Ca Request And Authorization For Disclosure Of Health Information Page 3
Download a blank fillable Ca Request And Authorization For Disclosure Of Health Information in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Ca Request And Authorization For Disclosure Of Health Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Discrimination is Against the Law
The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Plan does
not exclude people or treat them differently because of race, color, national origin, age, disability, or sex
assigned at birth, gender identity or recorded gender. Furthermore, the Plan will not deny or limit
coverage to any health service based on the fact that an individual’s sex assigned at birth, gender identity,
or recorded gender is different from the one to which such health service is ordinarily available. The Plan
will not deny or limit coverage for a specific health service related to gender transition if such denial or
limitation results in discriminating against a transgender individual.
The Plan:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other
formats)
Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Plan has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity,
you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222,
Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: .
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil
Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights electronically through the Office for
Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or
phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical