ATS Columbus NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this Notice, please contact the Office Manager

1. CLIENT RIGHTS
2. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
   CONFIDENTIALITY
   NO STAFF MEMBER CAN GIVE ANY INFORMATION ABOUT A PATIENT AT ATS COLUMBUS UNLESS THAT PATIENT HAS SIGNED A RELEASE OF INFORMATION. ANY REQUESTS FOR INFORMATION, OUTSIDE OF A SIGNED PATIENT WAIVER, WILL BE SENT TO STACEY BOROWITZ AT DINSMORE LAW FIRM TO ENSURE FULL COMPLIANCE WITH HIPAA AND CFR 42 PART B. SPECIFICALLY,
   1. ALL PROVIDER STAFF ACCESS TO INDIVIDUAL CLIENT RECORDS, TREATMENT INFORMATION, DIAGNOSIS OR OTHER PROTECTED INFORMATION IS LIMITED TO ACCESS AND DISCLOSURE IN ACCORDANCE WITH APPLICABLE FEDERAL, AND STATE LAWS AND REGULATIONS.
   2. NO STAFF DISCUSSION OF PATIENTS OUTSIDE OF PATIENT CARE SPECIFIC DUTIES,
   3. NO USE OF LAST NAMES IN FRONT OFFICE OR LOBBY AT ANY TIME; PATIENTS CALLED BY FIRST NAME ONLY.
   4. ATS COLUMBUS MAINTAINS CONFIDENTIALITY IN ACCORDANCE WITH FEDERAL AND STATE LAW, IN ACCORDANCE WITH HIPPA AND 42 C.F.R. PART 2.
   ALL PROTECTED INFORMATION AT ATS COLUMBUS IS LIMITED TO DISCLOSURE IN ACCORDANCE WITH APPLICABLE FEDERAL AND STATE LAWS AND REGULATIONS.
   5. ALL MEDICAL RECORDS AT ATS COLUMBUS ARE PAPER CHARTS AND ARE LOCKED ONSITE AT THE END OF EACH DAY. ALL PATIENT RECORDS ARE STORED ACCORDING TO FEDERAL AND STATE REGULATIONS.
   6. HIPAA AND CONFIDENTIALITY:
   AS A CONDITION OF EMPLOYMENT AND CONTINUED EMPLOYMENT, EMPLOYEES MUST AGREE TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE AND LOCAL LAWS, ORDINANCES, RULES, REGULATIONS, ORDERS AND GUIDELINES INCLUDING WITHOUT LIMITATION, THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996, AS AMENDED (“HIPAA”). AS SET FORTH ABOVE, HIPAA RELATES TO THE STANDARDS FOR SAFEGUARDING THE CONFIDENTIALLY OF PATIENT’S MEDICAL INFORMATION. ALL EMPLOYEES ARE REQUIRED TO KNOW THESE STANDARDS AND COMPLY WITH THE POLICIES OF THE PRACTICE THAT PERTAIN TO THE PROTECTION OF PATIENT MEDICAL INFORMATION. ATS COLUMBUS PROVIDES HIPAA COMPLIANCE GUIDELINES TO ALL EMPLOYEES, AND ALL EMPLOYEES ARE REQUIRED TO REVIEW AND REMAIN FAMILIAR WITH THOSE GUIDELINES AS A CONDITION OF EMPLOYMENT.
   
   Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.
   Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
   Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.
   Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
   Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.
   We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
   We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.
   We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.
   Other Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object
   We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:
   Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
   Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.
   Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
   Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
   Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
   Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.
   Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred.
   Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
   Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
   Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
   Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
   Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.
   Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
   Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
   Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.
   Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object
   We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgement, determine whether the disclosure is in your best interest.
   Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.
   Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
   2.YOUR RIGHTS Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
   You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.
   Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.
   You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
   Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction in writing.
   You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.
   You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
   You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.

3. CLIENT RIGHTS

• ALL PATIENTS HAVE THE RIGHT TO BE TREATED WITH CONSIDERATION AND RESPECT FOR PERSONAL DIGNITY, AUTONOMY AND PRIVACY.
• ALL PATIENTS HAVE THE RIGHT TO BE TREATED IN THE LEAST RESTRICTED FEASIBLE ENVIRONMENT AND CAN EXPECT TO BE PROTECTED FROM PHYSICAL, SEXUAL OR EMOTIONAL ABUSE, AND INHUMANE TREATMENT.
• ALL PATIENTS WILL HAVE THE RIGHT TO PARTICIPATE IN ANY SERVICE CONSISTENT WITH STANDARD OF CARE IN AN INDIVIDUAL PATIENT PLAN REGARDLESS OF THE REFUSAL OF ANY OTHER SERVICES UNLESS THAT SERVICE CONFLICTS WITH PATIENT SAFETY AND REQUIRES THEIR PARTICIPATION.
• ALL PATIENTS HAVE THE RIGHT TO REFUSE ANY SERVICE, THERAPY OR ANY MEDICATION UNLESS SUCH
• REFUSAL IS DEEMED TO BE A RESULT OF MENTAL INCOMPETENCE AT THE DISCRETION OF THE ATTENDING
• PHYSICIAN AND COULD LEAD TO HARM OF PATIENT OR STAFF.
• ALL PATIENTS HAVE THE RIGHT TO PARTICIPATE IN THE DEVELOPMENT, REVIEW AND REVISION OF THEIR OWN INDIVIDUALIZED TREATMENT PLAN AND TO RECEIVE A COPY OF IT.
• ALL PATIENTS HAVE THE RIGHT TO FREEDOM OF UNNECESSARY OR EXCESSIVE MEDICATION AND TO BE FREE FROM RESTRAINT OR SECLUSION UNLESS THERE IS IMMEDIATE RISK OF PHYSICAL HARM TO SELF OR OTHERS.
• ALL PATIENTS HAVE THE RIGHT TO BE INFORMED OF THEIR CARE AND THE RIGHT TO REFUSE UNUSUAL OR
• HAZARDOUS TREATMENT PROCEDURES.
• ALL PATIENTS HAVE THE RIGHT TO BE ADVISED AND THE RIGHT TO REFUSE OBSERVATION BY OTHERS AND BY TECHNIQUES SUCH AS ONE-WAY VISION MIRRORS, TAPE RECORDERS, VIDEO RECORDERS, TELEVISION, MOVIES, PHOTOGRAPHS OR OTHER AUDIO AND VISUAL TECHNOLOGY. THIS RIGHT DOES NOT PROHIBIT AN AGENCY FROM USING CLOSED-CIRCUIT MONITORING TO OBSERVE SECLUSION ROOMS OR COMMON AREAS, WHICH DOES NOT INCLUDE BATHROOMS OR SLEEPING AREAS;
• ALL PATIENTS HAVE THE RIGHT TO CONFIDENTIALITY OF COMMUNICATIONS AND PERSONAL IDENTIFYING
• INFORMATION WITHIN THE LIMITATIONS AND REQUIREMENTS FOR DISCLOSURE OF CLIENT INFORMATION UNDER STATE AND FEDERAL LAWS AND REGULATIONS.
• ALL PATIENTS HAVE THE RIGHT TO HAVE ACCESS TO ONE’S OWN CLIENT RECORD UNLESS ACCESS TO CERTAIN INFORMATION IS RESTRICTED FOR CLEAR TREATMENT REASONS. IF ACCESS IS RESTRICTED, THE TREATMENT PLAN SHALL INCLUDE THE REASON FOR THE RESTRICTION, A GOAL TO REMOVE THE RESTRICTION, AND THE TREATMENT BEING OFFERED TO REMOVE THE RESTRICTION;
• ALL PATIENTS HAVE THE RIGHT TO BE INFORMED A REASONABLE AMOUNT OF TIME IN ADVANCE OF THE
• REASON FOR TERMINATING PARTICIPATION IN A SERVICE, AND TO BE PROVIDED A REFERRAL, UNLESS THE SERVICE IS UNAVAILABLE OR NOT NECESSARY.
• ALL PATIENTS HAVE THE RIGHT TO BE INFORMED OF THE REASON FOR DENIAL OF A SERVICE.
• ALL PATIENTS HAVE THE RIGHT NOT TO BE DISCRIMINATED AGAINST FOR RECEIVING SERVICES ON THE BASIS OF RACE, ETHNICITY, AGE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, SEXUAL ORIENTATION, PHYSICAL OR MENTAL HANDICAP, DEVELOPMENTAL DISABILITY, GENETIC INFORMATION, HUMAN IMMUNODEFICIENCY VIRUS STATUS, OR IN ANY MANNER PROHIBITED BY LOCAL, STATE OR FEDERAL LAWS;
• ALL PATIENTS HAVE THE RIGHT TO KNOW THE COST OF SERVICE
• ALL PATIENTS HAVE THE RIGHT TO BE VERBALLY INFORMED OF ALL CLIENT RIGHTS, AND TO RECEIVE A WRITTEN COPY UPON REQUEST;
• ALL PATIENTS HAVE THE RIGHT TO EXERCISE ONE’S OWN RIGHTS WITHOUT REPRISAL, EXCEPT THAT NO RIGHT EXTENDS SO FAR AS TO SUPERSEDE HEALTH AND SAFETY CONSIDERATIONS;
• ALL PATIENTS HAVE THE RIGHT TO FILE A GRIEVANCE
• ALL PATIENTS HAVE THE RIGHT TO HAVE ORAL AND WRITTEN INSTRUCTIONS CONCERNING THE PROCEDURE FOR FILING A GRIEVANCE, AND TO ASSISTANCE IN FILING A GRIEVANCE IF REQUESTED;
• ALL PATIENTS HAVE THE RIGHT TO BE INFORMED OF THEIR OWN CONDITION AS PART OF THEIR INFORMED
• CONSENT
• ALL PATIENTS HAVE THE RIGHT TO CONSULT WITH AN INDEPENDENT TREATMENT SPECIALIST OR LEGAL
• COUNSEL AT ONE’S OWN EXPENSE

4. CLIENT GRIEVANCE PROCEDURE

• THE PATIENT WILL GIVE ANY GRIEVANCE TO OUR IN-HOUSE CLIENT ADVOCATE, MEREDITH RAMSEY, UNLESS THE COMPLAINT IS ABOUT HER, IN WHICH THE MANAGER MARISA STREB SHALL BE THE CLIENT ADVOCATE. THESE INDIVIDUALS WILL BE THE PATIENT GRIEVANCE ADVOCATE UNLESS PATIENT WISHES TO DESIGNATE OUTSIDE ADVOCATE. WE WILL REFER TO DINSMORE & SHOHL, LLP IF NEEDED.
  
  CLIENT RIGHTS MANAGERS:
  MEREDITH RAMSEY
  FRONT DESK RECEPTIONIST
  ATS COLUMBUS
  AVAILABILITY M-F 10:00AM-4:30 PM
  
  MARISA STREB
  OFFICE MANAGER
  ATS COLUMBUS
  AVAILABILITY M, W, TH 8:30AM-12:30PM
  614-594-9774 614-594-9774
  
  
  THE CLIENT ADVOCATE WILL TAKE ANY WRITTEN GRIEVANCE OR WILL PUT IN TO WRITING ANY GRIEVANCE GIVEN VERBALLY. ALL GRIEVANCES MUST INCLUDE THE DATE, APPROXIMATE TIME, DESCRIPTION OF THE INCIDENT AND NAMES OF INDIVIDUALS INVOLVED IN THE INCIDENT OR SITUATION BEING GRIEVED. THE WRITTEN GRIEVANCE MUST BE DATED AND SIGNED BY THE CLIENT, THE INDIVIDUAL FILING THE GRIEVANCE ON BEHALF OF THE CLIENT OR HAVE AN ATTESTATION BY THE CLIENT ADVOCATE THAT THE WRITTEN GRIEVANCE IS A TRUE AND ACCURATE REPRESENTATION OF THE CLIENT’S GRIEVANCE. THE GRIEVANCE ADVOCATE WILL MEET WITH OWNERSHIP AND A STATEMENT OF RESOLUTION/DECISION WILL BE ISSUED WITHIN 20 BUSINESS DAYS OF RECEIPT OF SAID GRIEVANCE. ANY EXTENUATING CIRCUMSTANCES INDICATING THAT THIS TIME PERIOD WILL NEED TO BE EXTENDED MUST BE DOCUMENTED IN THE GRIEVANCE FILE AND WRITTEN NOTIFICATION GIVEN TO CLIENT.
  
  IF REQUESTED, THE CLIENT CAN REQUEST TO FILE A COMPLAINT WITH OUTSIDE ORGANIZATIONS AND WILL BE PROVIDED ON THIS DOCUMENT THE MAILING ADDRESS AND PHONE NUMBER OF EACH.

1. ADAMH – ALCOHOL, DRUG, AND MENTAL HEALTH BOARD OF FRANKLIN COUNTY, 447 E. BROAD ST., COLUMBUS, OH 43215, P. 614-224-1057
2. OHIO DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES, 30 E BROAD ST, 36TH FLOOR, COLUMBUS OH 43215, P. 614-466-2596
3. DISABILITY RIGHTS OF OHIO, 200 CIVIC CENTER DR, SUITE 300, COLUMBUS OH, 43215, P. 614-466-7264
4. US DEPARTMENT OF HEALTH & HUMAN SERVICES, 233 NORTH MICHIGAN AVE, SUITE 1300, CHICAGO, IL 60601, P. 312-353-1385, F. 312-353-0718.
   
   ATS COLUMBUS WILL MAINTAIN FOR 2 YEARS FROM RESOLUTION, AND A COPY OF GRIEVANCE, DOCUMENTATION REFLECTING PROCESS USED AND RESOLUTION/REMEDY OF THE GRIEVANCE AND DOCUMENTATION, IF APPLICABLE OF EXTENUATING CIRCUMSTANCES FOR EXTENDING THE TIME PERIOD FOR RESOLVING THE GRIEVANCE BEYOND 20 DAYS.
   
   ALL GRIEVANCES WILL BE ACKNOWLEDGED WITH A WRITTEN RECEIPT WITHIN 3 BUSINESS DAYS AND WILL INCLUDE THE FOLLOWING:
   
   • DATE GRIEVANCE WAS RECEIVED
   • SUMMARY OF GRIEVANCE
   • OVERVIEW OF INVESTIGATION PROCESS
   • TIMETABLE FOR COMPLETION OF INVESTIGATION AND NOTIFICATION OF RESOLUTION
   • TREATMENT PROVIDER CONTACT NAME, ADDRESS, AND TELEPHONE NUMBER.