIPAA PRIVACY POLICY SARASOTA COUNTY GOVERNMENT EMPLOYEE MEDICAL BENEFIT PLAN HIPAA PRIVACY POLICY Purpose: The following privacy policy is adopted to ensure that the Sarasota County Government Employee Medical Benefit Plan

More information

PUD No. 1 of Clallam County Standard Tort Claim Form Packet

PUD No. 1 of Clallam County Standard Tort Claim Form Packet Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Standard Tort Claim. A New Law that Impacts Presenting a Standard Tort

More information

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. How To Apply For Benefits

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. How To Apply For Benefits Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - 4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)

More information

HIPAA POLICIES & PROCEDURES AND ADMINISTRATIVE FORMS TABLE OF CONTENTS

HIPAA POLICIES & PROCEDURES AND ADMINISTRATIVE FORMS TABLE OF CONTENTS HIPAA POLICIES & PROCEDURES AND ADMINISTRATIVE FORMS TABLE OF CONTENTS 1. HIPAA Privacy Policies & Procedures Overview (Policy & Procedure) 2. HIPAA Privacy Officer (Policy & Procedure) 3. Notice of Privacy

More information

Virginia Association of Counties Group Self Insurance Risk Pool Disability Insurance Claim Packet Instructions

Virginia Association of Counties Group Self Insurance Risk Pool Disability Insurance Claim Packet Instructions Claim Packet Instructions Your Disability Benefit Claim We realize that being disabled is difficult. Even though you are unable to work, your financial obligations do not go away. To help you through these

More information

ROWAN UNIVERSITY POLICY

ROWAN UNIVERSITY POLICY ROWAN UNIVERSITY POLICY Title: Authorization for Release of Information and Providing Patients with Copy of Medical Records Subject: IRT Clinical Systems Policy No: Applies: School of Osteopathic Medicine

More information

Standard Tort Claim Form Packet

Standard Tort Claim Form Packet Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Standard Tort Claim. A New Law that Impacts Presenting a Standard Tort

More information

Metropolitan Living, LLC 151 W. Burnsville Parkway, Suite 101 Burnsville, MN 55337 Ph: (952) 564-3030 Fax: (651) 925-0031

Metropolitan Living, LLC 151 W. Burnsville Parkway, Suite 101 Burnsville, MN 55337 Ph: (952) 564-3030 Fax: (651) 925-0031 The Health Insurance Portability and Accountability Act (HIPAA) and Client Privacy Statement This notice describes how your medical information may be used and disclosed and how you can get access to this

More information

Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address:

Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address: Patient Demographics Name: _ of Birth: SS# Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Email: _ Home Address Insurance Information Insurance Provider: Group

More information

Application Checklist. This checklist applies to both new enrollments and re-enrollments.

Application Checklist. This checklist applies to both new enrollments and re-enrollments. Application Checklist For Patient Applications This checklist applies to both new enrollments and re-enrollments. Please keep a copy of all application documents for your records including your New Mexico

More information