Hea 1685 Form PDF Details

If you’re an individual or a business looking for health insurance coverage in the United States, you’ve likely encountered the Health Insurance Act of 1985 (HEA 1685) form. The HEA 1685 is a mandatory form that must be filled out by all individuals or organizations available to purchase health insurance benefits. Filling it out accurately and completely can feel like a daunting task, but understanding what’s required on this important document helps ensure your application will move along smoothly and efficiently. In this blog post, we'll provide an overview of what's included on the HEA 1685 Form and how to complete it properly!

QuestionAnswer
Form NameHea 1685 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesohio department of health r302 form, hea1685, ohio department of health complaint, anonymous report to health department

Form Preview Example

PROVIDER AND CONSUMER SERVICES UNIT

DIVISION OF QUALITY ASSURANCE

OHIO DEPARTMENT OF HEALTH

COMPLAINT FORM

You may file this complaint ANONYMOUSLY, by NOT providing us your name and address. Skip to Section II if you wish to remain anonymous. If you remain anonymous, ODH will not be able to contact you to obtain additional information or notify you of the results of the complaint investigation.

Section I Complainant Information – Complete only if you wish to receive our acknowledgement and notification letters with the results of the complaint investigation

Complainant Name:

Street Address:

City:

State:

 

Zip:

 

 

 

 

Primary Telephone:

 

Secondary Telephone:

( )

 

(

)

 

NOTE: All person-identifiable information is confidential.

Section II Facility Information

Facility Name:

Address:

City:

State:

Zip

Telephone:

Section III Resident(s)/Patient(s) Information

 

Resident/Patient Name:

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

Relationship to Resident/Patient:

 

Is the Resident/Patient still in the facility?

 

 

 

 

฀ Yes

฀ No

 

 

 

Additional Name(s):

 

 

 

 

 

 

Name:

 

 

Date of Birth:

 

 

 

Relationship to Resident/Patient:

Is the Resident/Patient still in the facility?

฀ Yes

฀ No

 

 

 

 

 

 

 

 

Name:

 

 

Date of Birth:

 

 

 

Relationship to Resident/Patient:

Is the Resident/Patient still in the facility?

฀ Yes

฀ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section IV Alleged Wrongdoer(s) Information – if applicable or known

Name:

Title:

Additional Name(s)/Title:

Name and Title:

Name and Title:

Name and Title:

HEA1685 REV. 4/08

Page 1 of 2

Section V Narrative Description

Provide a narrative description of your complaint which should include date, time and location of the incident. Include name and phone number of any witness(es), if applicable.

HEA1685 REV. 4/08

SUBMIT THIS FORM TO ODH

Page 2 of 2

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Pay attention while completing this document. Make sure that all necessary fields are filled in properly.

1. Start filling out your ohio board of health complaints with a selection of essential blank fields. Get all the necessary information and ensure there is nothing left out!

hea1685 completion process described (part 1)

2. Just after this selection of blanks is completed, go to type in the relevant information in all these: Section III ResidentsPatients, Is the ResidentPatient still in, Additional Names, Name Date of Birth Relationship to, Name Date of Birth Relationship to, Section IV Alleged Wrongdoers, Title, Name and Title, Name and Title, Name and Title, and HEA Rev.

Name and Title, Section IV Alleged Wrongdoers, and Name Date of Birth Relationship to of hea1685

As to Name and Title and Section IV Alleged Wrongdoers, make sure you double-check them in this section. These two are certainly the most important fields in this form.

3. Completing Section V Narrative Description is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

hea1685 writing process clarified (part 3)

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