State of connecticut health form

    • [PDF File]State of Connecticut

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      State of Connecticut Health Enhancement Program CO-1317 REV PHYSICIAN NOTIFICATION FORM Important Information This form should be used if your provider does not feel it is clinically appropriate for you to have a screening required by HEP, or if you have completed a requirement that is not available in existing claim data.

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    • [PDF File]CSU Health Form - Southern Connecticut State …

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      Jun 23, 2014 · Connecticut)StateUniversity)Student)Health)Services)Form) Page2) PLEASE&RETAIN&A&COPY&OF&THIS&HEALTH&FORM&FORYOURRECORDS&&&&BOTH&SIDES/PAGES&OF&THIS&FORM&MUST&BE ...

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    • [PDF File]Health Enhancement Program - State of Connecticut …

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      State Of Connecticut. Office of the State Comptroller . Healthcare Policy & Benefit Services Division. 55 Elm Street . Hartford, CT 06106-1775 . www.osc.ct. gov. Health Enhancement Program . CO-1316 Revised 5/2012 . COMPLIANCE NOTIFICATION FORM . Important Information . The Health Enhancement Program rewards members for taking steps to help ...

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    • [PDF File]APPOINTMENT OF HEALTH CARE [AGENT] …

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      to someone who knows my values and health care wishes. By signing this appointment of health care representative, I appoint a health care representative with legal authority to make health care decisions on my behalf in such case or at such time. I appoint _____ to be my health care representative.

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    • State of Connecticut Department of Education Health ...

      State of Connecticut Department of Education Health Assessment Record To Parent or Guardian: In order to provide the best educat ional experience, school personnel must understand your child’ s health needs. This form requests information from you (Part 1) which …

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    • [DOCX File]State of Connecticut

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      State of Connecticut. Department of Developmental Services. DEFERRED, LIMITED, and/or DECLINED CARE ... limit or decline preventive and/or recommended health care and identify a plan to advocate for, ... This form is completed by a member of the support team and submitted to the regional Health Services Director /Director of Nursing , Public ...

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    • [DOC File]STATE OF CONNECTICUT

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      Once the paid leave has expired and the employee is on unpaid military leave, the employee may elect to continue the health coverage by paying the full amount of the State’s group rate through the agency payroll office if the duration of the unpaid leave will be less than four (4) months.

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    • [DOC File]STATE OF CONNECTICUT – DEPARTMENT OF SOCIAL SERVICES

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      Instructions for Completing the Health Screen Form W-1506WEB . CONNECTICUT HOME CARE PROGRAM FOR ELDERS ELECTRONIC HEALTH SCREEN FORM. This form is for use by health care professionals only. Please type or write as neatly as possible. Please …

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    • [DOT File]STATE OF CONNECTICUT

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      STATE OF CONNECTICUT. ... including, but not limited to, those of the Occupational Safety and Health Act (“OSHA”), the State of Connecticut Department of Environmental Protection and any relevant Environmental Protection Agency (“EPA”) regulations, guidelines and procedures. ... SEEC FORM 11. NOTICE TO EXECUTIVE BRANCH STATE CONTRACTORS ...

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    • [DOC File]Retirement Health Insurance Open Enrollment ... - Connecticut

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      I hereby authorize the State Comptroller to make deductions, if applicable, from my pension check and/or bill me as necessary for the medical and/or dental insurance indicated above. Retiree/Survivor Signature Date CO-744 HEALTH BENEFITS . State Of Connecticut. Office of the State Comptroller. Healthcare Policy & Benefit Services Division

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    • [DOCX File]UConn Health Personal Service Agreement - Revised 6-2-17

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      Mar 05, 2018 · Contractor agrees that the sole and exclusive means for the presentation of any claim against UConn Health, UCHCFC, the State of Connecticut, and/or their agencies, departments, officers or employees arising from this Agreement shall be in accordance with Chapter 53 of Connecticut General Statutes (Claims Against the State) and Contractor ...

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    • [DOC File]Retirement Health Insurance Open Enrollment ... - Connecticut

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      Sep 15, 2015 · NO Employing Agency: Agency Telephone Number: Preparer’s Name: Preparer’s Signature: (Print Name of Authorized Agency Employee) CO-1314 HEP Enrollment Form . State Of Connecticut. Office of the State Comptroller. Healthcare Policy & Benefit Services Division. Retirement Health Insurance Unit. 55 Elm Street. Hartford, CT 06106-1775

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    • [DOC File]AUTHORIZATION TO USE AND DISCLOSE PROTECTED …

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      State of Connecticut Requirement [For studies involving medical interventions, or questions about any of the following topics use the following paragraph:] The State of Connecticut statutes require that any release of information pertaining to AIDS, HIV infection, behavioral health services, psychiatric care, or treatment for alcohol and/or ...

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    • [DOCX File]Authorization to Use and Disclose Protected Health Information

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      Jun 26, 2020 · State of Connecticut Requirement. Connecticut law requires your specific authorization to use or disclose the sensitive information regarding mental health, HIV tests and related information, and alcohol and/or substance abuse information. I allow the following information to be used and/or disclosed (circle your choice and initial):

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    • [DOC File]Retirement Health Insurance Open Enrollment Application

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      Employing Agency: Agency Telephone Number: Preparer’s Name: Preparer’s Signature: (Print Name of Authorized Agency Employee) CO-744 HEALTH BENEFITS . State Of Connecticut. Office of the State Comptroller. Healthcare Policy & Benefit Services Division. Retirement Health Insurance Unit. 55 Elm Street. Hartford, CT 06106-1775. www.osc.ct.gov

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