Behavioral Health Fund Request (BHF)

4f. PREFERRED METHOD OF CONTACT

I certify that to the best of my knowledge and belief, the information provided above is complete and correct. I understand that if the information provided is false or incomplete, I may be responsible for the total cost of treatment provided. I authorize access to medical information needed to determine health care and/or Medicare benefits payable for substance use services. I authorize payment of any third party benefits directly to the Department of Human Services. This authorization expires one year from the date services were rendered. I understand that I may revoke this authorization at any time except to the extent that actions have taken in advance of my revocation. If I revoke this authorization, I may be responsible for the total cost of treatment.

Instructions for completing the BHF Request (DHS-2780A)

Box 1. Financial Eligibility Start Date – Enter the start date as the first billable date of service. This could be the date of the comprehensive assessment or the first date of treatment services provided. The date of the comprehensive assessment must be included in this span in order for the provider to be paid for it. Box 2. PMI Number, if any – Recipient PMI can be found in MN–ITS Eligibility Search by doing a search of a combination of the recipient's name, date of birth, and social security number. If one is not found in MN–ITS eligibility search then leave this field blank and the County/Tribe will set the client up with one. Providers must search in MN–ITS eligibility search to find the new PMI number after the County/Tribe assigns one for the client.

Box 4. Client Address – Enter the client's address as reported by the client.

Box 4a. City Box 4b. State Box 4c. Zip Code Box 4d. Client phone number(s) Box 4e. Client Email address Box 4f. Preferred method of contact Phone email

Box 5. Residence Type – Check the box type of residence client identifies they are residing in at time of application. Box 6. Previous Residence Address (if applicable) – If client is residing in an excluded facility at time of application enter full address client identifies as residing at prior to residence in an excluded facility (MN 256G.02, Subd. 6 Box 7. Race – Check the box representing the race of the client as reported by the client. Box 8. Client Alias, if any – Enter any other name this client has been known as previously such as nicknames, maiden names, prior married names, etc. Box 8. Date of Birth – Enter the client's date of birth as reported by the client. Box 10. County of Residence – Enter the three digit county code from the drop down menu that represents the county in which the client currently resides. Box 11. Social Security Number – Enter SSN as reported by client Box 12. Language – Enter the language the client understands best as reported by the client Box 13. Hispanic – Check whether the client is Hispanic or not. Box 14. Marital Status – Enter a valid value from the drop down menu that best describes the client’s marital status. Box 15. Gender – Enter the gender in which the client associates with most. This field is in the process of being updated to be more inclusive and the form will be updated as appropriate. Box 16. Is client incarcerated? – check yes or no Box 16a. If yes, Correctional Facility – Enter name, and NPI if known, of Correctional Facility where client is residing at time of application. Box 16b. Date Incarceration Began – If unknown, write in "unknown." Box 16b. Date Incarceration Ends – Enter date client is anticipated to discharge from the correctional facility. If unknown, write in "unknown." Box 17. Financially Responsible Person – Last Name Box 17a. First Name Box 17b. Middle initial Box 18. Financially Responsible Person's Address, if different from client

Box 18a. City Box 18b. State Box 18c. Zip Code Box 19. Limited Eligibility – choose one of the valid values to identify the eligibility of the client. Box 20. Annual Income – (https://edocs.dhs.state.mn.us/lfserver/Public/DHS-6770-ENG) Enter the annual income calculated prospectively from the date of the first date of service forward one year. This is different from the MA determinations which calculate retrospectively, BHF calculates forward one year. This allows a recipient to gain immediate funding for their treatment needs under BHF and then pursue Medicaid enrollment while receiving treatment. Upon retro MA approval, previously paid claims will be reprocessed under MA so that no county share is applied. Box 21. Household Size – (https://edocs.dhs.state.mn.us/lfserver/Public/DHS-6770-ENG) Enter the number of people in the household as defined as such on the Income Guidelines Box 22. Employer Name – Enter the name Box 22a. Street Address – Address of the employer where the insurance is issued

Box 22b. City Box 22c. State Box 22d. Zip Code

Box 23. Medicare Claim Number – Enter the Medicare claim number assigned for a Medicare enrolled recipient

Box 24. Health Insurance Company Name Box 24a. Health Insurance Company Street Address Box 24b. Health Insurance Company City Box 24c. Health Insurance Company State Box 24d. Health Insurance Company Zip Code

Box 25. Certificate or Policy Number – Enter the insurance certificate or policy number Box 25a. Group Name Number – Enter the insurance group name or number

Box 25b. Pre-Certification Number Box 26. Policyholder Name

Box 27. Relationship to client – Enter one of the following values: 1. Self 2. Spouse 3. Child Box 28. Client signature – Client signs attesting the statement above is accurate and authorizing third party billing

Box 28a. Date of client signature

Box 29. Financially responsible person's signature – have the financially responsible person sign if not the client

Box 29a. Date of financially responsible person's signature

Box 30. Contact name – Enter name of the sender of this document in case you need to be reached. Box 30a. Phone number – Enter phone number of the sender of this request. Box 30b. Fax number – Enter fax number of the sender of this request. Box 30c. Email address – Enter email address of the sender of this request.

State laws and federal rules protect your placement and treatment records. The federal rule is Title 42, part 2 of the Code of Federal Regulations. The state laws are Minnesota Statutes, chapter 13 and Minnesota Statutes, section 254A.09. The agency must not identify you to others without your consent. Your consent must be in writing. You do not have to answer the questions on this form. However, the state will not pay for your treatment unless you answer the questions. Your records are private. Agency employees working on your placement in treatment can see the records. Workers in this agency who arrange for payment have access to your records. Workers from the Minnesota Department of Human Services who send out treatment payments or check county records also have access to your records. Your records may be released outside the agency with your consent. Your records may also be released under the following conditions: 1. You are not identified as an alcohol or drug abuser in any way. This means a treatment center that treats other problems can release your name, but not say you are receiving alcohol or drug services. 2. A court orders the release of records after a hearing. 3. The disclosure is made during a medical emergency to medical treatment providers. 4. The disclosure is made to an agency which provides services such as bill collecting to the program. 5. A child abuse or neglect report is made. The report identifies the child, the child's caretaker and the alleged abuser. The amount and type of abuse and the identity of the reporter are also in the report. The abuse may be reported to local welfare or police agencies. 6. Staff in this agency and the Minnesota Department of Human services need the information to do their jobs. Your alcohol and drug abuse record normally may not be used in criminal investigations. Crimes in programs or against program workers may be reported to police. A threat to commit a crime also may be reported to police. A court may order release of records if the crime is very serious. You have the right to see your record. You have the right to obtain a copy of your record. The agency may charge you for the cost of finding the record and making copies. If you only want to see the record, the agency must provide it at no cost.

Breaking the federal privacy rule is a crime. The penalty is a fine of not more than $500 for the first offense and not more than $5,000 for repeat offenses. Suspected violations may be reported to: United States Attorney District of Minnesota 300 South 4th Street, Room 600 Minneapolis, Minnesota 55401 You may complain if your record is wrong. You may also complain if your record is not complete. The agency must reply within 30 days. If you disagree with the agency's decision, you may appeal to the State Department of Administration. Your appeal should include: 1. Your name, address, and telephone number, 2. The name and address of the agency which has the records, 3. Description of the dispute and the date it happened, and 4. The relief you want. If an agency breaks the state privacy law, you may also sue. Damages of not less than $100 or not more than $10,000 can be assessed by a court against the agency. Workers who break this law are guilty of a misdemeanor.

If you believe you have been discriminated against because of your race, color, creed, religion, national origin, disability, sex, sexual orientation, public assistance status, or age, while requesting or receiving alcohol or other drug abuse treatment services, you may file a discrimination complaint with one or more of the agencies listed below: Minnesota Department of Human Services Office for Equal Opportunity PO Box 64997 St. Paul, MN 55164-0997 Minnesota Department of Human Rights U.S. Department of Health and Human Services Office for Civil Rights, Region V-Chicago 233 North Michigan Avenue, Suite 240 Chicago, IL 60601-5519

Discrimination is against the law. The Minnesota Department of Human Services (DHS) does not discriminate on the basis of any of the following: race, color, national origin, creed, religion, public assistance status, marital status, age, disability, sex (including sexual orientation and gender identity) or political beliefs.

If you have a disability and need aids and services to have an equal opportunity to participate in our health care programs, DHS will provide them timely and free of charge. These aids and services include qualified interpreters and information in accessible formats.

If you have difficulty understanding English and need language help to access information and services, DHS will provide language assistance services timely and free of charge. These services include translated documents and interpreting spoken language. To request these free services from DHS, call DHS Health Care Consumer Support at 651-297-3862 or 800-657-3672. Or use your preferred relay service.

You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by a human services agency. You may contact any of the following three agencies directly to file a discrimination complaint.

U.S. Department of Health and Human Services' Office for Civil Rights (OCR)

You have a right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following: race, color, national origin, age, disability, or sex (including sexual orientation and gender identity Contact the OCR directly to file a complaint: Centralized Case Management Operations U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, DC 20201 800-368-1019 (voice), 800-537-7697 (TDD) 202-619-3818 (fax) OCRComplaint@hhs.gov (email) https://ocrportal.hhs.gov/

In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following: race, color, national origin, religion, creed, sex, sexual orientation, marital status, public assistance status, or disability. Contact the MDHR directly to file a complaint: Minnesota Department of Human Rights 540 Fairview Avenue North, Suite 201 St. Paul, MN 55104 651-539-1100 (voice) or 800-657-3704 (toll free) 711 or 800-627-3529 (MN Relay) 651-296-9042 (fax) Info.MDHR@state.mn.us (email) https://mn.gov/mdhr/intake/consultationinquiryform/

You have a right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following: race, color, national origin, creed, religion, public assistance status, marital status, age, disability, sex (including sexual orientation and gender identity), or political beliefs. Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint. DHS will notify you in writing of the investigation's outcome. You have the right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome. Be brief and state why you disagree with the decision. Include additional information you think is important. If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administrative actions. Contact DHS directly to file a discrimination complaint: Civil Rights Coordinator Minnesota Department of Human Services Equal Opportunity and Access Division PO Box 64997 St. Paul, MN 55164-0997 651-431-3040 (voice) or use your preferred relay service.