News Flash! Primary & Specialty Care Providers. Sharp Health Plan. Date: February 17, Subject: Member Grievance Forms

Tamaño: px
Comenzar la demostración a partir de la página:

Download "News Flash! Primary & Specialty Care Providers. Sharp Health Plan. Date: February 17, 2012. Subject: Member Grievance Forms"

Transcripción

1 I M P O R T A N T News Flash! A FAX Publication for Providers of Sharp Health Plan To: From: Primary & Specialty Care Providers Sharp Health Plan Date: February 17, 2012 Subject: Member Grievance Forms The California Code of Regulations (Section (b)(7)) applies to all health care service plans and states: Grievance forms and a description of the grievance procedure shall be readily available at each facility of the plan, on the plan's website, and from each contracting provider's office or facility. Grievance forms shall be provided promptly upon request. As a contracting provider, you are required to provide a copy of the Sharp Health Plan (SHP) Grievance Form to any member/patient who requests it. To assist you with meeting this requirement, we have attached copies of the SHP Grievance Forms. Please keep these forms on hand should a member/patient ask for one when they are in the office. If you need additional copies of the Grievance Form, they can be found on our website at: in the Forms section. They are also available by contacting SHP at (619) or by ing If you would like additional information regarding the Sharp Health Plan Grievance process related to your office, please contact SHP Network Dev/Provider Support at (619) or (619)

2 MEMBER GRIEVANCE / APPEAL FORM MAIL OR FAX YOUR COMPLETED FORM TO: 4305 University Avenue, Suite 200 San Diego, CA FAX (619) If you believe this case involves an emergency, call Sharp Health Plan immediately at (619) or toll-free at (800) Member Information Name (Last, First, Middle Initial) Member Plan ID Number Mailing Address (Street, City, State, Zip) Daytime Area Code/Telephone Number Evening Area Code/Telephone Number Patient Information (If Patient is different than Member) Name (Last, First, Middle Initial) Member Plan ID Number Mailing Address (Street, City, State, Zip) Daytime Area Code/Telephone Number Evening Area Code/Telephone Number Provider Information (If applicable) Doctor/Provider/Medical Group Name Area Code/Telephone Number Address (Street, City, State, Zip) G:\Common\CUSTOMER SERVICE\Reference\Appeal-Grievances\MEMBER GRIEVANCE FORM (English).doc

3 Instructions: Briefly outline the specific details of the problem and identify when the event(s) occurred. PLEASE BE SPECIFIC. Please include a statement regarding the outcome desired and what you believe the Plan can do to resolve your concern. If you have copies of documents, bills, checks, or other correspondence related to this problem that may help in the investigation and resolution, please include them with this form. If you need more pages to describe the issue, please attach them to this form. Member / Patient Signature I certify that this information is true and correct Date The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at and use your health plan s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line ( ) for the hearing and speech impaired. The department s Internet Web site has complaint forms, IMR application forms, and instructions online. G:\Common\CUSTOMER SERVICE\Reference\Appeal-Grievances\MEMBER GRIEVANCE FORM (English).doc Page 2 of 2

4 FORMULARIO PARA APELACIONES/INQUIETUDES DEL PARTICIPANTE COMPLETE EL FORMULARIO Y ENVIELO POR FAX O POR CORREO 4305 University Avenue, Suite 200 San Diego, CA FAX (619) Si usted cree que este caso implica una emergencia, llame a Sharp Health Plan inmediatamente al (619) , o sin cargo al (800) Información Sobre el Participante Nombre (Apellido, Nombre, Inicial Intermedia) Número de Identificación del Participante Número de Teléfono (Día) Número de Teléfono (Tardes) Información Sobre el Paciente (Si el Paciente no es el Participante) Nombre (Apellido, Nombre, Inicial Intermedia) Número de Identificación del Participante Número de Teléfono (Día) Número de Teléfono (Tardes) Información Sobre el Médico (Si aplica) Nombre del Médico/Proveedor/Grupo Médico Número de Teléfono G:\Common\CUSTOMER SERVICE\Reference\Appeal-Grievances\MEMBER GRIEVANCE FORM (Spanish).doc Page 1 of 2

5 Instrucciones: Describa brevemente los detalles específicos del problema e identifique cuándo ocurrieron los hechos. POR FAVOR, SEA ESPECIFICO. Díganos por favor cuál es el resultado que desea obtener y cómo piensa usted qué el Plan puede resolver su inquietud. Si usted tiene copias de documentos, cuentas, cheques u otra correspondencia relacionada con este problema que pueda ayudar en la solución del mismo, haga el favor de adjuntarla a este formulario. Si usted necesita más páginas para describir el problema, por favor anéxelas al formulario. Firma del Participante /Paciente Yo certifico que esta información es verdadera y correcta. Fecha El Departamento de Atención Administrada de la Salud de California está a cargo de regular los planes de servicios de atención de l a salud. Si tiene una queja contra su plan de salud, primero debe llamar por teléfono a su plan de salud al y emplear el proceso de presentación de quejas de su plan de salud antes de ponerse en contacto con el Departamento. La utilización de este procedimiento de presentación de quejas no prohíbe los derechos o remedios legales que usted pueda tener a su disposición. Si necesita ayuda con una queja que involucra una emergencia, una queja que su plan de salud no resolvió de manera satisfactoria o una queja que permaneció sin resolución durante más de 30 días, puede llamar al Departamento para que lo asistan. Es posible que también cumpla con los requisitos para una Revisión Médica Independiente (IMR, por su sigla en inglés). Si cumple con los re quisitos para una IMR, el proceso de la IMR brindará una revisión imparcial de las decisiones médicas tomadas por un plan de salud vinculadas a la necesidad médica de un servicio o tratamiento propuesto, de decisiones de cobertura de tratamientos de índole experimental o de investigación, y de las disputas de pago de servicios médicos de emergencia o de urgencia. El Departamento también tiene un número de teléfono sin cargo (1-888-HMO-2219) y una línea TDD ( ) para personas con dificultades del oído y del habla. El sitio de Internet del Departamento, presentación de quejas, solicitudes de IMR e instrucciones en línea., contiene formularios de G:\Common\CUSTOMER SERVICE\Reference\Appeal-Grievances\MEMBER GRIEVANCE FORM (Spanish).doc

Summary: Revised PacifiCare member grievance forms and the responsibilities of the provider group

Summary: Revised PacifiCare member grievance forms and the responsibilities of the provider group , 2009 Communication 09 xxxx Suggested Distribution: Administrator Medical Director Health Plan Coordinator Quality Management Utilization Management Operations Office Chief Financial Officer Product Type:

Más detalles

TITLE VI COMPLAINT FORM

TITLE VI COMPLAINT FORM TITLE VI COMPLAINT FORM Before filling out this form, please read the Arcata and Mad River Transit System Title VI Complaint Procedures located on our website or by visiting our office. The following information

Más detalles

www.deltadentalins.com/language_survey.html

www.deltadentalins.com/language_survey.html Survey Code: Survey 1 February 6, 2008 Dear Delta Dental Enrollee: Recent changes in California law will require that all health care plans provide language assistance to their plan enrollees beginning

Más detalles

TITLE VI COMPLAINT FORM

TITLE VI COMPLAINT FORM [CITY SEAL/EMBLEM] The Capital City of the Palm Beaches TITLE VI COMPLAINT FORM Title VI of the 1964 Civil Rights Act requires that "No person in the United States shall, on the ground of race, color or

Más detalles

Guide to Health Insurance Part II: How to access your benefits and services.

Guide to Health Insurance Part II: How to access your benefits and services. Guide to Health Insurance Part II: How to access your benefits and services. 1. I applied for health insurance, now what? Medi-Cal Applicants If you applied for Medi-Cal it will take up to 45 days to find

Más detalles

LOS ANGELES UNIFIED SCHOOL DISTRICT OFFICE OF PERMITS AND STUDENT TRANSERS

LOS ANGELES UNIFIED SCHOOL DISTRICT OFFICE OF PERMITS AND STUDENT TRANSERS INTER-DISTRICT PERMIT APPEALS If your inter-district permit application has been denied cancelled, or revoked, you may appeal the decision if you believe that an exception to district policy is warranted

Más detalles

INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN

INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN Informacion importante de saber: Una guarderia de niños para familias consite de un niño hasta 6 niños. Una

Más detalles

OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal.

OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal. OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal. For Clerk s Use Only (Para uso de la Secretaria solamente)

Más detalles

ALLIANCE GRIEVANCE PROCESS Frequently Asked Questions & Complaint Form

ALLIANCE GRIEVANCE PROCESS Frequently Asked Questions & Complaint Form ALLIANCE GRIEVANCE PROCESS Frequently Asked Questions & Complaint Form W What is the Alliance grievance process? This is the system for resolving member complaints about the services they get as Alliance

Más detalles

Student Violence, Bullying, Intimidation, Harassment

Student Violence, Bullying, Intimidation, Harassment Case 4:74-cv-00090-DCB Document 1690-6 Filed 10/01/14 Page 159 of 229 Student Violence, Bullying, Intimidation, Harassment COMPLAINT FORM (To be filed with any School District employee who will forward

Más detalles

Welcome to the CU at School Savings Program!

Welcome to the CU at School Savings Program! Welcome to the CU at School Savings Program! Thank you for your interest in Yolo Federal Credit Union s CU at School savings program. This packet of information has everything you need to sign your child

Más detalles

PROCEDIMIENTOS: QUÉ HACER CON EL PEDIMENTO UNA VEZ QUE SE HA COMPLETADO

PROCEDIMIENTOS: QUÉ HACER CON EL PEDIMENTO UNA VEZ QUE SE HA COMPLETADO CENTRO DE AUTOSERVICIO PROCEDIMIENTOS: QUÉ HACER CON EL PEDIMENTO UNA VEZ QUE SE HA COMPLETADO PASO 1: COPIAS Y SOBRES. Haga tres (3) copias de las páginas siguientes del pedimento; Haga dos (2) copias

Más detalles

Down Payment Assistance Application Packet

Down Payment Assistance Application Packet Down Payment Assistance Application Packet Please assure that all needed items are attached and complete. Please note that your application will not be considered until all documents are received. 1. Down

Más detalles

For more information regarding these forms please go to the Texas Department of Insurance website http://www.tdi.state.tx.us/forms/form20employer.

For more information regarding these forms please go to the Texas Department of Insurance website http://www.tdi.state.tx.us/forms/form20employer. CAPROCK Claims Management, LLC ROCK SOLID PERFORMANCE AND RESULTS PO Box 743427 Dallas, TX 75374 (888) 812-3577 Fax (972) 934-3091 IMPORTANT NOTICE FOR REQUIRED FILING FORMS DWC FORM-5 & DWC FORM-7 Caprock

Más detalles

Registro de Semilla y Material de Plantación

Registro de Semilla y Material de Plantación Registro de Semilla y Material de Plantación Este registro es para documentar la semilla y material de plantación que usa, y su estatus. Mantenga las facturas y otra documentación pertinente con sus registros.

Más detalles

Janssen Prescription Assistance. www.janssenprescriptionassistance.com

Janssen Prescription Assistance. www.janssenprescriptionassistance.com Janssen Prescription Assistance www.janssenprescriptionassistance.com Janssen Prescription Assistance What is Prescription Assistance? Prescription assistance programs provide financial help to people

Más detalles

Title VI Complaint Procedures

Title VI Complaint Procedures Title VI Complaint Procedures As a recipient of federal dollars, HELP of Ojai, Inc. is required to comply with Title VI of the Civil Rights Act of 1964 and ensure that services and benefits are provided

Más detalles

Workers Compensation Non-Subscriber Form

Workers Compensation Non-Subscriber Form Workers Compensation Non-Subscriber Form Texas is unique in one very important respect: It s the only state in which employers have the choice to carry workers compensation insurance or not. There are

Más detalles

Formulario de Postulación Estudiante de Intercambio Application Form / Exchange Student

Formulario de Postulación Estudiante de Intercambio Application Form / Exchange Student Formulario de Postulación Estudiante de Intercambio Application Form / Exchange Student Información Personal Personal Information Nombres First Name Apellidos Last Name Dirección permanente Permanent Address

Más detalles

UNIVERSIDAD GABRIELA MISTRAL Departamento de Relaciones Internacionales. Formulario de Postulación (Aplication For Admission/Exchange Student)

UNIVERSIDAD GABRIELA MISTRAL Departamento de Relaciones Internacionales. Formulario de Postulación (Aplication For Admission/Exchange Student) Personal Data Nombre/First Name Apellidos/Last Name Dirección/Permanent Address Numbers/Street Ciudad City/Province País Country Teléfono Local Phone Number (with area codes) E-mail Fecha de Nacimiento

Más detalles

DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS

DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS DAVID L. LAKEY, M.D. DIRECTOR P.O. Box 149347 Austin, Texas 78714-9347 1-888-963-7111 TTY (teletipo): 1-800-735-2989 www.dshs.state.tx.us 1 de marzo,

Más detalles

RENT CONTROL BOARD OF THE TOWN OF WEST NEW YORK, N.J. 428-60 TH STREET WEST NEW YORK, N.J. 07093-2231 (201) 295-5290/91/92

RENT CONTROL BOARD OF THE TOWN OF WEST NEW YORK, N.J. 428-60 TH STREET WEST NEW YORK, N.J. 07093-2231 (201) 295-5290/91/92 FELIX E. ROQUE, MD MAYOR DEPT. OF PUBLIC AFFAIRS RENT CONTROL BOARD RENTAL AGREEMENT APPLICATION NAME OF ADDRESS OF LANDLORD: PROPERTY ADDRESS: APARTMENT #: 3 COPIES (1) Original rental agreement signed

Más detalles

Screener for Peer Supporters

Screener for Peer Supporters Screener for Peer Supporters Primary Recruiter: Secondary Recruiter: Potential Peer Supporter Name: Phone #1: Home/Cell Phone #2: Home/Cell Address: City: Zip: Contact 1: Date: / / Contact 2: Date: / /

Más detalles

Puede pagar facturas y gastos periódicos como el alquiler, el gas, la electricidad, el agua y el teléfono y también otros gastos del hogar.

Puede pagar facturas y gastos periódicos como el alquiler, el gas, la electricidad, el agua y el teléfono y también otros gastos del hogar. SPANISH Centrepay Qué es Centrepay? Centrepay es la manera sencilla de pagar sus facturas y gastos. Centrepay es un servicio de pago de facturas voluntario y gratuito para clientes de Centrelink. Utilice

Más detalles

Title VI Complaint Form Horizon Cross Cultural Center (HORIZON) (formerly St. Anselm s Cross-Cultural Community Center) Office of Civil Rights

Title VI Complaint Form Horizon Cross Cultural Center (HORIZON) (formerly St. Anselm s Cross-Cultural Community Center) Office of Civil Rights Title VI Complaint Form Horizon Cross Cultural Center (HORIZON) (formerly St. Anselm s Cross-Cultural Community Center) Title VI of the Civil Rights Act of 1964 provides that no person in the United States

Más detalles

Becoming Independent Title VI Program

Becoming Independent Title VI Program Title VI Complaint Procedures As a recipient of federal fund, Becoming Independent is required to comply with Title VI of the Civil Rights Act of 1964 and ensure that program and services are provided

Más detalles

Title VI Complaint Procedures

Title VI Complaint Procedures Title VI Complaint Procedures As a recipient of federal fund, Self-Help for the Elderly is required to comply with Title VI of the Civil Rights Act of 1964 and ensure that program and services are provided

Más detalles

Purpose of Sliding Scale Policy and Procedure Disclaimer Policy

Purpose of Sliding Scale Policy and Procedure Disclaimer Policy San Luis Valley Health s Behavioral Health department offers a sliding fee discount program to eligible patients. If you would like more information, please call 589-8008, or ask one of our Admitting Clerks

Más detalles

Limited TWO-YEAR Warranty SENSIO Inc. hereby warrants that for a period of TWO YEARS from the date of purchase, this product will be free from mechanical defects in material and workmanship, and for 90

Más detalles

PRINTING INSTRUCTIONS

PRINTING INSTRUCTIONS PRINTING INSTRUCTIONS 1. Print the Petition form on 8½ X 11inch paper. 2. The second page (instructions for circulator) must be copied on the reverse side of the petition Instructions to print the PDF

Más detalles

Lump Sum Final Check Contribution to Deferred Compensation

Lump Sum Final Check Contribution to Deferred Compensation Memo To: ERF Members The Employees Retirement Fund has been asked by Deferred Compensation to provide everyone that has signed up to retire with the attached information. Please read the information from

Más detalles

FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner

FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner

Más detalles

Cal Grant GPA Electronic Submission and Opt-out Notification As of 10.13.15

Cal Grant GPA Electronic Submission and Opt-out Notification As of 10.13.15 12338 McCourtney Road Grass Valley, CA 95949 Phone: 530-272-4008 Fax: 530-272-4009 www.johnmuircs.com Cal Grant GPA Electronic Submission and Opt-out Notification As of 10.13.15 Assembly Bill 2160, commonly

Más detalles

Voter Information Guide and Sample Ballot

Voter Information Guide and Sample Ballot Voter Information Guide and Sample Ballot Special Election San Bernardino Mountains Community Hospital District Tuesday, June 4, 2013 Elections Office of the Registrar of Voters 777 East Rialto Ave. San

Más detalles

Dolores de cabeza Trabaje con su doctor para evitar las visitas a la Sala de Emergencia

Dolores de cabeza Trabaje con su doctor para evitar las visitas a la Sala de Emergencia Headaches, Working with your Doctor to Avoid the Emergency Room Dolores de cabeza Trabaje con su doctor para evitar las visitas a la Sala de Emergencia Conozca a su equipo de cuidados para los dolores

Más detalles

Required Documentation for Charity Care

Required Documentation for Charity Care Patchogue, New York 11772 Required Documentation for Charity Care The completed signed application listing all family members, must be filled out and returned to the Patient Financial Services Department

Más detalles

IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR

IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR Subject: Important Updates Needed for Your FAFSA Dear [Applicant], When you completed your 2012-2013 Free Application for Federal Student Aid

Más detalles

MANUAL EASYCHAIR. A) Ingresar su nombre de usuario y password, si ya tiene una cuenta registrada Ó

MANUAL EASYCHAIR. A) Ingresar su nombre de usuario y password, si ya tiene una cuenta registrada Ó MANUAL EASYCHAIR La URL para enviar su propuesta a la convocatoria es: https://easychair.org/conferences/?conf=genconciencia2015 Donde aparece la siguiente pantalla: Se encuentran dos opciones: A) Ingresar

Más detalles

MISSISSIPPI EMPLOYEES

MISSISSIPPI EMPLOYEES 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone (757) 460-6308 Fax (757) 457-9345 MISSISSIPPI EMPLOYEES MANCON Employees, Included in this packet is the following information: 1. Job Insurance

Más detalles

Southern California Lumber Industry Retirement Fund

Southern California Lumber Industry Retirement Fund Southern California Lumber Industry Retirement Fund Established Jointly by Employers and Local Unions Telephone (562) 463-5080 (800) 824-4427 Facsimile (562) 463-5894 www.lumberfund.org January 9, 2015

Más detalles

The Home Language Survey (HLS) and Identification of Students

The Home Language Survey (HLS) and Identification of Students The Home Language Survey (HLS) and Identification of Students The Home Language Survey (HLS) is the document used to determine a student that speaks a language other than English. Identification of a language

Más detalles

\RESOURCE\ELECTION.S\PROXY.CSP

\RESOURCE\ELECTION.S\PROXY.CSP The following is an explanation of the procedures for calling a special meeting of the shareholders. Enclosed are copies of documents, which you can use for your meeting. If you have any questions about

Más detalles

OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal.

OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal. OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal. Person Filing: (Nombre de persona:) Address (if not

Más detalles

MajestaCare Healthy Baby Program

MajestaCare Healthy Baby Program MajestaCare Healthy Baby Program Helping you have a healthy baby Para que tenga un bebé saludable Your baby s provider After your baby becomes a member of MajestaCare health plan, you will get a letter

Más detalles

Goodwill Serving the People of Southern Los Angeles County. Title VI Notice to the Public

Goodwill Serving the People of Southern Los Angeles County. Title VI Notice to the Public Title VI Notice to the Public Notifying the Public of Rights Under Title VI (Goodwill SOLAC) operates its programs and services without regard to race, color, and national origin in accordance with Title

Más detalles

Creating your Single Sign-On Account for the PowerSchool Parent Portal

Creating your Single Sign-On Account for the PowerSchool Parent Portal Creating your Single Sign-On Account for the PowerSchool Parent Portal Welcome to the Parent Single Sign-On. What does that mean? Parent Single Sign-On offers a number of benefits, including access to

Más detalles

Affordable Care Act Informative Sessions and Open Enrollment Event

Affordable Care Act Informative Sessions and Open Enrollment Event 2600 Cedar Ave., P.O. Box 2337, Laredo, TX 78044 Hector F. Gonzalez, M.D., M.P.H Tel. (956) 795-4901 Fax. (956) 726-2632 Director of Health News Release. Date: February 9, 2015 FOR IMMEDIATE RELEASE To:

Más detalles

PRODUCT ASSEMBLY INSTRUCTIONS

PRODUCT ASSEMBLY INSTRUCTIONS PRODUCT ASSEMBLY INSTRUCTIONS KARLSEN SWIVEL GLIDER RECLINER SAM S CLUB #402411 BERKLINE #4160061 PLEASE READ THIS BOOKLET CONTAINS IMPORTANT INFORMATION. KEEP FOR FUTURE REFERENCE. Page (Pagina) 1 of

Más detalles

PRODUCT ASSEMBLY INSTRUCTIONS

PRODUCT ASSEMBLY INSTRUCTIONS PRODUCT ASSEMBLY INSTRUCTIONS HAUGEN SOFA SAM S CLUB # 610256 BERKLINE #2450438 PLEASE READ THIS BOOKLET CONTAINS IMPORTANT INFORMATION. KEEP FOR FUTURE REFERENCE. Page 1 of 10 CUSTOMER SERVICE INFORMATION

Más detalles

Passaic County Technical Institute 45 Reinhardt Road Wayne, New Jersey 07470

Passaic County Technical Institute 45 Reinhardt Road Wayne, New Jersey 07470 Note: Instructions in Spanish immediately follow instructions in English (Instrucciones en español inmediatamente siguen las instrucciónes en Inglés) Passaic County Technical Institute 45 Reinhardt Road

Más detalles

Spanish Version provided Below

Spanish Version provided Below Spanish Version provided Below Greater Waltown United Holy Church s Summer Reading and Math Program 706 Belvin Avenue Durham, N. C. 27712 (919) 220-7087 May 3, 2015 Dear Parent/Guardian: Summer can be

Más detalles

AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES

AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES SCOPE OF POLICY This policy applies to all agency staff members. Agency staff members include all employees, trainees, volunteers, consultants, students,

Más detalles

Daly Elementary. Family Back to School Questionnaire

Daly Elementary. Family Back to School Questionnaire Daly Elementary Family Back to School Questionnaire Dear Parent(s)/Guardian(s), As I stated in the welcome letter you received before the beginning of the school year, I would be sending a questionnaire

Más detalles

Organización de Planificación Metropolitana de Broward (Broward Metropolitan Planning Organization)

Organización de Planificación Metropolitana de Broward (Broward Metropolitan Planning Organization) Organización de Planificación Metropolitana de Broward (Broward Metropolitan Planning Organization) PROCEDIMIENTOS DE DENUNCIA DE DISCRIMINACIÓN - TÍTULO VI La Organización de Planificación Metropolitana

Más detalles

INSTRUCTIONS FOR COMPLETING THE UA_SGE_FT_03_FI_IE FORM REGARDING NATURAL PERSONS DATA FOR THE UA SUPPLIERS DATABASE

INSTRUCTIONS FOR COMPLETING THE UA_SGE_FT_03_FI_IE FORM REGARDING NATURAL PERSONS DATA FOR THE UA SUPPLIERS DATABASE INSTRUCTIONS FOR COMPLETING THE UA_SGE_FT_03_FI_IE FORM REGARDING NATURAL PERSONS DATA FOR THE UA SUPPLIERS DATABASE This form is for use by both Spanish and foreign natural persons. Due to the new requirements

Más detalles

PB #11-111-OPE. Attachment: Please use Print on M-687r Referral to Treatment Program (Rev. 11/30/11) (Rev. 11/30/11)

PB #11-111-OPE. Attachment: Please use Print on M-687r Referral to Treatment Program (Rev. 11/30/11) (Rev. 11/30/11) FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Stephen Fisher, Assistant Deputy Commissioner Office

Más detalles

INSTRUCTIONS FOR COMPLETING THE UA-SGE-FT-05-FI-IE FORM REGARDING NATURAL PERSONS DATA FOR THE UA SUPPLIERS DATABASE

INSTRUCTIONS FOR COMPLETING THE UA-SGE-FT-05-FI-IE FORM REGARDING NATURAL PERSONS DATA FOR THE UA SUPPLIERS DATABASE INSTRUCTIONS FOR COMPLETING THE UA-SGE-FT-05-FI-IE FORM REGARDING NATURAL PERSONS DATA FOR THE UA SUPPLIERS DATABASE This form is for use by both Spanish and foreign natural persons. Due to the new requirements

Más detalles

CNS Paragraph Form Date: 09.02.11

CNS Paragraph Form Date: 09.02.11 CNS Paragraph Form Date: 09.02.11 Program Area 03 (01=PA, 02=FS, 03=MA, 04=HP) Paragraph Number U0223 Version Number 00001 Effective Date 2011 Title Administrative Renewal for Aged, Blind and Disabled,

Más detalles

P.O. BOX en Miami + Correspondencia Local

P.O. BOX en Miami + Correspondencia Local Gracias por permitirnos presentarles nuestras tarifas y beneficios. P.O. BOX en Miami + Correspondencia Local TIPO DE SERVICIO PLANES PRECIO MENSUAL EXCEDENTES POR GRAMO Plan Silver 2 Kilos / Mes $30 $0.011

Más detalles

We appreciate your time and patience as we work towards resolving this problem.

We appreciate your time and patience as we work towards resolving this problem. Please download the attached Barking Dog Incident Log Take the time to fill out the log completely, When at least seven (7) days of habitual barking are documented, the log should be returned to Animal

Más detalles

LOS ANGELES UNIFIED SCHOOL DISTRICT STUDENT EMERGENCY INFORMATION FORM Parent Information: Please fill out completely and sign where indicated. In a major emergency, it is school district policy to retain

Más detalles

Solicitud para Licencia de matrimonio (Marriage License Request)

Solicitud para Licencia de matrimonio (Marriage License Request) Solicitud para Licencia de matrimonio (Marriage License Request) Este documento contiene una traducción de la solicitud en línea para obtener una Licencia o permiso de matrimonio (o Marriage License, en

Más detalles

RECIBIRÁS EN TU CUENTA INSTITUCIONAL, UNA CARTA DE PREADJUDICACIÓN CON LOS DATOS DE TU MOVILIDAD. SI NO SON CORRECTOS, COMUNÍCALO A erasmus@upm.

RECIBIRÁS EN TU CUENTA INSTITUCIONAL, UNA CARTA DE PREADJUDICACIÓN CON LOS DATOS DE TU MOVILIDAD. SI NO SON CORRECTOS, COMUNÍCALO A erasmus@upm. UNA VEZ PUBLICADA LA RESOLUCIÓN RECTORAL CON LOS LISTADOS DE ADMITIDOS, TIENES UN PLAZO DE 15 DÍAS PARA PODER RENUNCIAR A LA MOVILIDAD ADJUDICADA, ENTREGANDO EL DOCUMENTO DE RENUNCIA EN LA OFICINA DE MOVILIDAD

Más detalles

HEAD START MEDICATION ADMINISTRATION

HEAD START MEDICATION ADMINISTRATION HEAD START MEDICATION ADMINISTRATION Dear Parents/Guardians: It is the policy of Head Start to cooperate with each Head Start child's parent/guardian and his/her physician by administering and providing

Más detalles

Exceptional Children s Foundation Title VI Notice to the Public

Exceptional Children s Foundation Title VI Notice to the Public Title VI Notice to the Public Notifying the Public of Rights Under Title VI Exceptional Children s Foundation The Exceptional Children s Foundation (ECF) operates its programs and services without regard

Más detalles

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION FORM 16-1 AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Completion of this document authorizes the disclosure and use of health information about you. Failure to provide all information requested

Más detalles

Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts?

Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts? Albany Housing Authority RESIDENT COMMISSIONER ELECTION Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts? RUN FOR RESIDENT COMMISSIONER

Más detalles

Person ID:
, Mailed:

Person ID: <MPI_ID> <Primary Applicant/AREP FMLNS> <Address Line 1> <Address Line 2> <City>, <State> <Zip> Mailed: <Current Date> Person ID: , Mailed: Your HUSKY Health Coverage is Scheduled to End on August 31st Dear

Más detalles

Health Plan of Nevada, Inc.

Health Plan of Nevada, Inc. HMO Option 1 Lifetime Maximum Benefit $1,000,000 Annual Copayment Maximum $2,000 per Member / $4,000 per Family Covered Services Physician Services - Office Visit/Consultation Hospital Services - Elective

Más detalles

Your HUSKY Health Coverage Category is Changing

Your HUSKY Health Coverage Category is Changing Connecticut s Official Health Insurance Marketplace Person ID: , Mailed: Your HUSKY Health Coverage

Más detalles

IMMIGRATION Canada. Temporary Resident Visa. Mexico City Visa Office Instructions. Table of Contents IMM 5878 E (10-2015)

IMMIGRATION Canada. Temporary Resident Visa. Mexico City Visa Office Instructions. Table of Contents IMM 5878 E (10-2015) IMMIGRATION Canada Table of Contents Document Checklist Temporary resident visa (available in Spanish) Emergency Processing Request Form Temporary Resident Visa Mexico City Visa Office Instructions This

Más detalles

Certified translation Traducción certificada. Qué es una Declaración de Impacto de la Víctima?

Certified translation Traducción certificada. Qué es una Declaración de Impacto de la Víctima? Translated from English to Spanish Traducido del inglés al español Certified translation Traducción certificada Victim Impact Statements "Declaraciones de Impacto de la Víctima" June 2014 Junio 2014 Qué

Más detalles

La Compensación por Desempleo Instrucciones para Solicitar los Documentos de la Proposición de Pruebas

La Compensación por Desempleo Instrucciones para Solicitar los Documentos de la Proposición de Pruebas La Compensación por Desempleo Instrucciones para Solicitar los Documentos de la Proposición de Pruebas Si tiene un caso pendiente ante la Oficina de Apelaciones de casos de Compensación por Desempleo,

Más detalles

Sample Customer Rights and Complaint Resolution Procedure and Customer Complaint Form

Sample Customer Rights and Complaint Resolution Procedure and Customer Complaint Form Participating in workforce services administered by the Texas Workforce Commission (Commission) or Workforce Development Board (Board) grants you the right to file a complaint regarding your workforce

Más detalles

Recomendación para el Programa de Servicios Académicos Avanzados

Recomendación para el Programa de Servicios Académicos Avanzados Recomendación para el Programa de Servicios Académicos Avanzados Este formulario debe ser devuelto antes de: 11 de diciembre de 2015 PERMISO de los padres y formulario de recomendación Fecha de hoy Nombre

Más detalles

EXPAND HORIZONS. When you gaze out at the horizon, what do you see? You see where one vista ends and another one begins. You think POSSIBILITIES

EXPAND HORIZONS. When you gaze out at the horizon, what do you see? You see where one vista ends and another one begins. You think POSSIBILITIES EXPANDING HORIZONS EXPAND HORIZONS IS WHAT PAUL CUFFEE SCHOOL DOES. When you gaze out at the horizon, what do you see? You see where one vista ends and another one begins. You think POSSIBILITIES Selected

Más detalles

Encl.: Teacher/Teacher Assistant Information Request Form

Encl.: Teacher/Teacher Assistant Information Request Form To: All Parents/Legal Guardians in Title I Schools From: Charlotte-Mecklenburg Schools Title I Department Date: Subject: Right to Know Notification to Parents of Teacher and Teacher Assistant Qualifications

Más detalles

FORMULARIO DE AUTORIZACIÓN MIM #710-S AUTHORIZATION FORM MIM #710-S

FORMULARIO DE AUTORIZACIÓN MIM #710-S AUTHORIZATION FORM MIM #710-S FORMULARIO DE AUTORIZACIÓN MIM #710-S AUTHORIZATION FORM MIM #710-S 500 Eastowne Drive Chapel Hill, NC 27514 Para radiografías favor de enviar a: Radiology Films please send: ATTN: IMAGING SUPPORT (919)

Más detalles

Administración de ingresos. Voluntaria

Administración de ingresos. Voluntaria Administración de ingresos Voluntaria Qué es Administración de ingresos (Income Management)? La Administración de ingresos (Income Management) es una manera de ayudarle a administrar su dinero a fin de

Más detalles

PREMIUM BOOKLET B U PA GROUP

PREMIUM BOOKLET B U PA GROUP PREMIUM BOOKLET B U PA GROUP EFFECTIVE JANUARY 1, 2015 ADMINISTRATIVE NOTES Rates are in U.S. dollars and don t include taxes. Rates do not apply to Puerto Rico, the U.S. Virgin Islands, or Brazil. An

Más detalles

El límite mínimo para las cuentas comerciales grandes es de $2,000/mes por el uso del servicio.

El límite mínimo para las cuentas comerciales grandes es de $2,000/mes por el uso del servicio. ONNETIUT OBERTURA DEL FORMULARIO DE FAX PARA: XOOM Energy lientes omerciales No. FAX: 866.452.0053 FEHA: NOMBRE DE EMPRESARIO INDEPENDIENTE: # IDENTIFIAIÓN DE NEGOIO: ORREO ELETRÓNIO: # DE PÁGINAS: TELÉFONO:

Más detalles

Chattanooga Motors - Solicitud de Credito

Chattanooga Motors - Solicitud de Credito Chattanooga Motors - Solicitud de Credito Completa o llena la solicitud y regresala en persona o por fax. sotros mantenemos tus datos en confidencialidad. Completar una aplicacion para el comprador y otra

Más detalles

Premio Miembro Profesional Ejemplar en la Academia

Premio Miembro Profesional Ejemplar en la Academia Premio Miembro Profesional Ejemplar en la Academia Se premiará anualmente al miembro profesional responsable de la promoción, progreso y reconocimiento de las disciplinas profesionales en la academia que

Más detalles

Q. What is the 1095-B form and why does it matter to me?

Q. What is the 1095-B form and why does it matter to me? FAQ This tax season, certain Medicaid members will receive Form 1095-B from the Georgia Medicaid/ PeachCare for Kids program. Select members who receive their healthcare coverage through Fee-for-Service

Más detalles

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

TEXAS DEPARTMENT OF STATE HEALTH SERVICES TEXAS DEPARTMENT OF STATE HEALTH SERVICES DAVID L. LAKEY, M.D. COMMISSIONER P.O. Box 149347 Austin, Texas 78714-9347 1-888-963-7111 TTY: 1-800-735-2989 www.dshs.state.tx.us August 15, 2013 Dear Birthing

Más detalles

ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights

ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights ODJFS Bureau of Civil Rights I NEED AN INTERPRETER, PLEASE. Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of national origin. If you do not speak English well, social services,

Más detalles

La Red ofrece muchos beneficios, entre los que se incluyen los siguientes:

La Red ofrece muchos beneficios, entre los que se incluyen los siguientes: , _ Empleador: Empleado: Fecha de Accidente: Número de Archivo: Número del Estado: Estimado Empleado: Para las reclamaciones de compensación legal por accidentes de trabajo que sean compensables, su empleador

Más detalles

UNIVERSIDAD DE MONTEVIDEO

UNIVERSIDAD DE MONTEVIDEO UNIVERSIDAD DE MONTEVIDEO Formulario de admisión para estudiantes internacionales Application form for International Students PHOTO Semestre 1 (marzo-julio) / Semester 1 (March-July) Año/ Year Semestre

Más detalles

Beneficios de Fundar una Corporación Sin Fines de Lucro Benefits of Establishing a Non-Profit Corporation

Beneficios de Fundar una Corporación Sin Fines de Lucro Benefits of Establishing a Non-Profit Corporation ISSN 2152-6613 Beneficios de Fundar una Corporación Sin Fines de Lucro Benefits of Establishing a Non-Profit Corporation Evaluación Capacitación Rendimiento NPERCI Publication Series No. 2 Flordeliz Serpa,

Más detalles

2015 16 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program

2015 16 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program 2015 16 Student Eligibility Verification Advanced Placement (AP) and/or International Baccalaureate (IB) Exams AP Exam IB Exam AP and IB Exams I. Student Information Last Name First Name MI Grade High

Más detalles

School Food and Nutrition Services - 703.791.7314 Facilities Management Services - 703.791.7221

School Food and Nutrition Services - 703.791.7314 Facilities Management Services - 703.791.7221 SUPPORT SERVICES To: All Principals All Food Service Managers Approved by: Dave Cline Contact Person: Serena Suthers SUPPORT SERVICES Spring Break Refrigerator/Freezer Checks This notice remains in effect

Más detalles

Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387

Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387 Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387 January 27, 2009 Courtesy_Title Full_Name 1 Mail_Address_2 Mail_Address_1

Más detalles

Adult Application 18 and over ONLY ******************************** Aplicación de Adultos Solo para mayores de 18 años

Adult Application 18 and over ONLY ******************************** Aplicación de Adultos Solo para mayores de 18 años Adult Application 18 and over ONLY ******************************** Aplicación de Adultos Solo para mayores de 18 años FREE GRATIS Beacon Programs Adult Enrollment Form Beacon PROGRAMS Participant Information

Más detalles

I understand that I must request that this waiver be reconsidered annually, each school year. Parent/Guardian Signature: Date:

I understand that I must request that this waiver be reconsidered annually, each school year. Parent/Guardian Signature: Date: Page 1 of 7 PARENTAL EXCEPTION WAIVER EDUCATION CODE 311(a): Children who know English (Exhibit 1) Name: School: Grade: Date of Birth: Language Designation: My child possesses good English language skills

Más detalles

Northwestern University, Feinberg School of Medicine

Northwestern University, Feinberg School of Medicine Improving Rates of Repeat Colorectal Cancer Screening Appendix Northwestern University, Feinberg School of Medicine Contents Patient Letter Included with Mailed FIT... 3 Automated Phone Call... 4 Automated

Más detalles

NOTA: Este es un ejemplo de código de barras.

NOTA: Este es un ejemplo de código de barras. la Revisión Independiente de la Ejecución Hipotecaria Esta es la Guía en idioma español para completar el Formulario de solicitud de revisión en inglés IMPORTANTE El Formulario de solicitud de revisión

Más detalles

Division of Behavioral Health Services Bureau of Compliance

Division of Behavioral Health Services Bureau of Compliance Division of Behavioral Health Services Bureau of Compliance 150 North 18 th Avenue, Suite 260 JANET NAPOLITANO, GOVERNOR Phoenix, Arizona 85007 SUSAN GERARD, DIRECTOR (602) 364-4558 (602) 364-4762 FAX

Más detalles

2015 DENTAL DIRECTORY

2015 DENTAL DIRECTORY 2015 DENTAL DIRECTORY DIRECTORIO DENTAL 2015 County / Condado: EL PASO H5928_15_003_PNO_DENTAL_EP Accepted H5928_15_003_PNO_DENTAL_EP_SPA Accepted Care1st Health Plan HMO Plan Provider Directory This directory

Más detalles

Salud Plan Highlights

Salud Plan Highlights Salud con Health Net Groups Salud Plan Highlights HMO, PPO and EPO Health care coverage for your diverse workforce Herminia Escobedo, Health Net We get members what they need. Salud con Health Net Latino

Más detalles

LAC-2009-09 Modificación 2.3.3.3. DIRECT ALLOCATIONS TO ISPs DISTRIBUCIONES INICIALES A ISPs

LAC-2009-09 Modificación 2.3.3.3. DIRECT ALLOCATIONS TO ISPs DISTRIBUCIONES INICIALES A ISPs LAC-2009-09 Modificación 2.3.3.3 DIRECT ALLOCATIONS TO ISPs DISTRIBUCIONES INICIALES A ISPs Current Policy 2.3.3.3. Direct Allocations to Internet Service Providers LACNIC may grant this type of allocation

Más detalles