Please complete the attached form and return it either in person, fax, mail or email Our Records Custodian, Cove Records Custodian, 4422 E. Columbus Dr. Tampa, FL 33605, F: (813) 384-4179, recordsrequest@covebh.org. Records requests are processed within 15 business days from the date of receipt of the completed form.
Record Copy Fees Paper copies
Patient request, $.25 per page after the first 3 pages.
State Attorneys, Attorney Generals and Public Defenders, $10 per research hour and $.15 per page thereafter.
All other requestors, $1 per page for the first 25 pages, then $.25 per page thereafter.
Electronic copies
Records prior to February 3, 2020, flat rate fee $6.50
Records February 3, 2020-present, no charge
If any fees incur, an invoice will be sent to you in the same way your request was received. All record copy fees must be paid either in person or by phone to receive the records.
Records can be mailed, emailed, faxed or picked up in person.
Sliding Fee Discount Program
NOTICE TO PATIENTS
This practice serves all patients regardless of inability to pay. Discounts for essential services are offered based on the family size and income (Sliding Fee Discount Program).
For more information, ask the front desk or visit our website..
Thank you
AVISO PARA PACIENTES
Esta Clinica sirve a todos los pacientes, independientemente de la incapacidad de pago. Descuentos para los servicios eseciales son ofrecidos dependiendo de tamano de la Familia y de los ingresos (Descuento por tarifa deslizantes).
Usted puede solicitar un descuento en la recepcion o visite nuestro sitio de web.
Gracias.
Patient Grievance
Notifying the Public of Rights Under Title VI / Notificación al Público de los Derechos bajo el Título VI
Cove Behavioral Health, Inc.
Cove Behavioral Health, Inc.operates its programs and services without regard to race, color, and national origin in accordance with Title VI of the Civil Rights Act. Any person who believes she or he has been aggrieved by any unlawful discriminatory practice under Title VI may file a complaint with Cove Behavioral Health, Inc.
Cove Behavioral Health Inc. opera sus programas y servicios sin tener en cuenta la raza, el color o nacionalidad de acuerdo con el Título VI de la Ley de Derechos Civiles. Cualquier persona que crea que ella o él ha sido agraviado por cualquier práctica discriminatoria ilegal bajo el Título VI puede presentar una queja ante Cove Behavioral Health Inc.
For more information on Cove Behavioral Health, Inc.’s civil rights program, and the procedures to file a complaint, contact 813-384-4225; Email or visit our administrative office at 4422 E. Columbus Drive, Tampa, FL 33605. For more information, visit www.dacco.org.
Para más información respecto del programa de derechos civiles de Cove Behavioral Health Inc., y los procedimientos para presentar una queja, contacte 813-384-4225; correo electrónico; visitar 4422 E. Columbus Drive Tampa, FL 33605.
Si necesita información en otro idioma, comuníquese al 813-384-4225
