PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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PERMISSION TO RELEASE CONFIDENTIAL INFORMATION Patient Name I give permission to ( ) and/or ( ), and/or the following person/agency/group: Provider/Agency/Group Address City State ZIP To give information and records regarding my treatment, medical and/or behavioral health condition to the following professional person/agency, physician and/or facility: Provider/Agency/Group Address City State ZIP Information to be released or exchanged includes (check all that apply): ______ History and physical ______ Discharge and Summary ______ Behavioral <strong>Health</strong> Treatment Records ______ Lab Reports ______ Physical <strong>Health</strong> Treatment Records ______ Medication Records ______ Information on HIV /STD Treatment ______ Other The reason for this release is: ______ Diagnosis and Treatment ______ Coordination of Care ______ Insurance Payment Purposes ______ Other (specify) _____________________________________________ 123
PERMISSION TO RELEASE CONFIDENTIAL INFORMATION I understand that my health and behavioral health records are protected from being shared under Federal and state laws. I may change this permission. This permission is valid until changed or sixty (60) days after I have completed treatment, whichever is sooner. Once I revoke this permission, no information can be released except as allowed by law. A file copy is as good as the original. This authorization was explained to me and I signed it of my own free will on: The _____________ day of ___________________, 19____. ______________________________________ Signature of Client _____________________________________ Signature of Witness Signature of Parent, Guardian, or Authorized Representative, if needed The person signing this authorization is entitled to a copy. TO PERSON RECEIVING THE CONFIDENTIAL INFORMATION: PROHIBITION ON REDISCLOSURE NOTICE OF CLIENT’S REFUSAL TO RELEASE INFORMATION: I have reviewed the above release of information form. I refuse to authorize release of health and behavioral health information to mental health or alcohol or drug abuse treatment providers or physical health providers. Signed this _____________ day of ___________________, 19____. ___________________________________________ Signature of Client ______________________________________ Signature of Witness Signature of Parent, Guardian, or Authorized Representative, if needed 124
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Parkland KIDSfirst, Parkland CHIP P
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Notification of Change in Provider
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CLAIMS SUBMISSION .................
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Quick Reference Checklist This manu
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Plan specified services. However, c
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CHIP Covered Services PCHP provides
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• Surgical implants • Other art
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Outpatient Mental Health Services I
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• Out-of-network services not aut
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CHIP Perinatal Covered Services Cov
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15 Covered Benefit CHIP Perinate Ne
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Covered Benefit CHIP Perinate Newbo
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• Personal comfort items includin
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• Donor non-medical expenses •
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SUPPLIES COVERED EXCLUDED COMMENTS/
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SUPPLIES COVERED EXCLUDED COMMENTS/
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Coordination between Physical and B
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in the provision of care and servic
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statement indicating that members s
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As the Primary Care Provider you mu
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Other Access Standards Service Stan
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Members Right to Select Network Oph
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HMO/Provider Coordination PCHP will
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45 • describe the range of medica
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Coordination of Care The Primary Ca
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Coordination with Texas Department
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Presentation at Emergency Room afte
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If the complaint is received verbal
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Expedited Appeal can be made verbal
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CHIP Eligibility CHIP KidsFirst Mem
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• Information concerning the grie
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Parkland Community Health Plan Memb
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Pregnant Teens Please call Parkland
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your income. Co-payments do not app
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Member’s Right to Designate an OB
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70 To report providers use this add
Page 79 and 80: 5. Network providers must report an
Page 81 and 82: To request to be a Specialist servi
Page 83 and 84: • OB/Gyn • Periodic Health Chec
Page 85 and 86: The table below provides HHSC Manag
Page 87 and 88: CHIP Cost Sharing Caps Members rece
Page 89 and 90: of these two dates: July 18, 2007,
Page 91 and 92: (DD) Diagnosis code by specific ser
Page 93 and 94: (PP) Attending physician ID (UB-04,
Page 95 and 96: (2) post-partum visits within 60 da
Page 97 and 98: CHIP Member Enrollment and Disenrol
Page 99 and 100: • In order to synchronize all CHI
Page 101 and 102: Provider Participation Requirements
Page 103 and 104: • Evidence of state licensure, an
Page 105 and 106: U1 U2 U3 Medically necessary delive
Page 107 and 108: PROCEDURE DESCRIPTION PROCEDURE COD
Page 109 and 110: provider actually treating the memb
Page 111 and 112: themselves appropriately and follow
Page 113 and 114: Medical Record Standards The medica
Page 115 and 116: 1. History and Physical Examination
Page 117 and 118: WIC services include providing nutr
Page 119 and 120: As soon as the member knows they wi
Page 121 and 122: 3) by the director to the employee
Page 123 and 124: In addition to the previously state
Page 125 and 126: Prior Authorization The CHIP Perina
Page 127 and 128: Appendix A Universal Referral/Prior
Page 129: Appendix B Consent for Disclosure 1
Page 133 and 134: EXAMPLE FORM PRIVATE PAY AGREEMENT
Page 135 and 136: Appendix D Clinical Practice Guidel
Page 137 and 138: Appendix D - Continued Clinical Pra
Page 139 and 140: Appendix D - Continued Clinical Pra
Page 141 and 142: RATIONALE: Attention-Deficit/ Hyper
Page 143 and 144: Appendix G Urinary Tract Infections
Page 145 and 146: Follow-up • Follow-up urine cultu
Page 147 and 148: RATIONALE: Prevention of RSV Illnes
Page 149 and 150: RATIONALE: Treatment of Group A Str
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PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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