Nevada Chapter, NBDF
7500 W. Lake Mead Blvd
Suite 9 #458
Las Vegas, NV 89128
Phone (702) 564-4368
Fac (702) 446-8134
Contact
Nevada Chapter, NBDF
7500 W. Lake Mead Blvd
Suite 9 #458
Las Vegas, NV 89128
Phone (702) 564-4368
Fac (702) 446-8134
Contact

Counseling Services Program Application

In response to requests from the bleeding disorders community, the Nevada Chapter has created a program in collaboration with Nevada Counseling Providers.  Providers located in the Las Vegas area and will provide both in-person, tele-health, and group counseling services for all approved applicants. 

More information about our provider partners can be found on their websites:

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

Eligible applicants are individuals with a bleeding disorder or an immediate family member or designated caregiver of an individual with a bleeding disorder.  If your application is approved, NBDFNV will pay for up to eight (8) one-hour sessions that may also be renewable upon submission of an additional request in coordination with the Provider.  NBDFNV will facilitate the funding of the program and follow all federal and state laws, to include HIPAA privacy standards.  At no time will NBDFNV request or obtain any specific clinical information from the provider, ever.  Any information requested will be related to insurance coverage, if applicable, and the documented request for continued services as applicable. 

Continued payment of counseling services is dependent upon the amount of funding available. NBDFNV will never make a determination regarding the need for counseling services. This is between you and your provider.

This program is not intended to take the place of any current health insurance coverage you may have or any government program you may participate in, to include but not limited to Medicare or Medicaid.

This application is intended to obtain basic information on any health insurance coverage you may or may not have.  The questions in this application are used solely to determine you or your child’s eligibility in the NBDFNV Counseling Program and will not be used for any other purpose or shared with anyone except the provider you are referred to upon approval.

Completion of this application will automatically register you with the Nevada Chapter of NBDF and place you on the mailing list.

BASIC INFORMATION
First Name *
Middle
Last Name *
Month
/
Day
/
Year
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Preferred format (please select all that apply):
What is your preferred time of day for sessions? (Please check all that apply)
Do you have internet access at home capable of video chatting?
Do you have a device capable of video chatting?
Are you able to commit to regularly scheduled meetings over the next 4-8 weeks or as recommended by a counselor?
Do you have a bleeding disorder?
Are you an immediate family member of an individual with a bleeding disorder with whom you live within the same household?
Do you currently have health insurance?
First Name *
Last Name *
Are you enrolled in any other state or federal health insurance program? Do not include food, housing, or other assistance programs that do not provide health insurance or direct medical coverage.

I understand that the information contained within this application will be shared with the contracted therapy provider at either OASIS Counseling or The Practice at UNLV as part of the referral process. I give my permission to share the information included in this form.

I understand that my participation will be known only to the NBDFNV staff running the program and that at no time will any personal health information be shared between my provider and NBDFNV.  Health plan remittance advice or explanation of benefits (EOB) associated with insurance claims, if applicable, will be shared by my provider with NBDFNV to comply with program requirements.

First Name *
Middle
Last Name *
Relationship of requestor (please check):
(Must have authority to act on behalf of individual who will be receiving services.)
First Name *
Last Name *
Submission Date / Fecha de solicitud

CONFIDENTIALITY

Applicants and information pertaining to funding requests are considered confidential to the full extent permitted by law. All Nevada Chapter of NBDF Advisory Board/Emergency Assistance Committee members are required to sign a confidentiality agreement. 

Information from the Nevada Chapter of NBDF's Counseling services applications may be compiled for statistical purposes and for compliance with local, state, federal or affiliate organization requirements.  However, any publication of this data will be in aggregate form only and will not include names or any other information that could be used to identify individual applicants or recipients.

No personal information will be used or disclosed for any purposes other than that for which it was collected without applicants' written permission.  At no time will personal information be shared with any individual, company, and organization outside the Nevada Chapter of the National Bleeding Disorders Foundation.

Resource Links

Nevada Chapter, NBDF
7500 W. Lake Mead Blvd
Suite 9 #458
Las Vegas, NV 89128
Phone (702) 564-4368
Fac (702) 446-8134
Contact
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