Whitman County
LEOFF I Board
Policies and Procedures
FORMS
#1 Employee's Statement
#2 Employer's Statement and Report on Application for Disability Retirement
#3 List of Health Care Providers
#4 Health Care Provider Statement
#5 Health Care Provider Treatment Plan
#6 Medical Expense Claim
#7 Medical Expense Claims Procedures
#8 Employer Statement Regarding Medical Expense Claim
#9 Medical Request for Home Health Care
#10 Approval/Rejection of Claim Form Letter
#11 Response to Request for Medical Payment/Reimbursement (Medicare)
#12 Response to Request for Medical Payment/Reimbursement (Non-Medicare)
#13 Member Insurance Coverages (to be completed annually)
#14-A Nomination Letter 'Firefighter Representative
#14-B Nomination Form ' Firefighter Representative
#14-C Nomination Certification ' Firefighter Representative
#14-D Ballot Form ' Firefighter Representative
#14-E Election Certification ' Firefighter Representative
#15-A Nomination Letter - Law Enforcement Officer Representative
#15-B Nomination Form ' Law Enforcement Officer Representative
#15-C Ballot Form ' Law Enforcement Officer Representative
#15-D Election Certification ' Law Enforcement Officer Representative
#15-E Nomination Certification ' Law Enforcement Officer Representative
#17 HIPAA - Response to Access Health Information Record Letter
#18 HIPAA - Revocation of Authorization for Use or Disclosure of Health Care Information-2 Pages
#19 HIPAA - Request for Corrected/Amended Health Information
#20 HIPAA - Response to Request for Corrected/Amended Health Information
#21 HIPAA - PHI Disclosure Log
#22 HIPAA - Acknowledgement
#23 HIPAA - Sample Grievance Resolution Letter
#24 HIPAA - Confidentiality Statement
#25 HIPAA - Authorization to Release Private Information (2-Pages)