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April 17, 2023

Get Tested for HIV – Free, Fast, and Confidential

Randall Chesley HIV Testing and Education HIV Prevention, HIV Testing, HIV Testing and Education

Copyright © 2023 Cove Behavioral Health, All Rights Reserved

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Record Request Form
990

Florida Department of Children and Families

Agency for Health Care Administration

Records Request on Website

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

Record Request Form

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, contact the front desk at 813-384-4000.

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 por llamada a 813-384-4000.

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

Patient Grievance GP5-606

Patient Grievance GP5-606

Patient Grievance Form

Patient Grievance Form

Cove Van Transportation Discrimination Complaint Form

Cove Van Transportation Discrimination Complaint Form

Cove Van Transportation Discrimination Complaint Form - Spanish Version

Cove Van Transportation Discrimination Complaint Form - Spanish Version

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