Đơn đăng ký tham gia chương trình bảo hiểm sức khỏe cá ... · phương thức...

n ng k ny dnh cho ng k bo him trc tip vi BlueShield cho BlueShield Chng trnh C nhn v Gia nh (IFP, Individual and Family Plan). ng k hoc sa i bo him nhn c thng qua Covered California, hy lin h trc tip vi Covered California.

N NG K THAM GIA PHI C IN BNG MC XANH HOC EN, IN HOA CC CH CI. Bo m qu v tr li tt c cu hi y v chnh xc nht c th v bao gm ph bo him ca thng u tin trnh vic tr li n ng k tham gia. Np TT C cc trang, t 1 n 12, n ng k tham gia y ca qu v bao gm bt k ti liu h tr no khc cho Blue Shield Attn: I&B Applications, P.O. Box 3008, Lodi, CA 95241-9969 hoc fax: (888) 386-3420. Gi BlueShield theo s (888) 256-3650 hoc lin h i l ca qu v c tr gip in n ng k. Nn nh du cc nh sau:

(CH DNH CHO I L)

M TH TRNG

L do ng k: c ng k m c Thi gian ng k c bit (chn mt)Bng cch chn mt s kin ng k/ t cch c bit, qu v xc nhn theo s hiu bit chnh xc nht ca qu v rng qu v iu kin ng k c bit. Ngy xy ra s kin iu kin c th ghi danh c bit: ______/_______/______ Vui lng gii thch loi s kin iu kin c th ghi danh c bit: __________________________________________________________________________

__________________________________________________________________________

Lu : Qu v phi np n trong vng 60 ngy k t khi xut hin s kin chn bo him ny.c ng k mi c Chuyn chng trnh c Thm ngi ph thuc (chn mt)Nu thm ngi ph thuc vo bo him hin c v/hoc yu cu chuyn chng trnh, vui lng cung cp m s ng k Blue Shield ca ngi ng k hin ti: ___________________

Phn 1 Thng tin ngi ng k chnhQu v c iu kin ng k chng trnh bo him sc khe c nhn v gia nh Blue Shield nu qu v l: c dn California v cha ghi danh ng k bo him Medicare. (Cc) la chn chng trnh bo him y t, nha khoa v/hoc nhn khoa c chn cho ngi ng k chnh s p dng cho tt c cc c nhn/ngi ph thuc bao gm trong n ng k ny. Nhng c nhn mun ng k mt la chn chng trnh bo him khc vi ca ngi ng k chnh phi in vo mt n ng k ring v np ring ph/ph bo him ca thng u tin.

S An Sinh X Hi/M s thu ca ngi ng k_____ _____ _____ _____ _____ _____ _____ _____ _____

Tn Tn m

H

c Nam c N kt hn: c C c Khng Ngi Sng Chung: c C c Khng Ngy sinh (thng/ngy/nm) ____/____/_______

S in thoi c quan ca ngi ng k tham gia ( ) S in thoi nh ca ngi ng k tham gia ( )

S fax ca ngi ng k tham gia ( ) S in thoi di ng ca ngi ng k tham gia ( )

Ti hiu v ng rng (cc) s in thoi ti cung cp trong n ng k ny s c s dng bi Blue Shield lin h vi ti v hp ng/n bo him Blue Shield ca ti. Tu theo HIPAA (o lut v Trch nhim v Tnh linh ng vi Bo him Y t), ti hiu rng thng tin c th c cung cp trong mt tin nhn in thoi c ghi li trc vi thng tin quan trng v bo him ca ti, cc la chn gia hn v cc thng tin khc m Blue Shield xc nh l c lin quan n bo him ca ti. Ti ng cho php BlueShield lin h vi ti v/hoc bt k ngi ph thuc no c bo him trong hp ng/n bo him ca ti theo (cc) s in thoi m ti cung cp, bao gm bt k sno ti cung cp m kt ni vi mt in thoi di ng.

K tt

_____

a ch email ca ngi ng k:

Ti hiu v ng rng a ch email ti cung cp trong n ng k ny c th c s dng bi Blue Shield lin lc vi ti v hp ng/n bo him Blue Shield ca ti. Ti hiu rng thng tin gi cho ti qua email c th bao gm cc thng tin quan trng v bo him ca ti, cc la chn gia hn v bt k thng tin no khc m Blue Shield xc nh l c lin quan n bo him ca ti. Ti ng cho php Blue Shield lin h vi ti v/hoc bt k ngi ph thuc no c bo him trong hp ng/n bo him ca ti theo email m ti cung cp trong n ng k ny.

K tt

_____

Nu hin l hi vin Blue Shield, hy cung cp m s ca Ngi ng k:

a ch nh (KHNG Hp th bu in) Cn H S

Thnh ph Tiu bang M ZIP

a ch gi ha n (nu khc trn) Cn H S


a ch gi ng bu in (nu khc vi a ch nh) Cn H S


M ZIP cng ty ca ngi ng k M ZIP cng ty ca v/chng/ngi sng chung nh

Lit k (nhng) tn khc dng trc y

La chn Chng trnh bo him sc khe (ch nh du vo mt ): Chng trnh ca Blue Shield of California:

Chng trnh Exclusive PPO Chng trnh Trio HMO

c BlueShield Platinum 90 PPOc BlueShield Gold 80 PPO

c Silver 70 Off Exchange PPOc Silver 1850 PPOc BlueShield Bronze 60 PPO

c BlueShield Bronze 60 HDHP PPOc BlueShield Minimum Coverage PPO

c BlueShield Platinum 90 HMO Trioc BlueShield Gold 80 HMO Trioc Silver 70 Off Exchange HMO Trio

n ng k tham gia Chng trnh Bo him Sc khe C nhn v Gia nh Blue ShieldBlue Shield of California v Blue Shield of California Life & Health Insurance Company

Blu

e S

hie

ld o

f Ca

lifo

rnia

is a

n in

de

pe

nd

en

t m

em

be

r o

f th

e B

lue

Sh

ield

Ass

oc

iatio

n

C

1290

0-H

CR

-PR

-VI (

1/18

)

C12900-HCR-VI n ng k tham gia Chng trnh Bo him Sc khe C nhn v Gia nh Blue Shield 1

C12

900

-HC

R-P

R-V

I (1/

18)

Tn vit tt ca ngi ng k tham gia chnh _________

Phn 1 Thng tin ngi ng k chnh (tip theo): Qu v phi np n ng k bo him trc ngy 15 ca thng bo him c hiu lc vo ngy u tin ca thng tip theo. Nu qu v np n ng k gia ngy 16 v ngy cui cng ca thng, bo him s c hiu lc vo ngy u tin ca thng th hai tip theo. Ngy c hiu lc trong thi gian ghi danh c bit c th khc vi trong ghi danh m. Xem Phn 5(b), Mc 5 bit chi tit.

Ngy c hiu lc theo yu cu (xem Phn 5(b), Mc 5 bit thng tin) ___________ / ________ / _____________

Lu : Cc mu n Tm Tt v Quyn Li v Bo Him (SBC) sn c cho tt c cc chng trnh bo him y t. Cc mu n ny tm tt bo him v quyn li cho cc chng trnh mt cch ng b. ng nhp vo blueshieldca.com/sbc ti v cc mu n SBC cho bt k chng trnh no m qu v ng k.

(a) Ngi ng k chnh hin c c ng ti California khng? c C c Khng Nu khng, ngi ng k chnh c ng u? ________________________________________

Cho bit ngn ng u tin: c Ting Anh c Ting Ty Ban Nha c Ting Hoa c Ting Vit c Ting Hn Quc c Khc: _____________________________________

Phng thc lin lc u tin (nh du chn mt): c in thoi nh c in thoi ni lm vic c in thoi di ng c Th in t c Th tn thng thng

Thi gian thch hp nht lin lc: _____ c Sng c Chiu ti

nh du y nu qu v c bo him Blue Shield. c Nu c bo him trc y, hy cung cp m s ng k Blue Shield, nu bit: ____________________________

Qu v hoc bt k ngi no ng k bo him hin ti c iu kin cho v/hoc tham gia bo him Medicare khng? c C c KhngNu c, c iu kin hoc c tham gia. Vui lng ghi r tn ca (nhng) ngi ng k: ________________________________________________________________

Phn 2 La chn chng trnh bo him b sung cho ngi ng k tham gia chnh Qu v cng c th mua mt chng trnh bo him nha khoa, nhn khoa hoc gi nha khoa + nhn khoa v/hoc bo him nhn th b sung cho bo him y t ca mnh. Cc chng trnh bo him nha khoa, nhn khoa, nha khoa + nhn khoa v/hoc bo him nhn th cng sn c m khng cn bo him y t. Cc la chn chng trnh nha khoa v nhn khoa s p dng cho tt c cc c nhn/ngi ph thuc bao gm trong n ng k ny.

Cc la chn chng trnh nha khoa v nhn khoa (vui lng ch chn mt chng trnh nha khoa v/hoc mt chng trnh nhn khoa HOC gi Specialty Duo): c Dental HMO c Enhanced Dental HMO $0 c Dental PPO c Enhanced Dental PPO 50/1250 c Enhanced Dental PPO 25/500 c Gi Specialty DuoSM nha khoa + nhn khoa* c Ultimate Vision 15/25/120* c Ultimate Vision 15/25/150*

Ch dnh cho Dental HMO vo trang blueshieldca.com tm mt nh cung cp dch v nha khoa hoc nu c thc mc, hy gi s (888) 256-3650

Tn nh cung cp dch v nha khoa:

M s ca nh cung cp dch v Nha khoa

La chn bo him nhn th*: Bo him nhn th kh dng cho ngi ng k trn 1 tui. Bo him c cung cp theo cc mc tin sau: $10,000 (1-64 tui); $30,000 (1-64 tui); $60,000 (19-64 tui); $90,000 (19-64 tui); $100,000 (19-64 tui). c th mua bo him nhn th, phi hon tt mt n ng k bo him nhn th ring. bit mc gi bo him nhn th v ng k bo him, vui lng truy cp vo trang web ca chng ti ti blueshieldca.com/term-life.* c bo him bi Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

Phn 3(a) Thng tin ca ng n ph thuc l v/chng/ngi cng chung sngc V/chng c Ngi sng chung Gii tnh: c Nam c N Ngy sinh (thng/ngy/nm) ____/____/_______


Tn Tn m

H

Ni c tr ca v/chng/ngi sng chung c ging nh ca ngi ng k chnh khng? c C c KhngNu khng, ngi ng k ny sng u? (a ch, bao gm m ZIP v tiu bang) ______________________________________________________________________

Phn 3(b) Thng tin ng k ca ngi ph thuc l con ci Con ci ph thuc phi di 26 tui. Nu c nhiu hn tm ngi con ph thuc np n ng k bo him, vui lng nh km trang b sung cung cp tt c thng tin c lit k di y, ch k ca qu v v ngy thng.

c Nam c N Quan h: ___________________________ (v d: con trai/con gi)

Ngy sinh (thng/ngy/nm)

____/____/_______


Tn Tn m

H

Ni c tr ca ngi ng k l con ci ph thuc c ging nh ca ngi ng k chnh khng? c C c KhngNu khng, ngi ng k ny sng u? (a ch, bao gm m ZIP v tiu bang) ______________________________________________________________________


C12

900

-HC

R-P

R-V

I (1/

18)


Phn 3(c) Thng tin ng k ca ngi ph thuc l con cic Nam c N Quan h: ___________________________ (v d: con trai/con gi)


____/____/_______


Tn Tn m

H


Phn 3(d) Thng tin ngi ng k ph thuc l con cic Nam c N Quan h: ___________________________ (v d: con trai/con gi)


____/____/_______


Tn Tn m

H


Phn 3(e) Thng tin ngi ng k ph thuc l con cic Nam c N Quan h: ___________________________ (v d: con trai/con gi)


____/____/_______


Tn Tn m

H


Phn 3(f) Thng tin ngi ng k ph thuc l con cic Nam c N Quan h: ___________________________ (v d: con trai/con gi)


____/____/_______


Tn Tn m

H



C12

900

-HC

R-P

R-V

I (1/

18)


Phn 3(g) Thng tin ngi ng k ph thuc l con cic Nam c N Quan h: ___________________________ (v d: con trai/con gi)


____/____/_______


Tn Tn m

H


Phn 3(h) Thng tin ngi ng k ph thuc l con cic Nam c N Quan h: ___________________________ (v d: con trai/con gi)


____/____/_______


Tn Tn m

H


Phn 3(i) Thng tin ngi ng k ph thuc l con ci Nu trn tm ngi con ph thuc np n xin bo him, vui lng nh km thm trang b sung cung cp tt c cc thng tin c lit k di y, ch k ca qu v v ngy thng. nh du chn y nu c nh km trang b sung. c

c Nam c N Quan h: ___________________________ (v d: con trai/con gi)


____/____/_______


Tn Tn m

H



C12

900

-HC

R-P

R-V

I (1/

18)

Phn 4 y quyn cho tit l thng tin

Bng cch k tn vo mu dn ny, qu v ang y quyn tit l thng tin chm sc sc khe ca qu v v/hoc ngi ph thuc ca qu v bi nh cung cp dch v chm sc sc khe, cng ty bo him, t chc h tr vo him, chng trnh bo him sc khe, hoc i l bo him ca qu v cho Blue Shield of California hoc BlueShield of California Life & Health Insurance Company (gi chung l Blue Shield), nhm mc ch x l khiu ni v qun l cc khon quyn li theo tha thun dch v chm sc sc khe/hp ng bo him.

Ngoi ra, bng cch k tn vo mu n ny, qu v ang y quyn cho Blue Shield tit l nhng thng tin chm sc sc khe cho nh cung cp dch v chm sc sc khe, cng ty bo him, cng ty t bo him, t chc h tr bo him, chng trnh bo him sc khe, hoc i l bo him ca qu v v mc ch iu tra hoc nh gi bt k yu cu v quyn li no. Thng tin chm sc sc khe c s dng hoc tit l theo giy y quyn ny c th ti tit l v c th khng cn c bo v theo lut lin bang v quyn ring t ca thng tin sc khe na.

Qu v c quyn t chi k vo giy y quyn ny.

Qu v c cp mt bn sao ca giy y quyn ny sau khi qu v k tn.

Ht hn: y quyn ny s c hiu lc: 1) trong ba mi (30) thng k t ngy y quyn cho mc ch x l n ca qu v, x l mt yu cu phc hi hoc x l mt yu cu thay i quyn li; 2) cho n khi no cn cn x l yu cu bo him xy ra trong thi hn bo him; 3) cho thi hn bo him dnh cho tt c cc hot ng khc c tin hnh theo tha thun dch v chm sc sc khe/hp ng bo him.

Quyn thu hi: Ti hiu rng ti c th thu hi giy y quyn ny bt k lc no bng cch gi vn bn thng bo thu hi ca ti cho Blue Shield. Ti hiu rng vic hy b giy y quyn ny s khng nh hng n bt k hnh ng no m BlueShield thc hin da trn y quyn ny trc khi nhn c vn bn thng bo thu hi ca ti.

Ngi ng k/cha m hoc ngi gim h hp php Hm nay ngy

V/chng/ngi sng chung ca ngi ng k Hm nay ngy

Ngi ng k t 18 tui hoc hn Hm nay ngy




Tip theo Phn 5 cn phi c ch k ca qu v v ngy hin ti trong phn ny.


C12

900

-HC

R-P

R-V

I (1/

18)

Phn 5(a) Xc nhn tnh chnh xc ca ngi ng kVui lng c k phn sau. Mi thnh vin gia nh np n t 18 tui tr ln c yu cu xem li n ng k tham gia in v cung cp ch k ring ca mnh. Gi li mt bn ca n xin ny lu h s ca qu v.

Ti t chu trch nhim cho s chnh xc v y ca thng tin c cung cp trong n ng k tham gia ny. Ti t kim tra tt c thng tin c cung cp trong n ng k tham gia ny, mc d ti khng t in. Theo s hiu bit chnh xc nht v nim tin ca ti, mi thng tin trong mu n ny l chnh xc, ng s tht v y . Nu Blue Shield xc nh rng c s gian ln (bng hnh vi, hot ng, hoc thiu st) hoc bt k s c tnh trnh by sai lc d liu quan trng trong thng tin trn n ng k ny, ti hiu rng bo him c th b thu hi theo quy nh ca php lut.

Dnh cho ngi ng k c ngn ng u tin khng phi Ting Anh: Nu ti ch r trong Phn 1 rng ti c ngn ng u tin khng phi l Ting Anh v ti hon tt phn Ting Anh ca n ng k ny (hoc mt phin bn khc ngn ng u tin ca ti), th ti xc nhn rng ti hiu nhng cu hi ca n ng k tham gia ny.

Ch k ca ngi ng k/cha m hoc ngi gim h hp php Hm nay ngy Tn vit in (v quan h nu ngi ng k tham gia l tr v thnh nin)

Ch k ca v/chng/ngi sng chung ca ng n (nu ang np n) Hm nay ngy Tn vit in

Ch k ca thnh vin gia nh 18 tui tr ln (nu ang np n) Hm nay ngy Tn vit in




Phn 5(b) y quyn, iu khon v iu kinVui lng c k cc iu khon v iu kin sau y. Mi ngi ng k trn 18 tui phi xem li n xin hon chnh v cung cp s y quyn ca ring h cng nh ch k ring ca mnh. Gi li mt bn ca n xin ny lu h s ca qu v.1. n ng k tham gia bo him: iu quan trng l phi bit rng Blue Shield of California hoc Blue Shield of California Life & Health Insurance Company (khi thch hp) c quyn

t chi n ng k tham gia bo him ca qu v nu hin nay qu v khng iu kin. n ng k ca qu v phi c chp thun bi Blue Shield, v ngy c hiu lc bo him c ch nh trc khi bo him c th c hiu lc.

2. Ph/ph bo him thng u tin: Blue Shield yu cu np ph/ph bo him ca thng u tin ti thi im np n. Tm c tnh ph/ph bo him hng thng bng cch truy cp blueshieldca.com hoc lin lc vi i l ca qu v. Tham kho Phn 7 bit cc la chn thanh ton. Nu khng np ph/ph bo him th n ng k tham gia ca qu v s b tr li. Vui lng lu rng vic x l bt k khon thanh ton no cng khng cu thnh vic chp thun n ng k ca qu v vi Blue Shield hoc Blue Shield Life. Nu qu v hin nay khng iu kin tham gia bo him, th ph/ph bo him m qu v np cng vi n ng k s khng c x l. Nu qu v gi bng sc, th sc s b hy. Nu qu v in vo giy cho php thanh ton, th tn dng/th ghi n hoc ti khon vng lai ca qu v s khng c ghi n.

3. Ph bo him qu hn: Blue Shield bo lu quyn thu bt k khon ph bo him cha thanh ton no cho bo him trong khong thi gian 12 thng trc ngy c hiu lc ca bo him mi trc khi cp bo him mi.

4. Ph/ph bo him: Ph/ph bo him phi c thanh ton y v ng hn. Bo him s b chm dt nu khng thanh ton ph/ph bo him ng thi hn nh quy nh trong tha thun dch v chm sc sc khe/n bo him v theo quy nh ca php lut. (Bt buc) Bng cch nh du vo ny c , ti cng nhn v ng vi Chnh sch Thanh ton Ph bo him Blue Shield sau y. Ti cng xc nhn rng ti, hoc mt Ngi thanh ton Bn th ba c chp nhn, ang v s thanh ton tt c cc ph bo him trong tng lai cho bo him Blue Shield ca ti. Ngi ng k c trch nhim thanh ton ph/ph bo him cho BlueShield of California. BlueShield of California khng chp nhn cc khon thanh ton trc tip hoc gin tip cho cc ph/ph bo him t bt k ngi no hoc i tng no khng phi Ngi ng k, thnh vin gia nh hoc ngi gim h hp php ca h, hoc mt Ngi thanh ton Bn th ba c chp nhn. Ngi thanh ton Bn th ba c chp nhn l:

Chng trnh Ryan White HIV/AIDS thuc Mc XXVI ca Public Health Services Act (o lut Dch v Sc kho Cng cng) Cc b lc, t chc b lc ca ngi M Bn a hoc t chc ngi M Bn a thnh th Chng trnh hp php ca Lin bang, Tiu bang hoc a phng, bao gm c ngi c hng tr cp c ch o bi mt chng trnh ca chnh ph thay mt h thc hin

thanh ton.


C12

900

-HC

R-P

R-V

I (1/

18)

Tn vit tt ca ngi ng k tham gia chnh _________ Cc t chc t thin v cc t chc lin quan n Ngi ng k (nh nh th hoc ngi s dng lao ng) khi nhng iu sau y ng: thanh ton c m bo cho nm thuc

chng trnh, h tr c cung cp da trn cc tiu ch v tnh trng ti chnh v tnh trng sc kho khng c xem xt, t chc khng lin quan n mt nh cung cp dch v chm sc sc kho, v t chc khng c li ch ti chnh trong vic thanh ton mt yu cu bo him thuc chng trnh chm sc sc kho. Cc c quan/t chc c hng li ti chnh bao gm cc c quan/t chc nhn phn ln kinh ph ca h t cc n v c tin li trong vic thanh ton cc yu cu bo him sc kho, hoc cc c quan/t chc chu s kim sot trc tip hoc gin tip ca cc n v c tin li trong vic thanh ton cc yu cu bo him y t. Khi pht hin ra rng ph/ph bo him c thanh ton trc tip hoc gin tip bi mt ngi hoc t chc khng phi l nhng ngi c lit k trn hoc Ngi ng k, BlueShield of California c quyn t chi thanh ton v thng bo cho Ngi ng k rng khon thanh ton khng c chp nhn v cc khon ph/ph bo him vn cha c thanh ton. X l bt k khon thanh ton no khng t b quyn c t chi thanh ton v cc thanh ton trong tng lai thuc n bo him ny ca Blue Shield of California.

5. Ngy c hiu lc bo him: Nu qu v iu kin c nhn bo him, Blue Shield s thng bo cho qu v bit v ngy c hiu lc ca khon bao tr. Nu Blue Shield khng th chp nhn ngy c hiu lc theo yu cu ca qu v, hoc khng th bo him trc ngy c hiu lc theo yu cu ca qu v, th bo him s bt u trong thi gian sm nht c th. Cc khon chi ph/ ph bo him cn n phi c thanh ton trc khi bo him c hiu lc. Bt k khon ph pht sinh no i vi cc dch v nhn c trc ngy c hiu lc ca qu v hoc sau khi chm dt bo him s khng c chi tr.

Ngy c hiu lc ca thi gian ghi danh c bit c th khc so ca vi thi gian ghi danh m. Ngy c hiu lc c ch nh bi Blue Shield v c th sm nht l vo ngy mng 1 ca thng sau khi nhn c bin lai cho thi gian ghi danh c bit theo yu cu ca quy nh, hoc l ngy sinh i vi trng hp tr s sinh. bit thm thng tin v ngy c hiu lc cho thi gian ghi danh c bit, vui lng lin lc vi Blue Shield.

6. Chp thun ca n ng k: Qu v hiu rng ch c Blue Shield mi c th chp nhn n xin ca qu v v cp khon bao tr i vi chng trnh IFP theo yu cu trong mu n ny. i l hoc ngi mi gii ca qu v khng th ng k cho qu v tham gia bo him hay thay i bt k iu khon hay iu kin bo him no.

7. Cha m/ngi gim h: Nu qu v l cha m hoc ngi gim h ca ngi ng k l tr v thnh nin, vui lng k tn thay cho ngi ng k di cng ca Phn 5 ny. L cha m hoc ngi gim h hp php, qu v c xc nhn l ngi c th tm hiu v hnh ng thay mt ngi ng k v bo him ny (nh php lut cho php). Ngoi ra, qu v ng m ng tt c trch nhim thanh ton ph/ph bo him v tun theo nhng iu khon v iu kin bo him. Nu qu v khng phi l cha m ca ngi ng k tham gia, vui lng km theo chng t ta n ch nh qu v lm ngi gim h ca tr v thnh nin ny. nh du mt trong cc sau y v xc minh ngi c php thay mt tr v thnh nin ny (ngi ng k):

c Ch dnh cho cha m/ngi gim h hp php: ________________________________________________________________ (bao gm tn v quan h), hoc c Ngi c ti ch nh ________________________________________________________________________________ (bao gm tn v quan h); hoc c Ngi c ch nh h tr tr nng lc y t _________________________________________________________________ (bao gm tn v quan h). c nh du ny nu Blue Shield ch c php thay i hp ng sau khi c yu cu bng vn bn ca ngi c xc nh bn trn.8. y quyn cho v/chng/ngi sng chung c thc hin thay i: Nu qu v l mt ngi ng k c v/chng/ngi cng chung sng cng ang np

n ng k bo him, vui lng nu r liu qu v c y quyn cho v/chng/ngi cng chung sng ca qu v thc hin thay i hp ng/n bo him thay mt qu v khng. Qu v c th rt li s y quyn ny vo bt k lc no bng cch gi yu cu bng vn bn cho Blue Shield.

c Cc Khng

9. S y quyn cho i l ca qu v cung cp/nhn thng tin: nh du y nu qu v khng y quyn cho i l bo him, ngi mi gii hoc i l (gi l i l ca qu v) tip cn tt c thng tin trn n ng k tham gia ny.

c

10. Quy trnh cho php Blue Shield tit l thng tin c nhn v sc khe cho bn th ba: Nu qu v mun y quyn cho v/chng, ngi sng chung, hoc bn th ba truy cp thng tin sc khe c nhn ca qu v, vui lng hon tt mu n c tiu y quyn Blue Shield Tit l Thng tin C nhn & Sc khe cho Bn Th ba. nhn mu n ny, hy truy cp blueshieldca.com v nhp vo lin ktRing t cui trang, hoc gi (888) 256-3650.

11. Tr li thng tin c yu cu: Qu v ng hp tc vi Blue Shield (hoc Blue Shield Life, khi ph hp) bng cch cung cp, hoc cho php truy cp, ti liu v nhng thng tin khc c yu cu (nh lnh ca ta n cung cp bo him cho ngi ph thuc, v.v.) chng minh thng tin c cung cp trong n ng k tham gia bo him ny. Qu v xc nhn v ng rng vic khng hoc t chi cung cp nhng ti liu hoc thng tin c yu cu ny c th dn n vic thu hi hoc hy bo him ca qu v.

12. Nhn ti liu v lin lc theo cch in t so vi bn in: Qu v s nhn c k hoch phc li theo yu cu v ti liu lin quan n bo him n v thng tin lin lc qua email v/hoc trang web ca Blue Shield ti a ch blueshieldca.com, nu p dng. Cc ti liu c cung cp cho qu v qua blueshieldca.com nh sau:

Chng t Bo him v Tha thun v Dch v Chm sc Sc khe (EOC)/n bo him Tuyn b Quyn li (SOB) Tm tt Quyn li v Bo him (SBC) Xc nhn EOC hoc n bo him Nhn ti liu bn in t s xc nhn qu v ng nhn th t lin lc qua th in t. Qu v cng c quyn nhn bn ti liu in qua bu in min ph vo bt k thi im no. nhn cc ti liu in bng th, chn khng tham gia vo cc lin lc qua email, hoc nu qu v c thc mc, vui lng gi (888) 256-3650. Ti xem xt mi cu tr li c lin quan n ti trong n xin ny. Ti c bn tm tt quyn li, Tm Tt Quyn Li v Bo Him (SBC), cng nh nhng iu khon v iu kin bo him v y quyn nu trn. Bng ch k ca ti bn di, ti m bo rng thng tin c cung cp trong n ng k ny l hon chnh v chnh xc theo s hiu bit chnh xc nht ca ti, v ti hiu v ng vi cc iu khon v iu kin bo him v s u quyn m ti cung cp. (Quan trng: Mi ng n l ngi ln phi t k tn.) Ti hiu rng ti phi thng bo cho Blue Shield bit nu c bt k iu g thay i hoc khc vi nhng g ti trnh by trong n xin ny trc khi ti bt u ghi danh vi Blue Shield.

Ch k ca ngi ng k/cha m hoc ngi gim h hp php Hm nay ngy Tn vit in (v quan h ca qu v nu ngi ng k l tr v thnh nin)

Ch k ca v/chng/ngi sng chung ca ng n (nu ang np n) Hm nay ngy Tn vit in





Quan trng: Gi li n ng k ny trong vng 30 ngy k t ngy k. Chng ti phi nhn c n ng k ca qu v trong thi gian ghi danh m hoc trong vng 60 ngy k t khi c s kin khi u cho php Ghi Danh c Bit.


C12

900

-HC

R-P

R-V

I (1/

18)

Phn 6 Thng tin i l: c in hon tt bi i l y quyn ca Blue Shield1. Qu v in hon tt n ng k ny? c C c Khng

2. Nu c, qu v hi tng cu hi trong n ng k ny chnh xc nh quy nh khng? c C c Khng

3. Cc cu tr li c c ghi nhn li chnh xc nh c cung cp cho qu v khng? c C c Khng, km gii thch.

4. Qu v c mun tha thun dch v sc khe/hp ng bo him c gi trc tip n ngi ng k? c C c Khng

Tn i l cp cao (n v/c nhn c pht hoa hng)

a ch th in t c Cp nht th in t S ca i l

S in thoi ( ) c Cp nht s in thoi S fax ( ) c Cp nht fax

a ch ca i l

c Cp nht a ch


Tn i l cp cao S ca i l cp cao

Ch k ca i l (bt buc) Ngy hm nay (bt buc) Tn vit in

Cc i l: Vui lng bo m in y tng phn ca n ng k. Trong trng hp thiu hoc khng thng tin, Blue Shield c th lin lc trc tip vi ngi ng k ly thng tin hon chnh.

Phn 7 Ha n v thng tin thanh tonTnh ton ph/ph bo him c tnh hng thng

Truy cp blueshieldca.com xem l ph/ph bo him c tnh hng thng hoc trao i vi i l ca qu v bit l ph/ph bo him c tnh hng thng.

Phi np l ph/ph bo him thng u tin ti thi im np n ng k.

Blue Shield s cung cp mc l ph/ph bo him cui cng trc bt k ngy c hiu lc no ca bo him. Nu tng s tin cui cng khc vi mc l ph/ph bo him c tnh v cc s tin b sung c n li th cc khon tin phi c thanh ton trc khi bo him c hiu lc.

Cc la chn thanh ton

Ph/ph bo him thng u tin ca qu v c th c tr bng cc la chn di y:

Chuyn khon in t qua ti khon sc hoc ti khon tit kim ca qu v.

Th thanh ton thanh ton c x l thng qua vic ghi n hoc tn dng vo th ghi n hoc th tn dng ca qu v.

Np ngn phiu hoc lnh chuyn tin.

Cc la chn thanh ton: (Cn phi np ph/ph bo him cng vi n ng k ca qu v.)

Vui lng chn mt trong cc la chn bn di thanh ton:c Chuyn khon in t qua ti khon sc hoc ti khon tit kim (hon tt phn A di y)c Th thanh ton (th ghi n hoc th tn dng) (hon tt phn B di y)c Bng sc* hoc lnh chuyn tin (Ch khi n ng k c gi qua ng bu in)

* Khi qu v cung cp mt t sc thanh ton, qu v cho php Blue Shield hoc s dng thng tin t sc ca qu v thc hin chuyn khon in t mt ln t ti khon ca qu v hoc x l thanh ton nh l mt giao dch bng sc. Khi chng ti s dng thng tin ny t sc ca qu v thc hin chuyn khon in t, cc qu s c rt ra t ti khon ca qu v ngay khi chng ti chp nhn n ng k ca qu v v qu v s khng nhn c sc ca mnh tr li t t chc ti chnh ca qu v.


C12

900

-HC

R-P

R-V

I (1/

18)

Phn 7 (tip) Giy cho php thanh tonThng tin ngi ng k

Tn ngi ng k

a ch gi th Cn H S


S in thoi ban ngy ca ngi ng k ( )

Phng thc thanh ton

A. Thanh ton bng ti khon sc hoc ti khon tit kim: c Ti khon sc c Ti khon tit kim

S truy ngn/chuyn tip ngn hng

S ti khon ngn hng

(Cc) tn trn ti khon

Tn ca t chc ti chnh

a ch chi nhnh


S in thoi chi nhnh ( )

B. Th Thanh ton (Ch chp nhn Th Visa hoc MasterCard)

Tn ch th

a ch gi ha n ca ch th Cn H S


S th thanh ton

Loi th: c Visa c MasterCard Ngy ht hn (thng/nm) ___/_______

y quyn v ch k

Mt trong nhng iu khon sau s c p dng, ty thuc vo phng thc thanh ton m ti chn trn:

Thanh ton ph/ph bo him bng th thanh ton (th tn dng hoc th ghi n):Ti cho php chng trnh ca ti, Blue Shield of California hoc Blue Shield of California Life & Health Insurance Company (Blue Shield) thu ph hoc ghi n khon l ph/ph bo him thng u tin vo th tn dng hoc th ghi n ca ti (th thanh ton) c nhn din pha trn, v y quyn ny ch c hiu lc thu ph hoc ghi n khon l ph/ph bo him ca thng u tin phi tr cho Blue Shield. Ti hiu rng th thanh ton ca ti s c dng ghi n hoc thu ph/ph bo him thng u tin nu n ng k ca ti c chp thun. Ti cng hiu rng mc bo him khc nhau c th c p dng cho bo him n c ph duyt. Nu ti c chp nhn mt mc gi khc, Blue Shield s thng bo v l ph/ph bo him hng thng thc t, trc ngy bo him c hiu lc ban u v s tin s c thanh ton theo y quyn ny.

Thanh ton bng cch ghi n t ti khon sc/tit kim:Ti cho php chng trnh ca ti, Blue Shield of California hoc Blue Shield of California Life & Health Insurance Company (Blue Shield) ghi n khon l ph/ph bo him thng u tin vo ti khon ngn hng ca ti c nhn din pha trn, v y quyn ny ch c hiu lc ghi n khon l ph/ph bo him ca thng u tin phi tr cho Blue Shield. Ti hiu rng ti khon ngn hng ca ti s c dng ghi n l ph/ph bo him thng u tin nu n ng k ca ti c chp thun. Ti cng hiu rng mc bo him khc nhau c th c p dng cho bo him n c ph duyt. Nu ti c chp nhn mt mc gi khc, Blue Shield s thng bo v l ph/ph bo him hng thng thc t, trc ngy bo him c hiu lc ban u v s tin s c thanh ton theo y quyn ny.

Khi k tn bn di, ti ng vi cc iu khon v iu kin ca giy y quyn ny v ti xc nhn rng ti nhn c mt bn sao ca giy ny. Ti xc nhn rng mi giao dch thanh ton phi tun th cc quy nh ca lut php Hoa K.

Thanh ton c th c x l bi mt nh cung cp bn th ba thay mt cho Blue Shield.

Ch k ca ch th/ch ti khon Tn vit in

_____ _____ _____ _____ _____ _____ _____ _____ _____ ______/______/___________S An Sinh X hi Ngy


_____ _____ _____ _____ _____ _____ _____ _____ _____ ______/______/___________S An Sinh X hi Ngy


C12

900

-HC

R-P

R-V

I (1/

18)

Phn 7 Ha n v thng tin thanh tonTnh ton ph/ph bo him c tnh hng thng

Truy cp blueshieldca.com xem l ph/ph bo him c tnh hng thng hoc trao i vi i l ca qu v bit l ph/ph bo him c tnh hng thng.

Phi np l ph/ph bo him thng u tin ti thi im np n ng k.

Blue Shield s cung cp mc l ph/ph bo him cui cng trc bt k ngy c hiu lc no ca bo him. Nu tng s tin cui cng khc vi mc l ph/ph bo him c tnh v cc s tin b sung c n li th cc khon tin phi c thanh ton trc khi bo him c hiu lc.

Cc la chn thanh ton

Ph/ph bo him thng u tin ca qu v c th c tr bng cc la chn di y:

Chuyn khon in t qua ti khon sc hoc ti khon tit kim ca qu v.

Th thanh ton thanh ton c x l thng qua vic ghi n hoc tn dng vo th ghi n hoc th tn dng ca qu v.

Np ngn phiu hoc lnh chuyn tin.

Cc la chn thanh ton: (Cn phi np ph/ph bo him cng vi n ng k ca qu v.)

Vui lng chn mt trong cc la chn bn di thanh ton:c Chuyn khon in t qua ti khon sc hoc ti khon tit kim (hon tt phn A di y)c Th thanh ton (th ghi n hoc th tn dng) (hon tt phn B di y)c Bng sc* hoc lnh chuyn tin (Ch khi n ng k c gi qua ng bu in)

* Khi qu v cung cp mt t sc thanh ton, qu v cho php Blue Shield hoc s dng thng tin t sc ca qu v thc hin chuyn khon in t mt ln t ti khon ca qu v hoc x l thanh ton nh l mt giao dch bng sc. Khi chng ti s dng thng tin ny t sc ca qu v thc hin chuyn khon in t, cc qu s c rt ra t ti khon ca qu v ngay khi chng ti chp nhn n ng k ca qu v v qu v s khng nhn c sc ca mnh tr li t t chc ti chnh ca qu v.

Thng tin ngi ng k

Tn ngi ng k

a ch gi th Cn H S


S in thoi ban ngy ca ngi ng k ( )

Phng thc thanh ton

A. Thanh ton bng ti khon sc hoc ti khon tit kim: c Ti khon sc c Ti khon tit kim

S truy ngn/chuyn tip ngn hng

S ti khon ngn hng

(Cc) tn trn ti khon

Tn ca t chc ti chnh

a ch chi nhnh


S in thoi chi nhnh ( )

B. Th Thanh ton (Ch chp nhn Th Visa hoc MasterCard)

Tn ch th

a ch gi ha n ca ch th Cn H S


S th thanh ton

Loi th: c Visa c MasterCard Ngy ht hn (thng/nm) ___/_______

HY GI LI MT BN SAO CA N NG K NY


C12

900

-HC

R-P

R-V

I (1/

18)

y quyn v ch k

Mt trong nhng iu khon sau s c p dng, ty thuc vo phng thc thanh ton m ti chn trn:

Thanh ton ph/ph bo him bng th thanh ton (th tn dng hoc th ghi n):Ti cho php chng trnh ca ti, Blue Shield of California hoc Blue Shield of California Life & Health Insurance Company (Blue Shield) thu ph hoc ghi n khon l ph/ph bo him thng u tin vo th tn dng hoc th ghi n ca ti (th thanh ton) c nhn din pha trn, v y quyn ny ch c hiu lc thu ph hoc ghi n khon l ph/ph bo him ca thng u tin phi tr cho Blue Shield. Ti hiu rng th thanh ton ca ti s c dng ghi n hoc thu ph/ph bo him thng u tin nu n ng k ca ti c chp thun. Ti cng hiu rng mc bo him khc nhau c th c p dng cho bo him n c ph duyt. Nu ti c chp nhn mt mc gi khc, Blue Shield s thng bo v l ph/ph bo him hng thng thc t, trc ngy bo him c hiu lc ban u v s tin s c thanh ton theo y quyn ny.

Thanh ton bng cch ghi n t ti khon sc/tit kim:Ti cho php chng trnh ca ti, Blue Shield of California hoc Blue Shield of California Life & Health Insurance Company (Blue Shield) ghi n khon l ph/ph bo him thng u tin vo ti khon ngn hng ca ti c nhn din pha trn, v y quyn ny ch c hiu lc ghi n khon l ph/ph bo him ca thng u tin phi tr cho Blue Shield. Ti hiu rng ti khon ngn hng ca ti s c dng ghi n l ph/ph bo him thng u tin nu n ng k ca ti c chp thun. Ti cng hiu rng mc bo him khc nhau c th c p dng cho bo him n c ph duyt. Nu ti c chp nhn mt mc gi khc, Blue Shield s thng bo v l ph/ph bo him hng thng thc t, trc ngy bo him c hiu lc ban u v s tin s c thanh ton theo y quyn ny.

Khi k tn bn di, ti ng vi cc iu khon v iu kin ca giy y quyn ny v ti xc nhn rng ti nhn c mt bn sao ca giy ny. Ti xc nhn rng mi giao dch thanh ton phi tun th cc quy nh ca lut php Hoa K.

Thanh ton c th c x l bi mt nh cung cp bn th ba thay mt cho Blue Shield.


_____ _____ _____ _____ _____ _____ _____ _____ _____ ______/______/___________S An Sinh X hi Ngy


_____ _____ _____ _____ _____ _____ _____ _____ _____ ______/______/___________S An Sinh X hi Ngy

HY GI LI MT BN SAO CA N NG K NY


Blue Shield of California50 Beale Street, San Francisco, CA 94105 blueshieldca.com

Thng Bo Dnh Cho C Nhn V Yu Cu Khng Phn Bit i X V Kh Nng Tip Cn

Phn bit i x l hnh vi vi phm php lutBlueShieldofCaliforniatunthlutdnslinbanghinhnhvkhngphnbitixdatrnsctc,muda,xutx,tuitc,khuyttthocgiitnh.BlueShieldofCaliforniakhngloitrhocixvimtsngimtcchkhcbitdosctc,muda,xutx,tuitc,khuyttthocgiitnh.

Blue Shield of California:

Cungcpshtrvdchvminphchongikhuytttcthgiaotiphiuquvichng tinh:

- Phindchvinngnngkhiunnglc

- Thngtinbngvnbndinhiunhdngkhc(trongcbninkhln,bnghim,nhdngintcthtipcnvccnhdngkhc)

CungcpdchvngnngminphchocccnhnmngnngchnhkhngphiltingAnh, vd:

- Phindchvinnnglc

- Thngtincvitbngccngnngkhc

Nuquvcnccdchvny,hylinhiuPhiVinQuynDnScaBlueShieldofCalifornia.

NuquvchorngBlueShieldofCaliforniakhngcungcpccdchvnyhoccsphnbitixtheocchkhcdatrnvnsctc,muda,xutx,tuitc,khuyttthocgiitnh,quvcthgithanphinvi:

Blue Shield of California Civil Rights Coordinator P.O.Box629007 ElDoradoHills,CA95762-9007in thoi: (844) 831-4133 (TTY: 711) Fax: (916) 350-7405 Email: [email protected]

Quvcthtrctipgithanphinhocgibngth,faxhocemail.Nuquvcntrgiptrongvicnpthanphin,PiuPhiVinQuynDnScachngtisnsngtrgipquv.

Blu

e S

hie

ld o

f Ca

lifo

rnia

is a

n in

de

pe

nd

en

t m

em

be

r o

f th

e B

lue

Sh

ield

Ass

oc

iatio

n

A20

275

-REV

-VI (

10/1

6)

QuvcngcthnpyucuthanphintheonhdngintvquyndnsviU.S.DepartmentofHealthandHumanServices(BYTVDchVNhnSinhHoaK),PhngDnSthngquaCngThngTinThanPhincaPhngDnS,theoachhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf,hocbngthhocquainthoitheoach:

U.S. Department of Health and Human Services 200IndependenceAvenueSW. Room509F,HHHBuilding Washington,DC20201 (800)368-1019;TTY:(800)537-7697

Biumuthanphinctrnwww.hhs.gov/ocr/office/file/index.html.

IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For help at no cost, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198.

IMPORTANTE: Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. Tambin puede recibir esta carta en su idioma. Para ayuda sin cargo, por favor llame inmediatamente al telfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificacin de Blue Shield o al (866) 346-7198. (Spanish)

Blue Shield ID /

(866) 346-7198(Chinese)

QUAN TRNG: Qu v c th c l th ny khng? Nu khng, chng ti c th nh ngi gip qu v c th. Qu v cng c th nhn l th ny c vit bng ngn ng ca qu v. c h tr min ph, vui lng gi ngay n Ban Dch v Hi vin/Khch hng theo s mt sau th ID Blue Shield ca qu v hoc theo s (866) 346-7198. (Vietnamese)

MAHALAGA: Nababasa mo ba ang sulat na ito? Kung hindi, maari kaming kumuha ng isang tao upang matulungan ka upang mabasa ito. Maari ka ring makakuha ng sulat na ito na nakasulat sa iyong wika. Para sa libreng tulong, mangyaring tumawag kaagad sanumerong telepono ng Miyembro/Customer Service sa likod ng iyong Blue Shield ID kard, o (866) 346-7198. (Tagalog)

Baa kohwiindzindoo7g7: D77 naaltsoos7sh y77nitago b77n7ghah? Doo b77n7ghahg 7, naaltsoos nich8 yiid0o[tah7g77 a nihee hl=. D77 naaltsoos a[d0 t11 Din4 kehj7 1dooln77[ n7n7zingo b7ighah. Doo b22h 7l7n7g0 sh7k1 adoowo[ n7n7zing0 nihich8 b44sh bee hod7ilnih d00 n1mboo 47 d77 Blue Shield bee n47hod7lzin7g7 bined44 bik11 47 doodag0 47 (866) 346-7198 j8 hod77lnih. (Navajo)

: ? , .

. Blue Shield ID

/ (866) 346-7198 . (Korean)

blueshieldca.com

, , Blue Shield ID , (866) 346-7198 (Armenian)

: ? , . . / , Blue Shield, (866) 346-7198, . (Russian)

Blue Shield ID/(866) 346-7198 (Japanese)

. : .

) / .866( 346-7198 Blue Shield (Persian)

: ?

Blue Shield ID / , (866) 346-7198 (Punjabi)

? / Blue Shield (866) 346-7198 (Khmer)

. : . /

(Arabic)).866( 346-7198 Blue Shield

TSEEM CEEB: Koj pos tuaj yeem nyeem tau tsab ntawv no? Yog hais tias nyeem tsis tau, peb tuaj yeem nrhiav ib tug neeg los pab nyeem nws rau koj. Tej zaum koj kuj yuav tau txais muab tsab ntawv no sau ua koj hom lus. Rau kev pab txhais dawb, thov hu kiag rau tus xov tooj Kev Pab Cuam Tub Koom Xeeb/Tub Lag Luam uas nyob rau sab nraum nrob qaum ntawm koj daim npav Blue Shield ID, los yog hu rau tus xov tooj (866) 346-7198. (Hmong)

: / Blue Shield (866) 346-7198 (Thai)

: ? , : Blue Shield ID / , (866) 346-7198 (Hindi)

blueshieldca.com

blueshieldca.com

Notice of the Availability of Language Assistance ServicesBlue Shield of California Life & Health Insurance Company

Đơn đăng ký tham gia chương trình bảo hiểm sức khỏe cá ... · phương thức...

Documents