222 S. Rainbow Blvd
Suite 203
Las Vegas, Nevada 89145
Phone (702) 564-4368
Fax (702) 446-8134
Contact
222 S. Rainbow Blvd
Suite 203
Las Vegas, Nevada 89145
Phone (702) 564-4368
Fax (702) 446-8134
Contact

Aplicación del Programa de Servicios de Consejería

En respuesta a las peticiones de la comunidad de trastornos hemorrágicos, el capítulo de Nevada de la Fundación Nacional de Trastornos Hemorrágicos (NBDFNV) ha creado un programa en colaboración con los proveedores de consejería de Nevada.  Los proveedores ubicados en el área de Las Vegas proporcionarán servicios de consejería en persona, telesalud y de grupo para todos los solicitantes aprobados.

Puede encontrar más información sobre nuestros socios proveedores en sus sitios web:

The Practice at UNLV: https://www.unlv.edu/thepractice

 

Los solicitantes elegibles son personas con un trastorno hemorrágico o un familiar inmediato o cuidador designado de una persona con un trastorno hemorrágico.  Si se aprueba su solicitud, NBDFNV pagará hasta ocho (8) sesiones de una hora de duración que también pueden ser renovables si se presenta una solicitud adicional en coordinación con el proveedor.  NBDFNV facilitará la financiación del programa y seguirá todas las leyes federales y estatales, para incluir las normas de privacidad HIPAA.  En ningún momento NBDFNV solicitará u obtendrá información clínica específica del proveedor, nunca.  Cualquier información que se solicite estará relacionada con la cobertura del seguro, si corresponde, y con la solicitud documentada de servicios continuados, según corresponda.

 

El pago continuo de los servicios de consejería depende de la cantidad de fondos disponibles. NBDFNV nunca determinará la necesidad de servicios de consejería. Esto es entre usted y su proveedor.

 

Este programa no pretende sustituir ninguna cobertura de seguro médico actual que pueda tener o ningún programa gubernamental en el que pueda participar, para incluir pero no limitarse a Medicare o Medicaid.

Esta solicitud está destinada a obtener información básica sobre cualquier cobertura de seguro médico que pueda tener o no.  Las preguntas de esta solicitud se utilizan únicamente para determinar su elegibilidad o la de su hijo en el programa de consejería de NBDFNV y no se utilizarán para ningún otro propósito ni se compartirán con nadie, excepto con el proveedor al que se le remita tras la aprobación.

 

Al rellenar esta solicitud se registrará automáticamente en la sección de Nevada de NBDF y se le incluirá en la lista de correo.

INFORMACIÓN BÁSICA
First Name *
Middle
Last Name *
Month
/
Day
/
Year
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Formato preferido (seleccione todos los que correspondan):
¿Cuál es su horario preferido para las sesiones? (Por favor, marque todas las que correspondan)
¿Tiene acceso a Internet en casa y con capacidad para chatear por vídeo?
¿Tiene acceso a Internet en casa y con capacidad para chatear por vídeo?
¿Es capaz de comprometerse con citas regulares durante las próximas 4-8 semanas o según lo recomendado por un consejero?
¿Tiene un trastorno hemorrágico?
¿Es usted un familiar directo de una persona con un trastorno hemorrágico con la que vive en el mismo hogar?
¿Tiene un seguro médico actualmente?
First Name *
Last Name *
¿Está inscrito en algún otro programa de seguro médico estatal o federal? No incluya programas de alimentación, vivienda u otros programas de asistencia que no proporcionen un seguro de salud o una cobertura médica directa.

Entiendo que la información contenida en esta solicitud será compartida con el proveedor de terapia contratado, ya sea en OASIS Consejería o La Práctica en UNLV como parte del proceso de referencia. Doy mi permiso para compartir la información incluida en este formulario.

Entiendo que mi participación será conocida sólo por el personal de NBDFNV que dirige el programa y que en ningún momento se compartirá ninguna información personal de salud entre mi proveedor y NBDFNV.  Los avisos de remesa del plan de salud o la explicación de beneficios (EOB) asociados con los reclamos de seguros, si corresponde, serán compartidos por mi proveedor con NBDFNV para cumplir con los requisitos del programa.

First Name *
Middle
Last Name *
Relación del solicitante (marcar):
(Must have authority to act on behalf of individual who will be receiving services.)
First Name *
Last Name *
Submission Date / Fecha de solicitud

CONFIDENCIALIDAD

Los solicitantes y la información relativa a las solicitudes de financiación se consideran confidenciales en toda la medida permitida por la ley. Todos los miembros de la Junta Consultiva/Comité de Asistencia de Emergencia del Capítulo de Nevada de NBDF están obligados a firmar un acuerdo de confidencialidad.

La información de las solicitudes de servicios de consejería del capítulo de Nevada de NBDF puede ser recopilada con fines estadísticos y para cumplir con los requisitos locales, estatales, federales o de las organizaciones afiliadas.  Sin embargo, cualquier publicación de estos datos será en forma agregada solamente y no incluirá nombres o cualquier otra información que pueda ser utilizada para identificar a los solicitantes o beneficiarios individuales.

No se utilizará ni se divulgará ninguna información personal para fines distintos de aquellos para los que fue recopilada sin el permiso escrito de los solicitantes.  En ningún momento se compartirá la información personal con ninguna persona, empresa u organización ajena a la Sección de Nevada de la Fundación Nacional de Trastornos Hemorrágicos.

Resource Links

222 S. Rainbow Blvd
Suite 203
Las Vegas, Nevada 89145
Phone (702) 564-4368
Fax (702) 446-8134
Contact
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We are grateful for your donation and support of our organization. If you have made an error in making your donation or change your mind about contributing to our organization please contact us. Refunds are returned using the original method of payment. If you made your donation by credit card, your refund will be credited to that same credit card.

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Ongoing support is important to enabling projects to continue their work, so we encourage donors to continue to contribute to projects over time. But if you must cancel your recurring donation, please notify us.
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