Medical Information Release Consent Form In Contra Costa

State:
Multi-State
County:
Contra Costa
Control #:
US-00459
Format:
Word; 
Rich Text
Instant download

Description

This Consent to Release of Financial Information authorizes all banks, financial institutions, businesses, employers, credit reporting agencies and any other businesses to which this person is indebted or have assets located, to provide information concerning his/her finances and assets, without liability, to the person or entity named in this Consent form. This form is applicable in any state.

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FAQ

1-877-661-6230 Call if you have a medical problem or if you have a medical question.

Submitting Claims The claim submission timeframe for Contra Costa Health Plan is 180 days from the date of service, or primary explanation of benefits (EOB), for both contracted and non-contracted providers. Claims received after 180 days will be denied for untimely filing.

Submitting Claims The claim submission timeframe for Contra Costa Health Plan is 180 days from the date of service, or primary explanation of benefits (EOB), for both contracted and non-contracted providers. Claims received after 180 days will be denied for untimely filing.

Ways to File a Grievance or Appeal Call Member Services, Monday – Friday, 8am – 5pm at 1-877-661-6230 (Option 2) (TTY 711). If you have a clinically urgent issue, you can also reach our 24-Hour Nurse Advice Line at 1-877-661-6230 (Option 1).

Call 800-495-8885 800-495-8885 is the central number for making appointments at our county health centers. For same-day or next-day appointments, it's best to call as early as possible.

CCHP is the primary managed-care provider for Medi-Cal beneficiaries in Contra Costa and we also manage smaller plans for county employees and IHSS homecare workers. Our members have access to hundreds of family medicine doctors and specialists in our provider networks.

Call 800-495-8885 800-495-8885 is the central number for making appointments at our county health centers. For same-day or next-day appointments, it's best to call as early as possible.

Contra Costa Health Plan (CCHP) follows all applicable Federal and State laws in the use of Telemedicine services to provide consultation, access and quality of care to our Medi-Cal and Commercial members.

CCHP is the primary managed-care provider for Medi-Cal beneficiaries in Contra Costa and we also manage smaller plans for county employees and IHSS homecare workers. Our members have access to hundreds of family medicine doctors and specialists in our provider networks.

Call the 24/7 ACCESS Line at 1-888-678-7277. Anyone can call for themselves or someone they care about.

More info

By filling out the form below, you give the County of Contra Costa ("County") the absolute right and permission to the unlimited use of your image and likeness. Our Release of Medical Information (ROMI) Department helps you complete forms for disability or medical leave and provide required medical information.Release of Information: This form will allow your clinician to speak with other providers or concerned parties which you designate. Submit a medical request online, or find information about how to request medical care from Kaiser Permanente. This law requires that you sign a consent form authorizing: (1). A consent form that includes a request for medical records is valid for 90 days from the date of signature. Information and links to various college resources for college employees including faculty, staff and management. A woman reports that her STD test results were posted to Facebook after a worker at a Contra Costa County hospital gained access to her medical records. To get started, sign in to our website . Select My Care, and then select Health Records.

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Medical Information Release Consent Form In Contra Costa