HomeMy WebLinkAbout20042543.tiff CORRESPONDENCE RESPONSE
DEPARTMENT OF5/226/ ,&_i-Li
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BOARD OF COUNTY COMMISSIONERS
PHONE (970) 336-7204, Ext. 4200
FAX: (970) 352-0242
WIND
P. O. BOX 758
GREELEY, COLORADO 80632
C.
COLORADO
August 13, 2004
Sandra Chavez
'1830 5th St
Greeley CO 80631
Dear Ms. Chavez:
Thank you for contacting the Board of County Commissioners. As part of the review of your
concerns,the Weld County Paramedic Services was contacted for additional information. The
billing staff and Office Manager at the Paramedic Services believed that they have been
addressing your questions and concerns, and they have provided assurances that they will
continue to do so.
Please continue to communicate your questions and concerns to the billing staff, and they will
make sure that your account is managed professionally. You may continue to make monthly
payment as you have been. The office billing staff has set your mother's account up with a
payment plan and adjusted it to a lower amount of$10.00 dollars per month. A payment needs
to be made every thirty days to keep the account in good standing.
If you have any additional questions or concerns about this matter, please feel free to contact the
Director of the Weld County Paramedic Services, Dave Bressler, at 353-5700, extension 3211.
Mr. Bressler would appreciate the opportunity to discuss your mother's case and any other
remaining concerns you may have.
Sincerely,
BOARD OF
\}
COUNTY COMMISSIONERS
Robert D. Masden, Chair
Weld County Commissioners Office
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Apri 23,2004
To Whom It May Concern:
I am writing in regards to the income of David Chavez. Mr. Chavez is currently employed by Pm
Landscape & Nursery, Inc. and has been for a number of years. Al this time he receives a weddy
salary of$375.00 per week. Mr. Chavez is a valuable asset to the company, should there be any
question in regards to this matter please fed free to contact me personally at the office Moday-Friday
between eight and five.
Sincerely,
presiaeM
Pro ,. .: , _ : ursery,Inc.
WELD COUNTY PARAMEDIC SERVICES
:411)(t14 1121 M Street • Greeley CO 80631-9587
(970)353-5700 Ext. 3200
liVe (970)304 6408 Fax
COLORADO
Patient Name: Gloria S Rocha Run Number: 04-3187
Notice Date: April 22,2004 Date of Transport: 04/17/2004
Due Date: Upon Receipt
From: 183O5th St, Greeley, Co 80631
Gloria S Rocha
1830 5th St To: North Colorado Medical Center
Greeley CO 80631-1807
Primary Payor: Bill Patient
Contractual
Description Qty,; Price Allowance Amount
A0427 Als Emergency .Base Rate 1 . ..966.00 0.00 966.00
A0425 Mileage 2 30.00 0.00 30.00
A0422 Oxygen 1 60.00 0.00 60.00
93041 Cardiac Monitor 1 75.00 0.00 75.00
A0394 Iv/Io Therapy 1 60.00 0.00 60.00
PLEASE PAY THIS AMOUNT:' $1,191.00
Please pay the balance due on this invoice. If you have insurance which covers this service, please forward a copy
of your current insurance card to our office. If you have questions or to make payment arrangements, please
contact our office.
RPPWELD011
X X X Cut Along Dotted Line And Return With Remittance in Envelope Provided X X X
IF PAYING BY CREDIT CARD,FILL OUT BELOW
CHECK CARD USING FOR PAYMENT O ®
1121 M Street °.,„ IT.
Greeley CO 80631-9587 CARD NUMBER AMOUNT
ADDRESS SERVICE REQUESTED SIGNATURE EXP.DATE
REMIT TO:
April 22, 2004
WELD COUNTY PARAMEDIC SERVICES
04-3187-1 231344 28711 1121 M Street
Greeley CO 80631-9587
Ilrrlrllrrrrllrrrrllrrrrllrrrlllrrlrllrrrlrrrlrrllrll till Ilrrlrllrrrrllrrrrll111'11lrlrrrlrlrlrrlrlrrrl111111III111,.rl
Gloria S Rocha
1830 5th St
Greeley CO 80631-1807
Patient Name: Gloria S Rocha
Run Number: 04-3187
Amount Enclosed: S
1121 M Street HIPAA Nonce or Privacy Poetises
Greeley CO 80631-9587 Weld County Paramedic Services
Effective Dab:Ap114,2003
•
ADDRESS SERVICE REQUESTED Tuts notice describes bow heath irdomtatton about you my be need and disclose
and bow you can get amp to this infatuation.
Pion review N carefuNv.
I you have any questions about this notice,please contact David W.Bressler,Privacy
April22, 2004 Officer atl-g7a35a-570o extension 13211.
OUR PLEDGE REGARDING HEALTH INFORMATION
We understand that health information about you and your health core a personal.We
#BWNHRMD 231344 28711 are°omitted to protecting health intonation about you.We create a record of the care
#0422 1723 0028 7114# 04-3187-1 and senices you receive from us.We need this record b provide you with quality owe
and to comply with certain legal requirements.This notice apples to al of the records of
II,nInIlliallrunIIuelliehillaliIIauIn,InII,II lie' your cat generated by this health care practice,whether made by your personal doctor or
Gloria S Rocha others waking in this office.This notice w4 M you about the ways in which we may use
1830 5th St and disclose health infomaan about you.We also describe your nights to the health
Greeley CO 80631-1807 inlomatio^era heap about you,and describe morn obligation era have regarding the
use and disclosure d your heath infmn W ion.
We we required by law to:
• Make sure that health intamadon that identifies you is kept private.
• Gin you this notice of our legal duties aid privacy practices with respect b health
information about you.
• Follow the bmvc of the notice Mats currently in effect
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
The fdbang categories dascribe°Meant ways than we use and disclose heath
ihrmaion.
For each category of uses or disclosures we will explain what we mean and by to give
son*exarples.Not every use ordiscosure in a category wig be rated.Howev r.al of
ate wall we we permatbd to use and disclose information will fat elfin one of the
cabgorbs.
For Treatment We nay use health information about you to provide you with health care treatment or services.We may disclose health information about you to doctors,nurses,technicians health students,a other personnel who
are involved in tatting care of you.They may work at our offices,at the hospital it you we hospdaleed under our supervision,or al another doctor's office,lab,phwniiaoy,or other health care provider to whom we may refer you for
consultation,to take x-rays,bpalace lab lests to have prescriptions filed or for other treatment purposes.For example,a doctor beating you heaths leg may need to know If you have diabetes because dabeles may slow the
healing process.In addition,the doctor may need blel the dietitian at the hospital if you have diabetes no that we can arrange for appmpriek meals.We may also dialog?Math inbrmaton about you to an entity assisting in a
disaster relief effort so that your family can be rotted about your condpon,slats and location.
For Payment We may use aid disclose health information abed you so that the treahnent and services you receive torn us nay be billed to and payment collected from you,an insurance cOmpany,aatird parry.For example,
we may need to give your health plan infmrhaon about your office ask so your health plan will pay us or reimburse you for the visit We may Aso tell your heath plan about a vestment you we going to receive to obtain prior
approval or to determine whether your pion will cover the treatment
For Health Care Operations:We may use and disclose health information about you for operations of our health core practice.These uses and disclosures we necessary to run our practice and make sae that al of our patients
receive quaky ewe.For exarple,we may use heath information to levee our treatment and services and to evaluate the performance of our staff in owing for you.We may also combine health information about many patentt
decide what additional services we should offer,what services we not needed,whether certain new trepnents we effective,or to cmpam how we we doing with others and be see where we can make improvements.We may
remove information that identifies you torn Nis set at heats information so others may use ark study health care delivery without knowing the identity slow specific patients.
Research:Under certain circumstances,we nay use and disclose health inMmation about you for research purposes.For example,a research project may involve comparing the health and recovery or all patients who received
one medication to those who received another,for the sane condign.Al research project,however,we subject to a special approval process.This process evaluates a proposed research project and its use d health information,
tying to balance the research needs with patents'need for privacy of tear heath information.Before we use or disclose heath information for research,the project will have been approved through this research approval process:
but we may disclose health information about you to people prepaing to conduct a research project For example,we may help potential researchers look for patents with spedtc health needs,slang as the beat information they
review does not leave our facility.We will almost always ask for your specific permission if the researcher will have access to your name,address,a other information that reveals who you are,or will be involved in your care.
Organ and Tissue Dorados U you we an organ dono,we may release heath information to organizations that handle organ procurement or organ,eye or tissue trwaplantaoon a to en organ donation bank as necessary to
facilitate organ a tissue donation and transplanfaton.
As Required By Law:We will disclose health information about you when required to do so by federal,slate,or kcal law.
To Avert a Serious h a tto Health or SaMy:We may use and disclose health information about you when necessary to prevent a serious threat your heats and safety or the health and safety of the public or another person.
My disclosure,however,would only be to..•,.au able to help prevent the threat
MMery and Veterans:If you we a mentor of the armed trees or separated/discharged from military services,we may release heal information about you as retied by military command authorities or the Departmental
Veterans Affairs as may to apaahle.We may es:orelease hit info:maim about foreign pithy Ps Walla kuw PUP µ upriabbeign military authorities
Workers'Cmpsnsalbn:We may release health information about you for workers'compensation or similar pograns.These programs provide benefits for work-related injuries or press.
Public Health Rift:We may disclose heats information about you for public health activities.
These activities genrsy include the taxing:
To prevent a contra disease,injury or disadly.
To report bits aid deaths.
To report child abuse or neglect
To report reactions to medicaans or problems with products.
To notify people of recalls of products they may he using.
To notify a person wee may have been exposed b e disease or may be al risk for contracting a spreading a disease a aodian.
To notify the appropria a government authority fee believe a patient has been the victim or abuse,neped,ordarestc violence.We wit only make this disclosure if you agee co when required a authorized by law.
Heath Ovaigia Activities:We may disclose health intimation b a heath oversight agency for actvites authorized by law.These oversight activities include,bexample,audits,investigations,inspections and icensure.These
activities we necessary brew government to monitor the heath ewe system,government program,and compliance with civil rights Ian.
Lawsuits and Disputes:If you we involved in a lawsuits a dipute,we may disclose health information about you in response to a Gouda administrative order.We may also disclose health information abut you in response to
subpoena discovery request or other IawAd process by someone elm involved in the dispute,but only if efforts have been male to tell you about the request or to obtain an order protecting the taxman motion requested.
Law Erdaumnt We may release heats information if asked to do so by a law enforcement official:
• In response to a mud order,subpoena,warrant,summons or similar process
• To identify a hale a suspect hginve,matadal wiiess,a missing person
• Mote the victim d a trine I.under certain Sled cicustansas,we are unable to obtain the person's agreement
• About adeelhwebelieve may bey*resat d aiming conduct
• About manor conduct a our b3ly ..
• In emergency escnnstsrees to report a crime;the location of the Mine a victims;a the iderdty,description,a location of the person who committed the Mire
Caen,Health Examiners and Funeral Models:We may release heath intimation to a coroner or health examiner.This may be necessary,for exarple,to identify a deceased person or determine the cause of death.We
may also release balm information about patients to funeral*actors as recessay b nary out their dupes.
National Sanity and lrfigence Activities:We may release health information bout you to authorized federal officials for lntefgence,counwriMeggence,and other nanona security atEvites authorized by law
Protective Suvias for the President and Others:We may disclose health tmation about you to authorized fedora officials so they may provide protection to the President ober authoring persona or foreign heads a state or
caned spacial beesigaions.
Inmates:If you are an inhere of acorrectiorW institution or under the custody of a law enforcement MOM,we may release hand Infarrmtun about you to the correchona institution or law enticement official This release would
be necessary(1)for the institution to provide you with band care;(2)to protect your health and safety orate health and safety of others;a(3)bathe sally and security tithe corrections imitation.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the bloeimg tights regarding heath intimation we maintain about you.
Right to Inspect and Copy:You have the right to inspect and copy health inbmuhbn that may be used lo make decisions about your care.Usually,this includes health and billing records.
To inspect and copy heath information that may be used to nuke decisions about you,you must submit you request in wring to David W.Bressler,Privacy Officer If you request a copy of to information.we may charge a fee for
the tat of coping.mating a other supplies and services associated with your request
We may deny you request to inspect and copy in certain very lifted circumstances.N you are denied access b heath information,you may request that the denial be reviewed.Another licensed health care professional chosen by
our pratice at review your request and the stria.
The person conducing the review will not be the person who denied you request We col comply with to outcome of the review.
Right to Amend:N you feel that health infatuation we have about you is incorrect or incomplete,you may ask es to amend the incarnation.You have the right to request an amendment for as long as we keep the information.To
request an amendment your request nest be made in wring,subnibd to David W.Bressler,Privacy Officer.and must contained on one page of paper kgity hnMnitten a toed in at least 10-punt font size.In audition.you
nest provide a reason that supports your request bran amendment
We may deny your request for an arremkrent if it is not in wring or des not include a reason to support the request In addition,we may deny your request if you ask us to amend information that
• Was not created by us,unless the person or entity Mat created the informal&is no longer amiable to make the amendment
• Is not pat tae heath inbmnffion kept by arbour practice
• Is not pat dine intonation,stick you world be permitted to inspect and copy
• Is curate and complete
My amendment we make to your heaths information al be disclosed to those site whom we disclose information as previously specified.
Right be an Accounting of Disclosures:You have the right to requests list accounting Many disclosures df your heats information we have made,except for uses and disclosures for trabnent payment and health care
operations,as previously described.
To request this Odd Manures,you mud submit your request m writing to David W.Bracer,Privacy Otter.Your request must stab are paMd,which may not be longer than six yeas and may not include dies lobe Apt
14,2003.The fast fist you regent within a 12-month period will to bee.For additional lists,we may charge you for the cab of providing the but We veil nobly you of the cost involved aid you may choose to withdraw or modify your
request al that time before any costs are incurred.We will marl you a tic of tscbsues in paper form within 30 demotion request or nobly you h we as unable to supply the fist within thalami period and by what date we can
supply the list butts date wit not exceed a total dfi0 days tom the date you made the request.
Right to Request Restrictions:You have the right to request a resktoon a knAeson on the health Information we use a disclose abed you for treatment payment,or health care operations.You am have the right to request a
Foil on the health Intimation we disclose about you to someone who is involved in per care or the payment for your sae,such as a family mentor a mend.For exaple,you could ask that we restrict a specified nurse from use of
your information,a thane not disclose'animation to you spouse about a surgery you had.
Wear*not required to agree to your request for rublcdohs Kits not feaNde for us to ensue ow compliance or Sieve N WN negativity input the care we may provide you.Ifwe do agree.we will army with your
request mess the int maonn is needed to provide you amegency treanent To request a restriction,you must mike your request in wring to David W.Bressler,Privacy Officer.In you request you must let us what information
you wan limit and to wham you want the knitted*for example,use of any iaanaion by a specified nurse,a disclosure of speeded sugary to you spouse.
Right to Request Confidential Communications:You have to right to request that we cannurkcale at you about heath meters in a certain way or at a certain location.For example,you can ask that we only contact you at
coat a by mail toe post office box.
To request confidential communications,you must make your request in wring to David W.Bressler.Privacy Officer.We we not ask you the reason for your request We Mil accommodate at reasonable request.Your request
mud specify how or where you wish b te contacted.
Right to a Paper Copy of This Notes:You have the right Main a paper copy of this notice at any time.To San a copy,please request if horn David W.Bressler Privacy Officer.
You may also ask that a copy of this nice be senthough electronic mail.Kwe know that the electronic message has failed to be delivered,a paper copy oft the notice win be provided.
You may also obtain a copy of this native at our Web site,hlp:IMwweo.coati.co.usedepatnenls/paameddc_semceslanblare.hby.
Even f you have received a notice electronically,you and retain the right to receive a paper copy upon request
N the fat service delivery is deemed eecbgnbaly.other than by telephone,we provide electronic notice Inthe sax medium,aubmNaty and contemporaneously In response to afist motet for seance.
CHANGES TO THIS NOTICE
Wereseae to right t change this notice.We reserve to right to make the revised or changed notice effective for health Manton we already have about you as wont as an/ordination we receive ni the lyMre. We wui post
copy ate current notice in our teeny.TM notice MI contain onto first page,in the top igMhand corner,the effective dam.In addition,each tree you register for babnent or health are services,we will der you a copy of the
curer matte in effect
COWtANITS
Ifyou believe your privacy rights have been violated,you may file a complant nth us or with the Secretary of the Departmnt of Health and Human Services.To be a complaint with us,contact David W.Bressler,Privacy Officer.Al
complaints must he submitted in wring.You will not he penalized for Ming a complaint
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health Information red covered by its notice ate lam that apply to us with be male only with your written pervasion.K you provide us permission to use or disclose health information about you,you
may revoke that partition,in wilting,any lima If you revoke your pernissbn,we will no longer use a disclose heats intonation about you for the reasons covered by your written authorization.You understand that we are
unable to lake back any disclosures we have amen made with your permission,and that we are required to retain our records tithe care that we provided to you.
ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE
We we request that you sign a separate form or notice ackmwledging you have received a copy of this nice.0you choose,or are not able to sign,a staff member MN sign their mare,date.This acknowledgement will De filed with
your account record.
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