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P111-1 03/07/2019
HIGH PLAINS MENTAL HEALTH CENTER
Patient Information - Youth
Name: ________________________________ Age:_____Date of Birth:___________________
Address: ________________________________ Phone: (H)______________________________
City, State, Zip________________________________
Name of Youth’s Parent(s) or Guardian(s): ____________________________________________________
Address, City and State (if different from Youth’s address): _______________________________________
Home Phone:_________________ Work Phone:___________________ Cell Phone:___________________
May we correspond by mail, telephone and voicemail (if applicable) at the above HOME address and phone number? Yes No
May we correspond by telephone and voicemail (if applicable) at the above WORK address and phone number? Yes No
May we correspond by telephone and voicemail (if applicable) at the above CELL phone number? Yes No
If not, where may we contact you? The home address listed above will be used for all correspondence unless an alternate address and phone is given below:
Address _____________________________________ Phone __________________
_____________________________________ Whose address & phone is this?_____________________
GENDER
RACE
ETHNICITY
ELIGIBILITY FOR SSI OR SSDI
Male
American Indian or Alaska Native
Hispanic or Latino
Not Applicable
Female
Asian
Not Hispanic or Latino
Eligible and Receiving Payment
Transgender Male to
Female
Black or African American
Native Hawaiian or Other Pacific
Islander
White
Other
Eligible but not Receiving Payment
Potentially Eligible
Determined to be Ineligible by Review and Decision
Determination Decision on Appeal
Transgender Female
to Male
TOBACCO USE Never Used Have Used/Not Current User Occasional User Regular User Use Smokeless Tobacco
PRIMARY LANGUAGE ______________________________________________________________________
RELIGIOUS/SPIRITUAL AFFILIATION _______________________________________________________
HAS YOUR PARENT/GUARDIAN EVER SERVED IN THE MILITARY? Yes No
Education
Name of School: _____________________________________________Present Grade:________________
Special Education Services: Yes No Most grades are currently: A B C D F
Significant issues regarding school performance or behavior:______________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Recent History of Present Situation
Who referred you to us?____________________________________________________________________
Please describe the problems you are concerned about regarding this youth:
_______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________________________
How long have you been concerned about this youth? ____________________________________________
_______________________________________________________________________________________
Family history of mental illness? Yes No (e.g. depression, schizophrenia, etc) If yes, please
explain: ________________________________________________________________________________
_______________________________________________________________________________________
P111-2 03/07/2019
Family history of substance abuse? Yes No If yes, explain: _______________________________
_______________________________________________________________________________________
Has this youth experienced any abuse and/or neglect? (Victim or Perpetrator) Yes No Unsure
If yes, please explain:______________________________________________________________________
_______________________________________________________________________________________
Has this youth experienced any problems with his/her health and/or development, including meeting
developmental milestone? Yes No If yes, please explain: _______________________________
_______________________________________________________________________________________
Has this youth experienced any current or past problems with alcohol or other substance use? Yes No
If yes, please explain:______________________________________________________________________
_______________________________________________________________________________________
Current medications:______________________________________________________________________
_______________________________________________________________________________________
Current medical conditions_________________________________________________________________
_______________________________________________________________________________________
Please list all PREVIOUS (Mental health and/or Substance Abuse) treatment you have received (including
all High Plains MHC facilities):
Facility Location Type of Care Dates (if known)
(City, State) (Inpatient, Outpatient, Substance Use)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Please list all drug allergies and adverse reactions this youth has had to medications:
Name of Drug: Type of Adverse Reaction:
_____________________ _______________________________________________________________
_____________________ _______________________________________________________________
Name of Primary Care Physician: ____________________________________________________________
In emergency, who can we notify?
Name _________________________ Relationship ________________
Street Address ___________________________ Home Phone ________________
City ________________State ______Zip _________ Business Phone ______________
Form Completed by:__________________________________________ Date:______________________
For Office Use Only:
Reviewed By: ____________________________ Initials for additions:_________ Date: ________________
P113 11/16/2018
HIGH PLAINS MENTAL HEALTH CENTER
PATIENT SERVICES AND CONSENT FOR TREATMENT AND EVALUATION
THE FOLLOWING SERVICES ARE AVAILABLE (BASED ON MEDICAL NECESSITY)
THROUGH HIGH PLAINS MENTAL HEALTH CENTER
Diagnostic Evaluation
Conjoint/Marital Counseling
Family Counseling
Psychiatric Assessment
Medication Services
Community Psychiatric Support Treatment
Crisis Intervention
Psychosocial Rehabilitation – Ind or Group
Targeted Case Management
Screening/Concurrent Utilization Review
Competency to Stand Trial Evaluation
Parent Support & Training – Ind or Group
Independent Living Skill Building
Professional Resource Family Care
Substance Use Assessment
Group Substance Use Counseling
Language interpretation services are available as required when identified by patient and/or High Plains staff.
CONSENT FOR SERVICES AT HIGH PLAINS MENTAL HEALTH CENTER
Identified Patient: ________________________________ DOB:_________________________
Knowing my rights and the services available:
ADULT SEEKING SERVICES (Check box and sign below):
I hereby consent to receive treatment or an evaluation at High Plains Mental Health Center.
I am the legal guardian of the above named Identified Patient, who is 18 or older, and I hereby give my permission for
him/her to receive treatment or an evaluation at High Plains Mental Health Center. (You must provide HPMHC the
appropriate court document.)
CHILD SEEKING SERVICES (Check box and sign below) :
I am the parent or legal guardian of the above named Identified Patient, who is under age 18, and I hereby give my permission
for him/her to receive treatment or an evaluation at High Plains Mental Health Center.
IN THE MATTER OF DIVORCE OR OTHER LEGAL ORDERS OF CUSTODY: (Check One)
I share joint custody of this child with: Name______________________________________________________________
Address____________________________________________________________
City, State Zip ______________________________________________________
(A letter will be sent to the second parent notifying them of the request for services and an invitation to participate in services.)
I have sole custody of this child.
MINOR CONSENTING FOR HIS/HER OWN SERVICES (Check box and sign below):
I am 14-17 years of age and hereby consent to receive treatment or an evaluation at High Plains Mental Health Center. I
understand that, per KSA 59-29b49, I must authorize High Plains Mental Health Center to notify my parent or legal guardian
that I have sought services.
Initial and Date on each line below. Please use the full date on each line: MM/DD/YY
_____ __/__/___I have received a copy and verbal explanation of and understand the Rights and Responsibilities brochure.
_____ __/__/___I have received a copy and verbal explanation of the Notice of Information and Privacy Practices, and I consent to the use and
disclosure of protected health information as described in the Notice of Information and Privacy Practices.
_____ __/__/___I have received a copy and verbal explanation of and understand the Grievance Procedure as outlined in the Rights and
Responsibilities brochure and the Notice of Information Privacy Practices.
SIGN HERE: __________________________________________ Relationship: _______________________ Date: ________________
Printed Name of Person Authorized to Sign _______________________________________________________________
Internal Use Only:
The above signed has stated that (s)he/they has/have an understanding of their rights and meet the signature requirements. Per
K.S.A. 59-2949, I have determined that (s)he/they has/have the capacity to make the decision for treatment.
Therapist: ____________________________________________________ Date: _____________________
04/03/2013 P221
High Plains Mental Health Center
Child Entry Client Status Report
Name: __________________________________ DOB: __________________________________
Child Custody Status:
____
Child is in JJA Custody & lives at home.
_____ Child is in JJA custody & out of home placement.
_____ Child is under supervision of JJA, but not in their custody.
_____ Child is in DCF custody & out of home placement.
_____ Child is in DCF custody & lives at home.
_____ Child is under DCF supervision, but not in their custody.
_____ No JJA or DCF involvement.
Current Residential Setting:
_____ Jail/Detention
_____ State Hospital
_____ Inpatient Psychiatric Hospital
_____ Crisis Resolution/Stabilization unit.
_____ Drug/Alcohol Treatment Center.
_____ Residential Treatment/ Level VI.
_____ Group Home (Levels III/IV/V).
_____ Emergency Shelter.
_____ Therapeutic Foster Care.
_____ Foster Home.
_____ Temporarily Living w/ Relative/Family Friend.
_____ Permanent Home: Biological/Adoptive/Other.
_____ Independent Living.
_____ Homeless.
Current Educational Placement
_____ Not applicable (not listed below).
_____ Institutional instruction (psych hosp., detention, etc.)
_____ Residential School.
_____ Home-based instruction from school district.
_____ Special Education Classroom.
_____ Regular Classroom w/ Special Ed services or Consultations.
Regular Classroom (100% of day w/ no Special Ed).
_____ Home Schooling not provided by school district.
_____ Not in school (Suspended).
_____ Not in school (Graduated).
_____ Not in school working on a GED.
_____ Not in school (Expelled).
_____ Not in school (Drop-Out).
_____ Preschool.
_____ Other.
_____ Alternative Education placement w/ Intensive Psychosocial.
_____ Not in school. SUMMER Break.
_____ Therapeutic Services for Preschool Children.
_____ Enrolled in Post-Secondary Education (Tech/College/Professional Dev).
Law Enforcement Information (Last 30 days)
_____ Total Number of Arrests
_____ Law Enforcement Contact w/ Actual or Surrogate Parent(s)
Form Completed by: ____________________________________ Date:________________________
04/03/2013 C195
HIGH PLAINS MENTAL HEALTH CENTER
TREATMENT PLAN SIGNATURE PAGE
Pa
tient Name: _____________________________________ Date of Birth:_____________________
My
signature below indicates that the treatment plan dated ________________has been discussed with
me and that I have been involved in developing it.
_______
_____________________________________________ ________________________
Signature of Patient or Representative Date
P142 02/01/2019
HIGH PLAINS MENTAL HEALTH CENTER
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
Information Requested From
Name
Address
City
State
Zip
Telephone Number
Release Information To:
High Plains Mental Health Center Attn: Medical Records 208 E 7
th
Street Hays, KS 67601 Ph (785) 628-2871 Fax (785) 628-0330
I hereby authorize the disclosure of information checked below from the records of:
Name:
DOB:
SSN (last 4 digits):
Dates of Treatment:
The type and amount of information to be used or disclosed is as follows:
Entry/Admission Report
All of my Substance Use Disorder Records
School Records/Reports
Discharge Report
Verbal or Written Progress Reports/Consultations
Behavioral Reports
Psychological Evaluation
Medical History, Lab Results, X-Ray
Disciplinary Reports
Psychiatric Evaluation
Medications
Special Education Placement
Other
Information concerning IEP
It is understood that this information will be used for the purpose of:
Evaluation
Treatment
Follow-Up Care
Payment
Legal
Other (specify)
* I understand my records may include information regarding alcohol or drug treatment, HIV testing, HIV status, or AIDS.
* I understand I may revoke this authorization verbally or in writing at any time except for any information that has already been
sent. Unless I revoke it earlier, this authorization will automatically expire one year from date of signature unless otherwise
specified. (Specific date or event may not exceed one year):___________________________________________________________
* I understand that information used or disclosed to any entity other than a health plan or health care provider may no longer be
protected by federal privacy laws.
* I understand that High Plains Mental Health Center will not condition treatment on my signing this authorization.
Signature of Patient
Date
Signature of Legal Representative
Date
Printed Name of Signee
Relationship
Signature of Witness
Date
* Notice To Whomever Records are Disclosed: These records are protected by Federal Regulations (42 C.F.R. Part 2) and
Kansas Statutes. Any further disclose of this information is PROHIBITED.
P196-P 02/01/2019
HIGH PLAINS MENTAL HEALTH CENTER
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
Information Requested From:
High Plains Mental Health Center Attn: Medical Records 208 E 7
th
Street Hays, KS 67601 Ph (785) 628-2871 Fax (785) 628-0330
Release Information To:
Name
Address
City
State
Zip
Telephone Number
I hereby authorize the disclosure of information checked below from the records of:
Name:
DOB:
SSN (last 4 digits):
The type and amount of information I authorize the release of is as follows: (Please check all that apply)
Entry/Admission Report
Discharge Report
Psychological Evaluation
Other (specify)
All of my Substance Use Disorder Records
Verbal or written reports of progress and case consultation
Verbal or written notes/reports re: Medication Evals/Reviews
A letter of notification of the date of my admission into and discharge from services.
All of the records authorized above may be released unless actual dates of treatment are specified here:
* I understand my records may include information regarding alcohol or drug treatment, HIV testing, HIV status, or AIDS.
* I understand that this information will be used for the purpose of continuity of care between my physician and High Plains Mental
Health Center. Patient information is FAXED only when the transfer of information is critical.
* I understand I may revoke this authorization verbally or in writing at any time except for any information that has already been
sent. Unless I revoke it earlier, this authorization will automatically expire one year from date of signature unless otherwise
specified. (Specific date or event may not exceed one year):___________________________________________________________
* I understand that information used or disclosed to any entity other than a health plan or health care provider may no longer be
protected by federal privacy laws.
* I understand that High Plains Mental Health Center will not condition treatment on my signing this authorization.
Signature of Patient
Date
Signature of Legal Representative
Date
Printed Name of Signee
Relationship
Declination to Release Information
Please check one:
I am currently not being followed by any physician for medical reasons.
Do not release any information to my physician.
Signature of Patient
Date
Signature of Legal Representative
Date
* Notice To Whomever Records are Disclosed: These records are protected by Federal Regulations (42 C.F.R. Part 2) and Kansas
Statutes. Any further disclose of this information is PROHIBITED.
*Notice To Whomever Records are Disclosed: These records are protected by Federal Regulations (42 C.F.R. Part 2) and Kansas
Statutes. Any further disclosure of this information is PROHIBITED. 03/08/2017 P112
HIGH PLAINS MENTAL HEALTH CENTER
FEE AND PAYMENT AGREEMENT
INSURANCE AUTHORIZATION AND ACCEPTANCE OF FINANCIAL RESPONSIBILITY
Patient Name ______________________________DOB ___________Soc. Sec. #* _________________ Entry Date __________
Patient Address ________________________________ City _______________________ State __________ Zip _____________
Responsible Person _______________________________Relationship____________ DOB ________ Soc. Sec. #*___________
Mailing Address ________________________________City _______________________ State __________ Zip ____________
Cell Phone ____________________________Home Phone ______________________Work Phone________________________
Please list any payers including but not limited to Insurance, Medicaid, EAPs. List name of policy holder and DOB if other than patient.
Payer Name ___________________________________________ Policy Holder Name and DOB ___________________________
Payer Name ___________________________________________ Policy Holder Name and DOB ___________________________
Payer Name ___________________________________________ Policy Holder Name and DOB ___________________________
I request that payment be made on my behalf to High Plains Mental Health Center for services provided, under the medical direction
of Center physicians, during the treatment period that commenced on the above date. I authorize High Plains Mental Health Center to
release to the above listed entities or their agents, and every insurance plan that I have coverage under during the course of treatment,
any information needed to determine these benefits or the benefits payable for related services. I understand that the purpose of this
disclosure is to determine eligibility and payment for services. I understand I may revoke this consent at any time except for
information that has already been sent. Unless I revoke it earlier, this consent will expire when claims for all services provided to me
have been settled. *Denotes optional field
Kansas Medical Assistance Program: I understand that I am responsible for non-covered services which may include but not
limited to: -services provided when consumer was not eligible for Medicaid; the consumer was eligible when services were provided,
however, did not inform the provider of his/her Kansas Medical Assistance Program eligibility timely; services Medicaid does not
cover such as court appearances, telephone conferences/therapy, services in excess of Medicaid allowed benefits, and psychotherapy
for patients whose only diagnosis is mental retardation.
CHECK ONE: COMPLETE THIS SECTION EVEN WHEN YOU HAVE INSURANCE OR A MEDICAL CARD
I do NOT LIVE in the 20 county area served by High Plains Mental Health Center and understand I am not eligible for a sliding scale fee.
I live in _________________county and wish to apply for a sliding scale fee based on financial information which I have provided below.
I live in _________________county and do not wish to apply for the sliding scale fee. I am willing to pay the usual and customary fee for
services.
Total Family Income per year (Gross Pay before taxes and other deductions) $____________________
If self employed, how much did you use for all family expenses during the year? $____________________
How many people are supported by your family income? _____________
High Plains Mental Health Center is supported by patient fees and funds from state and local government. Your fee is based upon
financial information certified by you. The Percent of Reduction will be applied to charges on the account. Failure to provide
required information on insurance coverage will void the Percent of Reduction and charges will become payable at the Center’s usual
and customary charge. The Center reserves the right to adjust its usual and customary charge. Your Percent of Reduction will expire
upon discharge. High Plains provides services in 14 different locations. All statements are mailed from the Hays Office.
To the best of my knowledge, the above information is true and correct. I agree to pay for outpatient services at each visit or, if I have
insurance, upon receipt of statement indicating the balance due, and to pay Woodhaven Community Support Services monthly upon
receipt of statement indicating the balance due. I further understand that should benefits be denied or fees not be fully covered by my
insurance, I am responsible for payment of any balance due in accordance with this agreement. If unable to follow this policy, I am
responsible for contacting the Insurance Department (785) 628-2871. The Responsible Person of SPMI or SED patients may request a
special fee agreement beyond the sliding fee reduction when extenuating circumstances exist. If the request is denied the consumer
or responsible person may file a complaint with the Manager of Quality Improvement. No one will be denied necessary and
appropriate services that the Center is required to provide by K.A.R. 30-60-64, solely because of the patient's inability to pay the fees
charged by the center for those services. The Center reserves the right to refer delinquent accounts to a professional collection agency
and/or the Center’s attorney.
I have read and understand the terms of the Fee and Payment Agreement and agree to pay for services provided by High Plains Mental
Health Center to the patient listed above according to these terms.
I have received a copy and a verbal explanation of the Center’s Insurance, Billing, and Payment Policies, including treatment service
fees.
_______________ ________________________________________________________________
Date Signature of Responsible Person
OFFICE USE ONLY: Percentage of Reduction_______ Initials ______
P156-1 01/01/2017
HIGH PLAINS MENTAL HEALTH CENTER
BILLING, INSURANCE AND PAYMENT POLICIES EFFECTIVE 01/01/2017
OUTPATIENT SERVICES:
PAYMENT is due at the time of each visit. Payment of deductibles or co-insurance required under your insurance plan is due at
the time of the service. Payment is due on any other balances filed with your insurance or other third party coverage upon receipt
of a statement indicating the balance is due.
WESTSIDE SCHOOL:
Funding for services provided to students of Westside school is obtained through insurance coverage, DCF funds and USD 489
funds. Parents are not billed for services provided as part of Westside School. Westside students receiving other services in
addition to services at Westside will be billed according to the policies stated in the above paragraph for outpatient services.
COMMUNITY SUPPORT SERVICES, COMMUNITY BASED SERVICES AND REHABILITATION SERVICES:
PAYMENT for these services is due monthly upon receipt of statement indicating the balance due.
INSURANCE COVERAGE: The Center will prepare insurance claims for submission to your insurance carrier. Patients are
required to provide the Center with the necessary information/forms for filing claims. Insurance carriers will be billed at the
Center’s usual and customary charge, as required by law. If you have more than one form of insurance, we will bill the additional
carriers before determining any balance due from you.
Claims will be filed as services are performed. When payment or denial is received from your insurance carrier, the
balance due will be transferred to Your Responsibility. If you have a current Fee and Payment Agreement indicating a Percent of
Reduction as a Participating County Citizen, your Percent of Reduction will be applied to charges on the account. Failure to
provide required information on insurance coverage will void the Percent of Reduction and charges will become payable at the
Center’s usual and customary charge. We require that patients make regular payments during treatment toward any anticipated
balances due after insurance (deductible, co-insurance, insufficient payments). This will prevent a large balance which would
become due when insurance payment or denial is received. Any payments made by you which are later covered by insurance will
be refunded to you.
SPECIAL FEE CONSIDERATION: Patients should contact the Business Office (785) 628-2871 when they encounter problems
in meeting the payment requirements for services provided by High Plains Mental Health Center. Special fee consideration may
be available for patients meeting the criteria for these
arrangements.
INTERPRETERS FEES: KanCare members should contact their assigned MCO for interpreter services. Language
interpretation services for non-English speaking patients will be provided to patients for mandated services free of charge.
DELINQUENT ACCOUNTS: The Center reserves the right to refer delinquent accounts to a professional collection agency, the
State of Kansas debt setoff program and/or the Center’s attorney for collection.
POLICY ON MISSED APPOINTMENTS: Appointments made by you or on your behalf on staff schedules are reserved for you
and represent a mutual commitment. Your fee may be charged for appointments not kept unless arrangements are made to cancel
or change them at least one day (24hours) in advance. In addition, High Plains may modify your access to routine services based
on a pattern of missed appointments.
HAYS OFFICE BRANCH OFFICES
208 East 7
th
Street Colby Goodland Norton Osborne Phillipsburg
Hays, KS 67601 750 South Range 723 Main 211 South Norton 209 W. Harrison 783 7
th
Street
(785) 628-2871 Colby, KS 67701 Goodland, KS 67735 Norton, KS 67654 Osborne, KS 67473 Phillipsburg, KS 67661
1-800-432-0333 (785) 462-6774 (785) 899-5991 (785) 877-5141 (785) 346-2184 (785) 543-5284
FAX (785) 628-0330
In order to cover the cost of professional services offered, High Plains Mental Health Center relies on a combination of
funding from patient fees, county mill levies, state funding, and other small special funding grants to serve the people of
Northwest Kansas. In compliance with K.A.R. 30-60-17, it is the Center’s policy that no one will be denied medically
necessary and appropriate services that the center is required to provide by K.A.R. 30-60-64 solely because of the patient’s
inability to pay the fees charged by the Center for those services. Patients living in one of the counties that provide financial
support to the Center may complete an Application for Sliding Scale Fee and enter into an agreement to receive a Percent of
Reduction based on ability to pay. All statements are billed from the Hays Office.
P156-2 01/01/2017
HIGH PLAINS MENTAL HEALTH CENTER
FEE SCHEDULE
A complete listing of our fees is available upon request.
Outpatient and Substance Use Therapy Services:
Psychiatric Diagnostic Evaluation is $250.00 per event.
Substance Use Assessment/Referral is $250.00 per event.
Individual Outpatient Therapy ranges from $100.00 - $175.00, based on the duration of the service.
Group Therapy charge is $100.00 per session.
Family Therapy - $250.00 per session
Other Services:
Crisis Intervention LMHP –$225.00 per hour
Crisis Intervention BA/BS –$175.00 per hour
Crisis Intervention Attendant –$100.00 per hour
Community Psychiatric Supportive Treatment is $150.00 per hour.
Targeted Case Management charge is $125.00 per hour.
Attendant Care charge is $50.00 per hour
Adult Psychosocial Rehabilitation Group is $75.00 per hour.
Child and Adolescent Psychosocial Rehabilitation Group is $75.00 per hour.
Peer Support – Individual is $75.00 per hour.
Peer Support –Group is $50.00 per hour.
Medication Services
Psychiatric Diagnostic Evaluation with Medical Services by APRN or psychiatrist is $375.00 per event.
Medication Services by APRN or psychiatrist range from $100.00 - $250.00 based on the level of service
provided.
Evaluations:
Psychological Evaluations and testing for diagnostic and treatment purposes is $200.00 per hour.
Psychological evaluations are not eligible for a fee reduction. A $400 prepayment is required prior to
scheduling for patients who do not have insurance coverage.
Employment Evaluation: $300.00 per evaluation.
Competency to Stand Trial Evaluation: $315.00 per evaluation.
DUI Evaluation: $150.00 per event.
Alcohol and Drug Evaluation: $200.00 per hour. A pre-payment of $250.00 is required if financial
responsibility belongs to the patient. Alcohol and Drug Evaluations are not submitted to insurance.
DOT Evaluation: $200.00 per hour. A pre-payment of $250.00 is required if financial responsibility
belongs to the patient.
HAYS OFFICE BRANCH OFFICES
208 East 7
th
Street Colby Goodland Norton Osborne Phillipsburg
Hays, KS 67601 750 South Range 723 Main 211 South Norton 209 W. Harrison 783 7
th
Street
(785) 628-2871 Colby, KS 67701 Goodland, KS 67735 Norton, KS 67654 Osborne, KS 67473 Phillipsburg, KS 67661
1-800-432-0333 (785) 462-6774 (785) 899-5991 (785) 877-5141 (785) 346-2184 (785) 543-5284
FAX (785) 628-0330
Combined Notice of Non Discrimination and Accessibility Requirements 10/14/2016
High Plains Mental Health Center complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, sex, or any other protected class.
High Plains Mental Health Center does not exclude people or treat them differently because of race,
color, national origin, age, disability, sex, or any other protected class.
High Plains Mental Health Center:
• Provides free aids and services to people with disabilities to communicate effectively with us,
such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats,
other formats)
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Charlene Anderson, Manager of Quality Improvement.
If you believe that High Plains Mental Health Center has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, sex, or any other protected
class, you can file a grievance with: Charlene Anderson, Manager of Quality Improvement, 208 E 7
th
Street, Hays KS 67601, (785) 628-2871 (phone), (785) 628-1438 (fax). You can file a grievance in person
or by mail or fax. If you need help filing a grievance, Charlene Anderson, Manager of Quality
Improvement, is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office
for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html
Combined Notice of Non Discrimination and Accessibility Requirements 10/14/2016
Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de High Plains Mental Health Center, tiene derecho a
obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1 (844) 787-4924.
Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về High Plains Mental Health Center, quý vị sẽ có quyền được giúp và
có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1 (844) 787-4924.
如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱 High Plains Mental Health
Center ]方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話 [在此插入數字1 (844) 787-
4924。
Falls Sie oder jemand, dem Sie helfen, Fragen zum High Plains Mental Health Center haben, haben Sie das Recht, kostenlose
Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1
(844) 787-4924 an.
만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 High Plains Mental Health Center 에 관해서 질문이 있다면 귀하는 그러한
도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는1 (844)
787-4924 로 전화하십시오.
ຖ້າທ່ານ, ຫ ຼືຄົນທ ່ທ່ານກໍາລັງຊ່ວຍເຫ ຼືອ, ມ ຄໍາຖາມກ່ຽວກັບ High Plains Mental Health Center,
ທ່ານມ ສິດທ ່ຈະໄດ້ຮັບການຊ່ວຍເຫ ຼືອແລະຂໍ້ມູນຂ່າວສານທ ່ເປັນພາສາຂອງທ່ານບໍ່ມ
ຄ່າໃຊ້ຈ່າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ໂທຫາ 1 (844) 787-4924.
إن كان لديك أو لدى شخص تساعده أسئلة بخصوص High Plains Mental Health Center، فلديك الحق في الحصول على
المساعدة والمعلومات
.
1 (844) 787-4924 ـب لصتا مجرتم عم ثدحتلل .ةفلكت ةيا نود نم كتغلب ةيرورضلا
Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa High Plains Mental Health Center, may karapatan ka
na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1
(844) 787-4924.
s ngya s nyya, darmhamahote sain kuunye hkyinnhpyitkyaungg suu tait u u, High Plains Mental Health Center paatsaat.
mayyhkwannmyarr shipark myaha konekya mhar saint bharsarhcakarr aatwat aakuuaanye nhaint satainnaahkyetaalaat rashiraan
hkwin shisai . hcakarrpyan nhaint aatuu pyawwso raan, 1 (844) 787-4924 ko hkaw par .
Si vous, ou quelqu’un que vous êtes en train d’aider, a des questions à propos de High Plains Mental Health Center, vous avez le
droit d’obtenir de l’aide et l’information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1 (844) 787-4924.
ご本人様、またはお客様の身の回りの方でも、High Plains Mental Health Center
についてご質問がございましたら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。
料金はかかりません。通訳とお話される場合、1 (844) 787-4924 までお電話ください。
Если у вас или лица, которому вы помогаете, имеются вопросы по поводу High Plains Mental Health Center, то вы имеете
право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по
телефону 1 (844) 787-4924.
Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog High Plains Mental Health Center, koj muaj cai kom lawv
muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu
rau 1 (844) 787-4924.
اگر شما، يا کسی کە شما بە او کمک ميکنيد ، سوال در مورد High Plains Mental Health Center ، داشتە باشيد حق اين
را داريد کە کمک
و اطلاعات بە زبان خود را بە طور رايگان دريافت نماييد
1 (844) 787-4924. تماس حاصل نماييد
Kama wewe, au mtu unaye mpa usaidizi ana maswali kuhusu High Plains Mental Health Center, Una haki ya kupata habari hii na
msaada kwa lugha yako bila gharama. Kuzungumza na mkalimani, piga nambari hii: 1 (844) 787-4924.
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Completed 22 April 2021

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