<TiTle> <p>Please use the links below to download the following forms as PDF files:</p> <p><a href="#www#doctorshcp#com/wp-content/uploads/HRA_Short_English#pdf" target="_blank" rel="noopener noreferrer">Health Risk Assessment (English)</a> / <a href="#www#doctorshcp#com/wp-content/uploads/HRA_Short_Spanish#pdf" target="_blank" rel="noopener noreferrer">Health Risk Assessment (Spanish)</a></p> <p>Doctors HealthCare Plans is focused on providing the right care to  help your patients (our members) stay as healthy as possible# The Health Risk Assessment (HRA) or Health Risk Assessment Tool (HRAT) is used to survey your patients (our members) and obtain information about their health and lifestyle#  We can then use that information to jointly develop personalized care plans#</p> <p>HRAs should be completed within 90 days of enrollment and must be conducted annually or periodically as needed#  <strong><em>Completed HRAs should be faxed to Doctors HealthCare Plans at (786) 279-8208#</em></strong></p> <p><a href="#www#doctorshcp#com/wp-content/uploads/MRPD_Form#pdf" target="_blank" rel="noopener noreferrer">Medication Reconciliation Post-Discharge (MRP) Form</a></p> <p>Medication Reconciliation can prevent adverse drug effects events, especially for people with multiple prescription medications and post-discharge#  A potentially negative occurrence can occur if medications are not used and monitored appropriately#</p> <p><a href="/wp-content/uploads/Part_D_Physician_Coverage_Determination#pdf" target="_blank" rel="noopener noreferrer">Part D ��� Physician ��� Coverage Determination Form</a></p> <p>A coverage determination is necessary when a formulary medication requires a Prior Authorization, Step Therapy and/or Quantity Limit#  Exceptions, such as Tiering exceptions and Formulary exceptions, also require coverage determination# A tiering exception is when you believe a member should get a drug at a lower cost share# A formulary exception is when you believe a member needs a drug that is not on the plan���s formulary# All exception requests must be supported by a statement by the prescribing physician#  Standard Coverage Determinations will be made within 72 hours# Expedited Coverage Determinations will be made within 24 hours#</p> <p><a href="/wp-content/uploads/2018/09/Provider-Compliance-Requirements-Attestation-Form#pdf" target="_blank" rel="noopener noreferrer">Provider Compliance Requirements Attestation Form</a></p> <p>The Doctors HealthCare Plans, Inc# Provider Compliance Requirements Attestation form is completed by Participating Providers upon conclusion of the online interactive web-based compliance training modules on the CMS Medicare Learning Network (MLN)#  Submission of the form attests to the provider���s completion of the General Compliance Training and Fraud, Waste and Abuse training#   Completed forms must be submitted to the Department of Provider Relations for record keeping#</p> <p><a href="#www#doctorshcp#com/wp-content/uploads/Request_Claim_Review#pdf" target="_blank" rel="noopener noreferrer">Request for Claim Review Form for participating providers</a></p> <p>Claim disputes must be submitted on the Request for Claim Review Form within 120 days from the date of the Remittance Advice# Supporting documentation must include the Remittance Advice; additionally, clinical records, progress reports, CMS Guidelines, etc#, may be included# Incomplete forms will be returned to sender#  Allow 60 days for processing#</p> <p>Please submit the <a href="#www#doctorshcp#com/wp-content/uploads/Request_Claim_Review#pdf" target="_blank" rel="noopener noreferrer">Request for Claim Review Form</a> to:</p> <p>Doctors Healthcare Plans, Inc#<br> Attn#: Provider Inquiry Unit<br> 2020 Ponce de Leon Blvd, PH 1<br> Coral Gables, FL 33134</p> <p><strong>Waiver of Liability for Non-Participating Providers / Claim Appeals</strong></p> <p>Please submit claim request in writing together with a Waiver of Liability within 60 days of the Remittance Advice# Supporting documentation may include the Remittance Advice, clinical records, progress reports, CMS Guidelines, etc# Allow 60 days for processing# You may download the Waiver of Liability from: <a href="#www#cms#gov/Medicare/Appeals-and-Grievances/MMCAG/Notices-and-Forms#html" target="_blank" rel="noopener noreferrer" class="exitNotifierLink">#www#cms#gov/Medicare/Appeals-and-Grievances/MMCAG/Notices-and-Forms#html</a> or (<a href="#www#doctorshcp#com/wp-content/uploads/waiver_of_liability_statement#pdf">Waiver of Liability</a>)</p> <p>Please submit the appeal to:</p> <p>Doctors Healthcare Plans, Inc#<br> Attn: Grievance & Appeals <br> 2020 Ponce de Leon Blvd, PH 1<br> Coral Gables, FL 33134</p> <p><a href="#www#doctorshcp#com/wp-content/uploads/Request_for_Prior_Authorization_of_Benefits_Services_Form#pdf" target="_blank" rel="noopener noreferrer">Request for Prior Authorization of Benefits / Services Form</a></p> <p>Certain benefits and services require prior authorization; Prior authorization must be obtained from the Plan by the requesting Provider either on-line on the Provider Portal or using the <a href="#www#doctorshcp#com/wp-content/uploads/Request_for_Prior_Authorization_of_Benefits_Services_Form#pdf" target="_blank" rel="noopener noreferrer">Request for Prior Authorization of Benefits / Services Form</a># All informational elements must be completed legibly to the extent required to allow for timely processing#</p> <p>Expedited or Urgent requests for prior authorization attests that the PCP certifies that by applying the review time frame for standard authorization requests, the standard review time may seriously jeopardize the member���s life, health, or ability to regain maximum function#  For verification of those benefits or services requiring prior authorization, provider must verify the member���s eligibility and benefits online or by calling Provider Relations at (305) 422 ��� 9300 and selecting, Option 3#</p> <p><a href="#www#doctorshcp#com/wp-content/uploads/SNP_MOC_Evaluation#pdf" target="_blank" rel="noopener noreferrer">SNP MOC Training Attestation and Evaluation Forms</a></p> <p>Providers are required to undergo SNP Model of Care Training# This training provides an overview of SNPs and the responsibilities physicians and other participating health care providers have for their SNP patients#</p> <p><a href="#www#doctorshcp#com/wp-content/uploads/Bills_of_Rights#pdf" target="_blank" rel="noopener noreferrer">Bills of Rights</a></p> <p>Florida law requires that your healthcare provider or healthcare facility recognize your rights while you are receiving medical care and that you respect the healthcare providers��� or facility���s right to expect certain behavior on the part of patients#</p> <p>H4140_PRforms_C<br> Last Updated: 7/30/2019</p> ----sR;wnmr;bpc </div><!-- #entry-content --> <footer class="entry-footer"> </footer><!-- #entry-footer --> </article><!-- #post-## --> </main><!-- #main --> </div><!-- #primary --> <!-- Do the right sidebar check --> </div><!-- #closing the primary container from /global-templates/left-sidebar-check#php --> </div><!-- #row --> </div><!-- Container end --> </div><!-- Wrapper end --> ----vA;anpf;dyo <div class="wrapper" id="wrapper-footer"> <div class="container"> <div class="row"> <div class="col-md-12"> <footer class="site-footer" id="colophon"> ----NK;ptpg;hzp <div class="site-info text-center"> 2019 �� Doctors HealthCare Plans, Inc# <span class="sep"> </span> <br> Mailing Address: 2020 Ponce de Leon Blvd, Suite PH 1, Coral Gables Florida, 33134 <br><br>Please call Member Services at 786-460-3427 or 833-342-7463 (TTY: 711), 7 days a week 8 a#m# to 8 p#m# <br><br>Discrimination is against the law: Doctors HealthCare Plans, Inc# complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or religion# See our Non-Discrimination Notice Requirements (Section 1557 of the Affordable Care Act of 2010) with the Multi-language interpreter service# <br><br> <a href="/wp-content/uploads/NND_Multilanguage_English#pdf" target="_blank">Non-discrimination notice ��� English</a> | <a href="/wp-content/uploads/2018/09/NND_and_Multi-language-Spanish#pdf" target="_blank">Non-discrimination notice ��� Spanish</a> <br>Important Links and Information: <a href="#ahca#myflorida#com/contact/index#shtml" target="_blank" class="exitNotifierLink">AHCA</a> | <a href="#www#ncqa#org/tabid/59/Default#aspx" target="_blank" class="exitNotifierLink">HEDIS & NCQA</a> | <a href="/wp-content/uploads/2018/09/Notice_of_Privacy_Practices#pdf" target="_blank">Privacy Notice</a> | <a href="#www#medicare#gov/MedicareComplaintForm/home#aspx" target="_blank" class="exitNotifierLink">Medicare Complaint Form</a> | <a href="#www#medicare#gov/claims-and-appeals/medicare-rights/get-help/ombudsman#html" target="_blank" class="exitNotifierLink">Medicare Ombudsman</a> <br><br>Doctors HealthCare Plans, Inc# is an HMO with a Medicare contract# Enrollment in Doctors HealthCare depends on contract renewal# </div> ----sf;xoxk;fom ----QX;ogtk;gzo Office of Human Resources | Benefits Design & Management FMLA Certification of Health Care Provider for Employee���s Pregnancy Page 1 of 3 Revised: August 2010 FMLA CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE'S PREGNANCY Name ____________________________________ Health Care Provider, Address ____________________________________ Please return this form by _________________ to: ____________________________________ ____________________________________ Telephone (____) _______________ FAX: (____) _______________ The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee���s health care provider. Please complete the above return address and Section I before giving this form to your employee. Departments must maintain records and documents relating to medical certifications, re-certifications, or medical histories of employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files. IMPORTANT: UPON RECEIPT FROM HEALTH CARE PROVIDER, FAX A COPY OF THIS COMPLETED DOCUMENT TO: HR DISABILITY & LEAVES PROGRAM MANAGEMENT UNIT AT 480.993.0007 Employee���s name ____________________________________________ Employee���s job title: _____________________________________________________________________________________ Employee���s regular work schedule: __________________________________________________________________________ Department name: _________________________________________________________________________________ Department contact: _____________________________________________________________________________________ Provided to employee on: _____________________________________ (MUST BE PROVIDED) Employee���s essential job functions: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Check if Job Description, with essential functions, is attached: SECTION II: Instructions for Completion by the EMPLOYEE Please type/print your name on the top of page 2 before giving this form to your medical provider. The FMLA permits Arizona State University (���ASU���) to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. If requested by ASU, your response is required to obtain or retain the benefit of FMLA protections. Failure to provide a complete and sufficient medical certification by the date indicated above may result in a denial of your FMLA request. These same obligations apply to any and all ASU requests for periodic re-certification. ENSURE YOUR HEALTH CARE PROVIDER COMPLETES SECTION III & RETURNS THIS FORM BY THE DATE INDICATED SECTION I: Instructions for Completion by DEPARTMENT Office of Human Resources | Benefits Design & Management FMLA Certification of Health Care Provider for Employee���s Pregnancy Page 2 of 3 Revised: August 2010 Employee/Patient Name: ____________________________________________________________________________________ First Middle Last SECTION III: Instructions for Completion by the HEALTH CARE PROVIDER Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as ���lifetime,��� ���unknown,��� or ���indeterminate��� may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking leave. Please be sure to sign the form on the last page. Provider���s name and business address: (Print) ___________________________________________________________ _________________________________________________________________________________________________ Type of practice / Medical specialty: (Print) _______________________________________________________________ Telephone: ( ________ ) _____________________________ FAX :(________) _________________________________ PART A: MEDICAL FACTS 1. Medical diagnosis for which employee/patient is requesting leave: ___________________________________________ Approximate date condition commenced: _______________________________________________________________ Probable duration of condition:________________________________________________________________________ Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? No Yes. If so, dates of admission:__________________________________________________________________________ Date(s) you treated the patient for condition:_____________________________________________________________ ______________________________________________________________________________________________ Will the patient need to have treatment visits at least twice per year due to the condition? No Yes. Was medication, other than over-the-counter medication, prescribed? No Yes. Was the patient referred to other health care provider(s) for evaluation or treatment No Yes If so, state the nature of such treatments and expected duration of treatment: _______________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 2. Is the medical condition pregnancy? No Yes If so, expected delivery date:_____________________________ 3. Use the information provided by the employer in Section I to answer this question. If the employer fails to provide a list of the employee���s essential functions or a job description, answer these questions based upon the employee���s own description of his/her job functions. Is the employee unable to perform any of his/her job functions due to the condition: No Yes If so, identify the job functions the employee is unable to perform: ______________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Office of Human Resources | Benefits Design & Management FMLA Certification of Health Care Provider for Employee���s Pregnancy Page 3 of 3 Revised: August 2010 4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ PART B: AMOUNT OF LEAVE NEEDED 5. Will the employee be incapacitated and absent from work for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery? No Yes. If so, estimate the beginning and ending dates for the period of incapacity:___________________________________________ 6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the employee���s medical condition? No Yes. If so, are the treatments or the reduced number of hours of work medically necessary? No Yes. Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Estimate the part-time or reduced work schedule the employee needs, if any: __________ hour(s) per day; ___________days per week from______________ through ________________________ 7. Will the condition cause episodic flare-ups periodically preventing the employee from performing the job functions? No Yes; Is it medically necessary for the employee to be absent from work during the flare-ups? No Yes. Please explain: ________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Based upon the patient���s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days): Frequency: __________ time(s) Every: __________ week(s) or __________ month(s) Lasting: __________ hour(s) per episode or __________ day(s) per episode ADDITIONAL INFORMATION Attach additional sheets as needed. Please include your provider name and the employee���s name on each page and identify the question number with each of your answers. _______________________________ __________________________________ ____________ Health Care Provider���s Name (Print) Health Care Provider���s Signature Date HEALTH CARE PR<OVIDER: PLEASE RETURN THIS FORM TO THE ADDRESS AT THE TOP OF PAGE 1 BANKING CONDUCT AND CULTURE A Permanent Mindset Change Disclaimer This report is the product of the Group of Thirty���s Steering Committee and Working Group on Banking Conduct and Culture and reflects broad agreement among its participants. This does not imply agreement with every specific observation or nuance. Members participated in their personal capacity, and their participation does not imply the support or agreement of their respective public or private institutions. The report does not represent the views of the membership of the Group of Thirty as a whole. ISBN 1-56708-174-6 Copies of this paper are available for US$25 from: The Group of Thirty 1701 K Street, N.W., Suite 950 Washington, D.C. 20006 Tel.: (202) 331-2472 E-mail: info@group30.org, www.group30.org BANKING CONDUCT AND CULTURE A Permanent Mindset Change Published by Group of Thirty Washington, D.C. November 2018 <p>Please confirm your subscription</p> <p>You've signed up to receive the latest new just click the link below to confirm your subscription:<br /> <br /> <br />If you didn't request this email don't worry - you wont be subscribed if you don't click the confirmation link above!</p> <p><br /> <br /> <br />Copyright .All rights reserved.</p>