Office Visits (other than Preventive Care Services) This plan covers office and clinic visits to diagnose or treat a sickness or injury. Office visit copayments differ depending on the type of provider you see. This plan covers physician visits in your home if you have an injury or illness that: • confines you to your home; or • requires special transportation; and • because of this injury or illness, you are physically unable to travel to the provider’s
Consent to Transportation and Medical Treatment I consent to the use of first aid treatment and the use of generic and over-the-counter medications and treatments as directed by manufacturer labels, whether administered by the Released Parties or first aid personnel. In an emergency, I understand the Released Parties may try to contact the individual listed below as an emergency contact. If an emergency contact cannot be reached promptly, I hereby authorize the Released Parties to act as an agent for me to consent to any examination, testing, x-rays, medical, dental or surgical treatment for me as advised by a physician, dentist or other health care provider. This includes, but is not limited to, my assessment, evaluation, medical care and treatment, anesthesia, hospitalization, or other health care treatment or procedure as advised by a physician, dentist or other health care provider. I also authorize the Released Parties to arrange for transportation of me as deemed necessary and appropriate in their discretion. I, the Volunteer, do hereby release, forever discharge and hold harmless the Released Parties from any liability, claim, demand, and action whatsoever brought by me or on my behalf which arises or may hereafter arise on account of any transportation, first aid, assessment, care, treatment, response or service rendered in connection with my Activities with any of the Released Parties. If the Volunteer is less than 18 years of age, the parent(s) having legal custody and/or the legal guardian(s) of the Volunteer also hereby release, forever discharge and hold harmless the Released Parties from any liability, claim, demand and action whatsoever brought by such volunteer or on his/her behalf which arises or may hereafter arise on account of the decision by any representative or agent of the Released Parties to exercise the power to transport, administer first aid, and consent to assessment, examination, x-rays, medical, dental, surgical or other such health care treatment as set forth in the Parental Authorization for Treatment of, and Travel With, a Minor Child.
CONTRACTOR California Department of General Services Use Only CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.) BY (Authorized Signature) DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING ADDRESS STATE OF CALIFORNIA AGENCY NAME BY (Authorized Signature) DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING Exempt per: ADDRESS Exhibit A Project Summary & Scope of Work
Department of Health and Human Services An employee notified of a positive controlled substance or alcohol test result may request an independent test of their split sample at the employee’s expense. If the test result is negative, the Employer will reimburse the employee for the cost of the split sample test. An employee who has a positive alcohol test and/or a positive controlled substance test may be subject to disciplinary action, up to and including dismissal, based on the incident that prompted the testing, including a violation of the drug and alcohol free work place rules.
MANAGEMENT OF EVALUATION OUTCOMES 12.1 The evaluation of the Employee’s performance will form the basis for rewarding outstanding performance or correcting unacceptable performance.
Education and Prevention 6.1 The policy will be discussed and put forward for adoption on site at a meeting of all workers.
Workplace Violence Prevention and Crisis Response (applicable to any Party and any subcontractors and sub-grantees whose employees or other service providers deliver social or mental health services directly to individual recipients of such services): Party shall establish a written workplace violence prevention and crisis response policy meeting the requirements of Act 109 (2016), 33 VSA §8201(b), for the benefit of employees delivering direct social or mental health services. Party shall, in preparing its policy, consult with the guidelines promulgated by the U.S. Occupational Safety and Health Administration for Preventing Workplace Violence for Healthcare and Social Services Workers, as those guidelines may from time to time be amended. Party, through its violence protection and crisis response committee, shall evaluate the efficacy of its policy, and update the policy as appropriate, at least annually. The policy and any written evaluations thereof shall be provided to employees delivering direct social or mental health services. Party will ensure that any subcontractor and sub-grantee who hires employees (or contracts with service providers) who deliver social or mental health services directly to individual recipients of such services, complies with all requirements of this Section.
Musculoskeletal Injury Prevention and Control (a) The Hospital in consultation with the Joint Health and Safety Committee (JHSC) shall develop, establish and put into effect, musculoskeletal prevention and control measures, procedures, practices and training for the health and safety of employees.
Fraud, Waste, and Abuse Contractor understands that HHS does not tolerate any type of fraud, waste, or abuse. Violations of law, agency policies, or standards of ethical conduct will be investigated, and appropriate actions will be taken. Pursuant to Texas Government Code, Section 321.022, if the administrative head of a department or entity that is subject to audit by the state auditor has reasonable cause to believe that money received from the state by the department or entity or by a client or contractor of the department or entity may have been lost, misappropriated, or misused, or that other fraudulent or unlawful conduct has occurred in relation to the operation of the department or entity, the administrative head shall report the reason and basis for the belief to the Texas State Auditor’s Office (SAO). All employees or contractors who have reasonable cause to believe that fraud, waste, or abuse has occurred (including misconduct by any HHS employee, Grantee officer, agent, employee, or subcontractor that would constitute fraud, waste, or abuse) are required to immediately report the questioned activity to the Health and Human Services Commission's Office of Inspector General. Contractor agrees to comply with all applicable laws, rules, regulations, and System Agency policies regarding fraud, waste, and abuse including, but not limited to, HHS Circular C-027. A report to the SAO must be made through one of the following avenues: ● SAO Toll Free Hotline: 1-800-TX-AUDIT ● SAO website: xxxx://xxx.xxxxx.xxxxx.xx.xx/ All reports made to the OIG must be made through one of the following avenues: ● OIG Toll Free Hotline 0-000-000-0000 ● OIG Website: XxxxxxXxxxxXxxxx.xxx ● Internal Affairs Email: XxxxxxxxXxxxxxxXxxxxxxx@xxxx.xxxxx.xx.xx ● OIG Hotline Email: XXXXxxxxXxxxxxx@xxxx.xxxxx.xx.xx. ● OIG Mailing Address: Office of Inspector General Attn: Fraud Hotline MC 1300 P.O. Box 85200 Austin, Texas 78708-5200
How to Obtain Prescription Drug Preauthorization To obtain prescription drug preauthorization, the prescribing provider must submit a prescription drug preauthorization request form. These forms are available on our website or by calling the number listed for the “Pharmacist” on the back of your ID card. Prescription drugs that require preauthorization will only be approved when our clinical guidelines are met. These guidelines are based upon clinically appropriate criteria that ensure that the prescription drug is appropriate and cost- effective for the illness, injury or condition for which it has been prescribed. We will send you written notification of the prescription drug preauthorization determination within fourteen (14) calendar days of the receipt of the request. How to Request an Expedited Preauthorization Review You may request an expedited review if the circumstances are an emergency. Due to the urgent nature of an expedited review, your prescribing provider must either call or fax the completed form and indicate the urgent nature of the request. When an expedited preauthorization review is received, we will respond to you with a determination within seventy-two (72) hours or less. If we deny your request for preauthorization, you can submit a medical appeal. See Appeals in Section 5 for information on how to file a medical appeal. Formulary Exception Process When a prescription drug is not on our formulary, you can request that this plan cover the drug as an exception. To request a formulary exception, complete a Coverage Exception form (located on our website), contact our Customer Service Department, or have your prescribing provider submit a request for you. We will respond to you with a determination within seventy- two (72) hours following receipt of the request. For standard exception reviews, if the exception is approved, we will cover the prescription drug for the duration of the prescription, including refills. How to Request an Expedited Formulary Exception Review You may request an expedited review if a delay could significantly increase the risk to your health or your ability to regain maximum function, or you are undergoing a current course of treatment with a drug not on our formulary. Please indicate “urgent” on the Coverage Exception form or inform Customer Service of the urgent nature of your request. We will respond to you with a determination within twenty-four (24) hours following receipt of the request. For expedited exception reviews, if the exception is approved, we will cover the prescription drug for the duration of the exigency. For both standard and expedited exception reviews, if we grant your request for a formulary exception, the amount you pay will be the copayment at the highest formulary tier in your plan. Other applicable benefit requirements, such as step therapy, are not waived by this exception and must be reviewed separately. If we deny your request for a formulary exception, we will notify you with information on how to appeal our decision, including external appeal information.
