Filetype PDF | Posted on 17 Aug 2022 | 3 years ago
Authentication
digital resources
198x Filetype PDF File size 0.45 MB Source: www.premera.com
Other Coverage Questionnaire Enrollment
P.O. Box 91059 Customer Service: 800-722-1471
Seattle, WA 98111 Hearing Impaired: 800-842-5357
Dear Subscriber:
We appreciate your assistance in providing information about other health coverage you may have — thank you for your cooperation!
Please either review this form and call Customer Service at 1-800-722-1471 with the information or complete the form and mail to the
address above.
Subscriber Name and Address Date
Member ID
Group Number
Group Name
If you or your dependents have other health coverage, the information requested below will enable us to coordinate payment of your
claim(s) with your other carrier(s). Please refer to the back of this form for answers to the most often asked coordination of benefits
questions. If you require assistance in completing this form, please contact your employer or our Customer Service Department.
OTHER INSURANCE INFORMATION
Do you or any family members have any of the following:
1. Coverage with us (other than listed above)? No Yes If Yes, please complete the following line.
SUBSCRIBER NAME DATE OF BIRTH SUBSCRIBER ID NUMBER GROUP NUMBER
MONTH DAY YEAR
2. Medicare coverage No Yes If Yes, please complete the following sections. If there is more than one member with Medicare
Coverage, use a separate piece of paper. Please include a copy of your Medicare card(s) for each Medicare recipient.
NAME OF FAMILY MEMBER WITH MEDICARE COVERAGE MEDICARE ID NUMBER PART A EFF. DATE PART B EFF. DATE PART D EFF. DATE
/ / / / / /
RETIREMENT DATE ARE YOU ENTITLED TO MEDICARE DATES REQUIRED IF DATE OF ENTITLEMENT FIRST DIALYSIS TREATMENT KIDNEY TRANSPLANT
DUE TO ONE OF THE FOLLOWING: DISABILITY OR KIDNEY
/ / FAILURE CHECKED: / / / / / /
DISABILITY KIDNEY FAILURE
Are you entitled to Medicare for more than one reason? If so, give the reasons for your dual entitlement.
3. Other medical, dental, prescription drug, or vision coverage? No Yes
If Yes, please complete the following sections. If more than one policy, please attach additional paper.
IF ANOTHER HEALTH INSURANCE PLAN PAYS FIRST, SEND US A COPY OF THEIR EXPLANATION OF BENEFITS.
NAME OF POLICYHOLDER DATE OF BIRTH
OTHER INSURANCE COMPANY: MONTH DAY YEAR
COMPANY NAME
RELATIONSHIP TO OUR SUBSCRIBER
STREET ADDRESS
IS POLICY A GROUP COVERAGE? NO YES IS THIS COBRA COVERAGE? NO YES
IS COVERAGE AN INDIVIDUAL POLICY? NO YES
CITY STATE ZIP CODE POLICY ID # (SOCIAL SECURITY #, MEMBER #, ETC.)
TELEPHONE NUMBER GROUP #
( )
EFFECTIVE DATE OF COVERAGE EMPLOYER:
ARE YOU RETIRED? NO YES
ABOVE POLICY IS FOR:
MEDICAL DENTAL VISION PRESCRIPTION DRUGS
ABOVE POLICY COVERS:
SUBSCRIBER SPOUSE DEPENDENT CHILDREN
(OVER)
017316 (11-2007) www.premera.com Page 1 of 2
An Independent Licensee of the Blue Cross Blue Shield Association
4. If parents are divorced or legally separated, the following information is needed to determine which coverage will process claims first for
dependent children.
NAME OF PERSON WITH
CHILD’S NAME NAME OF PERSON RELATIONSHIP FINANCIAL RESPONSIBILITY RELATIONSHIP NAME OF OTHER
WITH CUSTODY TO CHILD LISTED FOR HEALTH COVERAGE TO CHILD COVERAGE
FIRST LAST ACCORDING TO PROVIDED*
DIVORCE DECREE
* If this is different from the Other Insurance Company listed in Question Number 3, please list all other coverage
information (e.g., telephone number, name of policyholder, ID Number, Group Number, etc.) on a separate sheet.
SIGNATURE OF SUBSCRIBER OR SPOUSE
It is a crime to knowingly provide false, incomplete, or misleading
information to an insurance company for the purpose of X
defrauding the company. Penalties include imprisonment, fines,
and denial of insurance benefits.
Questions and Answers to Help You Understand Coordination of Benefits (COB)
What is Coordination of Benefits (COB)?
COB is two or more health care companies working together to share the cost of health care expenses.
Why do we coordinate benefits?
Insurance regulations allow health care companies to coordinate benefits. These regulations allow us to keep your cost of health
care coverage as low as possible by avoiding payment of more than the total charge of bills submitted. These rules identify one
plan as “primary” (the company that pays first) and the other plan as “secondary” (the company that pays second.)
Who do I submit my bill(s) to first?
Ƈ If the patient is our Subscriber, submit to us first and the other plan second.
Ƈ If the patient is the spouse of our Subscriber, submit to the other plan first and to us second.
Ƈ If the patient is a dependent child, submit to the plan of the parent whose birthday falls earliest in the year. Example:
mother’s birth date is May 5th and father’s birth date is November 9, submit to the mother’s plan first.
Ƈ If the parents of the patient are divorced or legally separated, submit first to the plan of the parent with financial responsibility
for health care coverage according to the divorce decree. If not stated in the divorce decree, submit bill(s) in the following
order:
A. To the plan of the parent with custody;
B. To the plan of the spouse of the parent with custody;
C. To the plan of the natural parent without custody; or
D. To the plan of the spouse of the parent without custody.
Ƈ If you have two coverages with us, submit each bill with both Subscriber and Group identification numbers.
Ƈ If Medicare is your primary carrier, submit your bill(s) to us with a copy of the Medicare Explanation of Benefits.
Ƈ If you are the Subscriber of more than one health care coverage, the coverage which has been effective the longest is primary.
Submit your bill(s) to that carrier first.
Ƈ Retiree Plans may require any non-retiree coverage to be primary.
How do we coordinate benefits?
Ƈ When we receive your bill(s), we determine which health care company will process your bill(s) first.
Ƈ If you submit your bill(s) with a copy of your other health care company’s denial or an Explanation of Benefits, we will use this
information to process your bill(s) promptly.
Ƈ If we do not receive this information with your bill(s), we contact your other health care company to obtain the information
needed to process your bill(s). We always call those companies that coordinate over the telephone. This enables us to process
your bill(s) promptly.
When do I receive an “Other Coverage Questionnaire”?
Ƈ When we have conflicting, incomplete or outdated information, you will receive a questionnaire.
Ƈ When your other coverage cancels, we need new coverage information.
IMPORTANT REMINDERS
Ƈ When we request COB information, please return the form by the date indicated to assure prompt processing of your bill(s).
Ƈ Always keep your health care providers (doctor, dentist, etc.) updated with your correct health care coverage information.
017316 (11-2007) www.premera.com Page 2 of 2
Discrimination is Against the Law Oromoo (Cushite):
Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa
Premera Blue Cross complies with applicable Federal civil rights laws and yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee
does not discriminate on the basis of race, color, national origin, age, odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa
disability, or sex. Premera does not exclude people or treat them differently ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf
because of race, color, national origin, age, disability or sex. yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan
jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin
Premera: odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu.
• Provides free aids and services to people with disabilities to communicate Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa.
effectively with us, such as:
• Qualified sign language interpreters Français (French):
• Written information in other formats (large print, audio, accessible Cet avis a d'importantes informations. Cet avis peut avoir d'importantes
electronic formats, other formats) informations sur votre demande ou la couverture par l'intermédiaire de
• Provides free language services to people whose primary language is not Premera Blue Cross. Le présent avis peut contenir des dates clés. Vous
English, such as: devrez peut-être prendre des mesures par certains délais pour maintenir
• Qualified interpreters votre couverture de santé ou d'aide avec les coûts. Vous avez le droit
• Information written in other languages d'obtenir cette information et de l’aide dans votre langue à aucun coût.
Appelez le 800-722-1471 (TTY: 800-842-5357).
If you need these services, contact the Civil Rights Coordinator.
Kreyòl ayisyen (Creole):
If you believe that Premera has failed to provide these services or Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen
discriminated in another way on the basis of race, color, national origin, age, enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti
disability, or sex, you can file a grievance with: asirans lan atravè Premera Blue Cross. Kapab genyen dat ki enpòtan nan
Civil Rights Coordinator - Complaints and Appeals avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka
PO Box 91102, Seattle, WA 98111 kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo.
Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357 Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a,
Email AppealsDepartmentInquiries@Premera.com san ou pa gen pou peye pou sa. Rele nan 800-722-1471
(TTY: 800-842-5357).
You can file a grievance in person or by mail, fax, or email. If you need help
filing a grievance, the Civil Rights Coordinator is available to help you. Deutsche (German):
Diese Benachrichtigung enthält wichtige Informationen. Diese
You can also file a civil rights complaint with the U.S. Department of Health Benachrichtigung enthält unter Umständen wichtige Informationen
and Human Services, Office for Civil Rights, electronically through the bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera
Office for Civil Rights Complaint Portal, available at Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln
U.S. Department of Health and Human Services müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten
200 Independence Avenue SW, Room 509F, HHH Building zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in
Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD) Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471
Complaint forms are available at (TTY: 800-842-5357).
http://www.hhs.gov/ocr/office/file/index.html.
Hmoob (Hmong):
Getting Help in Other Languages Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum
tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv
This Notice has Important Information. This notice may have important thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue
information about your application or coverage through Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv
Cross. There may be key dates in this notice. You may need to take action no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub
by certain deadlines to keep your health coverage or help with costs. You dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj
have the right to get this information and help in your language at no cost. yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob
Call 800-722-1471 (TTY: 800-842-5357). ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau
ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471
- (Amharic): (TTY: 800-842-5357).
Ú 8n·EØ 8Įö +ï ÚÌł Ú 8n·EØ 8 v½ ·Ú Õ Premera Blue
Cross @ı 8Įö +ï
+¼ Úxł [Ç 8n·EØ ¼8Č Dij Cx
, Úx ł Iloko (Ilocano):
Õċ @ı½ ć[H [ıĮ 0ßn ùp [k¼3 ÕöÉ ôÜax 0 ï ¼3á Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a
Úô^½p Ú
ł Ú +ï ÞØô Ø ¤ijØ [LL½ 0ßn ÞØô `p pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion
½pł[8¤ DČ0 800-722-1471 (TTY: 800-842-5357) Úܼ ł maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue
Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar.
ΔϳΑέόϟ (Arabic): Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti
ϭ ϙΑϠρ ιϭλΧΑ ΔϣϬϣ ΕΎϣϭϠόϣ έΎόηϹ Ϋϫ ϱϭΣϳ Ωϗ .ΔϣΎϫ ΕΎϣϭϠόϣ έΎόηϹ Ϋϫ ϱϭΣϳ partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti
ΔϣϬϣ ΦϳέϭΗ ϙΎϧϫ ϥϭϛΗ Ωϗ .Premera Blue Cross ϝϼΧ ϥϣ ΎϬϳϠϋ ϝϭλΣϟ ΩϳέΗ ϲΗϟ ΔϳρϐΗϟ salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti
ΓΩϋΎγϣϠϟ ϭ ΔϳΣλϟ ϙΗϳρϐΗ ϰϠϋ υΎϔΣϠϟ Δϧϳόϣ ΦϳέϭΗ ϲϓ ˯έΟ· ΫΎΧΗϻ ΝΎΗΣΗ Ωϗϭ .έΎόηϹ Ϋϫ ϲϓ daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti
bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357).
ϝλΗ .ΔϔϠϛΗ Δϳ ΩΑϛΗ ϥϭΩ ϙΗϐϠΑ ΓΩϋΎγϣϟϭ ΕΎϣϭϠόϣϟ ϩΫϫ ϰϠϋ ϝϭλΣϟ ϙϟ ϕΣϳ .ϑϳϟΎϛΗϟ ϊϓΩ ϲϓ
800-722-1471 (TTY: 800-842-5357)˰Α Italiano (Italian):
Questo avviso contiene informazioni importanti. Questo avviso può contenere
୰ᩥ (Chinese): informazioni importanti sulla tua domanda o copertura attraverso Premera
ᮏ㏻▱᭷㔜せⓗイᜥࠋᮏ㏻▱ਟ㜭᭷㜝ᝍ㏱㐣 Premera Blue Cross ᥦⓗ Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe
⏦ㄳᡈಖ㞋ⓗ㔜せイᜥࠋᮏ㏻▱羧ਟ㜭ᴹ譇蠔襲缽ଟᝍྍ⬟㟂せᅾᡖṆ᪥ᮇ essere necessario un tuo intervento entro una scadenza determinata per
அ๓᥇ྲྀ⾜ື㸪௨ಖ␃ᝍⓗᗣಖ㞋ᡈ⪅㈝⏝⿵㈞ࠋᝍ᭷Ḓච㈝௨ᝍⓗẕ consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di
ㄒᚓ฿ᮏイᜥᖳຓࠋㄳ᧕㟁ヰ 800-722-1471 (TTY: 800-842-5357)DŽ ottenere queste informazioni e assistenza nella tua lingua gratuitamente.
Chiama 800-722-1471 (TTY: 800-842-5357).
037338 (07-2016)
᪥ᮏㄒ (Japanese): Română (Romanian):
ࡇࡢ㏻▱ࡣ㔜せ࡞ሗࡀྵࡲࢀ࡚࠸ࡲࡍࠋࡇࡢ㏻▱ࡣࠊPremera Blue Prezenta notificare con܊ine informa܊ii importante. Această notificare
Crossࡢ⏦ㄳࡲࡓࡣ⿵ൾ⠊ᅖ㛵ࡍࡿ㔜せ࡞ሗࡀྵࡲࢀ࡚࠸ࡿሙྜࡀ࠶ poate con܊ine informa܊ii importante privind cererea sau acoperirea asigurării
ࡾࡲࡍࠋࡇࡢ㏻▱グ㍕ࡉࢀ࡚࠸ࡿྍ⬟ᛶࡀ࠶ࡿ㔜せ࡞᪥ࢆࡈ☜ㄆࡃࡔ dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie
ࡉ࠸ࠋᗣಖ㝤ࡸ᭷ᩱࢧ࣏࣮ࢺࢆ⥔ᣢࡍࡿࡣࠊ≉ᐃࡢᮇ᪥ࡲ࡛⾜ືࢆ în această notificare. Este posibil să fie nevoie să ac܊iona܊i până la anumite
ྲྀࡽ࡞ࡅࢀࡤ࡞ࡽ࡞࠸ሙྜࡀ࠶ࡾࡲࡍࠋࡈᕼᮃࡢゝㄒࡼࡿሗࢧ࣏࣮ termene limită pentru a vă men܊ine acoperirea asigurării de sănătate sau
ࢺࡀ↓ᩱ࡛ᥦ౪ࡉࢀࡲࡍࠋ800-722-1471 (TTY: 800-842-5357)ࡲ࡛࠾㟁ヰ asisten܊a privitoare la costuri. Ave܊i dreptul de a ob܊ine gratuit aceste
informa܊ii ܈i ajutor în limba dumneavoastră. Suna܊i la 800-722-1471
ࡃࡔࡉ࠸ࠋ (TTY: 800-842-5357).
䚐ạ㛨 (Korean): Pɭɫɫɤɢɣ (Russian):
⸬ 䋩㫴㉐㜄⏈ 㩅㟈䚐 㥉⸨ᴴ ☘㛨 㢼㏩⏼␘. 㪽 㢨 䋩㫴㉐⏈ Ỵ䚌㢌 㐔㷡㜄 ɇɚɫɬɨɹɳɟɟ ɭɜɟɞɨɦɥɟɧɢɟ ɫɨɞɟɪɠɢɬ ɜɚɠɧɭɸ ɢɧɮɨɪɦɚɰɢɸ. ɗɬɨ
Ḵ䚌㜠 Ἤ⫠Ḕ Premera Blue Cross⪰ 䋩䚐 䀘ⶸ⫠㫴㜄 Ḵ䚐 㥉⸨⪰ ɭɜɟɞɨɦɥɟɧɢɟ ɦɨɠɟɬ ɫɨɞɟɪɠɚɬɶ ɜɚɠɧɭɸ ɢɧɮɨɪɦɚɰɢɸ ɨ ɜɚɲɟɦ
䔠䚜䚌Ḕ 㢼㡸 ㍌ 㢼㏩⏼␘. ⸬ 䋩㫴㉐㜄⏈ 䚩㐠㢨 ╌⏈ ⇔㬐☘㢨 㢼㡸 ㍌ ɡɚɹɜɥɟɧɢɢ ɢɥɢ ɫɬɪɚɯɨɜɨɦ ɩɨɤɪɵɬɢɢ ɱɟɪɟɡ Premera Blue Cross. ȼ
㢼㏩⏼␘. Ỵ䚌⏈ Ỵ䚌㢌 ᶨᵉ 䀘ⶸ⫠㫴⪰ ᷸㋁ 㡔㫴䚌ᶤ⇌ ⽸㟝㡸 㤼ᵄ䚌ὤ ɧɚɫɬɨɹɳɟɦ ɭɜɟɞɨɦɥɟɧɢɢ ɦɨɝɭɬ ɛɵɬɶ ɭɤɚɡɚɧɵ ɤɥɸɱɟɜɵɟ ɞɚɬɵ. ȼɚɦ,
㠸䚨㉐ 㢰㥉䚐 ⫼ᵄ㢰ᾀ㫴 㦤㾌⪰ 㼜䚨㚰 䚔 䙸㟈ᴴ 㢼㡸 ㍌ 㢼㏩⏼␘. ɜɨɡɦɨɠɧɨ, ɩɨɬɪɟɛɭɟɬɫɹ ɩɪɢɧɹɬɶ ɦɟɪɵ ɤ ɨɩɪɟɞɟɥɟɧɧɵɦ ɩɪɟɞɟɥɶɧɵɦ
ɫɪɨɤɚɦ ɞɥɹ ɫɨɯɪɚɧɟɧɢɹ ɫɬɪɚɯɨɜɨɝɨ ɩɨɤɪɵɬɢɹ ɢɥɢ ɩɨɦɨɳɢ ɫ ɪɚɫɯɨɞɚɦɢ.
Ỵ䚌⏈ 㢨⤠䚐 㥉⸨㝴 ⓸㟴㡸 Ỵ䚌㢌 㛬㛨⦐ ⽸㟝 ⺴㛺㢨 㛯㡸 ㍌ 㢼⏈ ȼɵ ɢɦɟɟɬɟ ɩɪɚɜɨ ɧɚ ɛɟɫɩɥɚɬɧɨɟ ɩɨɥɭɱɟɧɢɟ ɷɬɨɣ ɢɧɮɨɪɦɚɰɢɢ ɢ
Ề⫠ᴴ 㢼㏩⏼␘. 800-722-1471 (TTY: 800-842-5357) ⦐ 㤸䞈䚌㐡㐐㝘. ɩɨɦɨɳɶ ɧɚ ɜɚɲɟɦ ɹɡɵɤɟ. Ɂɜɨɧɢɬɟ ɩɨ ɬɟɥɟɮɨɧɭ 800-722-1471
(TTY: 800-842-5357).
Ďėď (Lao):
ĩ ĩ ĩ ĩ Fa’asamoa (Samoan):
ģýĩüùėĄĄĚ ċĚ úĭ ċĞĄĐĭ ėûĖĄ. ģýĩüùėĄĄĚ ĒėĀýĕċĚ úĭ ċĞĄĐĭ ėûĖĄùĨĺďùĖąûĭ ėēĩĒüĐĕ Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau
ĹĖù đĜĠ ûďėċûĝĩċûĒüĆĕùĖĄĦĉúĒüăĨėĄćĨėĄ Premera Blue Cross. ĒėĀýĕċĚ ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala
ĩ atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua
ďĖĄăĚ Đĭ ėûĖĄĥĄģýĩüùėĄĄĚ . ăĨėĄĒėĀýĕýĭ ėĢĆĖ ĄāĩĒüĀĭ ėĢĄĚ ĄùėĄāėċùĭ ėĄğĀ
Ĩ Ĩ atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei
ĢďĎėĐĕĢĉėĕĢĉĜ ĒēĖùĐėûďėċûĝĩċûĒüĆĕùĖĄĐĝúĕĉėą đĜĠ ûďėċþĨďÿĢđĜĠ ĒĢĎĜ Ēü fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le
ĩ ĩ
ûĨėĥþĩýĨėÿúĒüăĨėĄĦďĩ. ăĨėĄċĚ Đę ĀĦĀĩēĖąúĭ ċĞĄĄĚ ģĎĕ ûďėċþĨďÿĢđĜĠ ĒĢĆĖ ĄĉėĐė aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai
Ĩ
úĒüăĨėĄĤĀÿąĭ ĢĐÿûĨė. ĥđĩĤăđė 800-722-1471 (TTY: 800-842-5357). i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua
atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i
ŴƤȓîŷƄ (Khmer): ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471
ȒơĆéņǵĐȄřĨșŀǹāȒřȝŹřŬȽŅȩŹřžȟ āơșñřȥɇ ȒơĆéņǵĐȄřĨșŀǹāȒřȝƅŞȓƪƉ (TTY: 800-842-5357).
ēŹřŬȽŅȩŹřžȟ āơșñřȥƴșŬǵŏƅŶāȥȓŞŞŞŏ ǔìƄƇȠŞȥƄāƄŞơȥƴŚéňŶƄŻȞ Español (Spanish):
Premera Blue Cross ɇ ƅŞȓƪƉēŹř ìƉŞƄȒĆǰ ČŏơșñřȥȒŝéśȃāȒơĆéņǵĐȄř Este Aviso contiene información importante. Es posible que este aviso
ȅ contenga información importante acerca de su solicitud o cobertura a
ĨșŀǹāȒřȝɇ ƴŚéƅŞȓƪƉēƅŅƎìƄŞȒğćĞơŶŅŋŴŬ ĨƉȥéșŀŅȥȔŊĂēéȥĆŢơȥ través de Premera Blue Cross. Es posible que haya fechas clave en este
ŜŜ ȒĨȋŶşǵřǹāƄéƥŏȁéìƄŗŜƇȠŞȥƄāơȁîŴŬƄŞơȥƴŚé ǔƅšéȥĐșřȇŻȒĆĞȔŊƊɇ aviso. Es posible que deba tomar alguna medida antes de determinadas
ƴŚéŹřơǯŏŕǯŏŏȇƉŬȽŅȩŹřȒřȝ řǯāĐșřȇŻȒŝéśȃāŴƤƄŞơȥƴŚéȒīŻŶǯřƴơ fechas para mantener su cobertura médica o ayuda con los costos. Usted
Ȅ tiene derecho a recibir esta información y ayuda en su idioma sin costo
ƉȁŻȒƯȋŻɇ ơȄŶŏƄơȽŬŐ 800-722-1471 (TTY: 800-842-5357)ɇ alguno. Llame al 800-722-1471 (TTY: 800-842-5357).
S FaUc (Punjabi): Tagalog (Tagalog):
7^ RĄbI^ b\D @a^ FaM?aYc _g. 7^ RĄbI^ b\D Premera Blue Cross \Z Nd_aKc Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang
?\YfF 5Nf 5YFc UaYf W_NJN\SeYR FaM?aYc _h ^?Pc _ . g 7^ RĄbF^ F\D @a^ NaYc@a paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon
_h ^?Pc64 _R. Ff?Y Nd^c F^_N ?\YFf bYNJ@Mc _h\ f Fa =^ Pc ZaAN Fb\NJD WPP Pf tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue
7ENJd? _h N Nd_aR e 5NW NaYck N Sb_Z ?NJdG @a^ ?PW DNJd?M Pc Zhn _h ^?Pc _g ,N_ad R e Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring
mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang
WdoN b\NJD Nf 6SMc Va]a b\NJD FaM?aYc 5Nf WPP SaSN ?YR Pa 5bQ?aY _g ,?aZ panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na
800-722-1471 (TTY: 800-842-5357). walang gastos. May karapatan ka na makakuha ng ganitong impormasyon
at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471
̶γέΎϓ (Farsi): (TTY: 800-842-5357).
ϡέϓ ϩέΎΑέΩ ϡϬϣ ΕΎϋϼρ ̵ϭΎΣ Εγ ϥ̰ϣϣ Ϫϳϣϼϋ ϥϳ. ΩηΎΑϳϣ ϡϬϣ ΕΎϋϼρ ̵ϭΎΣ Ϫϳϣϼϋ ϥϳ
έΩ ϡϬϣ ̵Ύϫ ΦϳέΎΗ ϪΑ .ΩηΎΑ Premera Blue Cross ϕϳέρ ί Ύϣη ̵ ϪϣϳΑ εηϭ̡ Ύϳ ϭ ΎοΎϘΗ Å¥ (Thai):
Ϫϧϳίϫ ΕΧΩέ̡ έΩ ̮ϣ̯ Ύϳ ϥΎΗ ϪϣϳΑ εηϭ̡ υϘΣ ̵έΑ Εγ ϥ̰ϣϣ Ύϣη. ΩϳϳΎϣϧ ϪΟϭΗ Ϫϳϣϼϋ ϥϳ ¦³µ«¸¤Ê ¸
o°¤¨¼ ε´ ¦³µ«¸°µ¤Ê ¸
o°¤¨¼ ¸ÉεÁ´ ¸É¥ªµ¦µ¦¤´ ¦®¦´ º°
°Á
¦³´
ϕΣ Ύϣη. ΩϳηΎΑ ϪΗηΩ ΝΎϳΗΣ ̶λΎΧ ̵ΎϫέΎ̯ ϡΎΟϧ ̵έΑ ̶λΧηϣ ̵Ύϫ ΦϳέΎΗ ϪΑ ˬϥΎΗ ̶ϧΎϣέΩ ̵Ύϫ
£µ¡
°» » nµ Premera Blue Cross ¨³°µ¤¸Îµ®µ¦Ä¦³µ«¸ Ê°µ³» o°
Ώγ̯ ̵έΑ .ΩϳϳΎϣϧ ΕϓΎϳέΩ ϥΎ̴ϳέ έϭρ ϪΑ ΩϭΧ ϥΎΑί ϪΑ έ ̮ϣ̯ ϭ ΕΎϋϼρ ϥϳ Ϫ̯ ΩϳέΩ έ ϥϳ εÁ·µ¦£µ¥Ä宦³¥³Áª¨µ¸ÉÂn°Á¡ºÉ°³¦´¬µµ¦¦³´
£µ» ¡
°®¦» º°µ¦nª¥Á®¨º°¸É
αΎϣΗ (800-842-5357 ϩέΎϣηΎΑ αΎϣΗ TTY ϥέΑέΎ̯) 800-722-1471 ϩέΎϣη ΎΑ ΕΎϋϼρ
.ΩϳϳΎϣϧ έέϗέΑ ¤¸nµÄonµ¥ ¤» ¸··¸É³Åo¦´
o°¤¨Â¨³ªµ¤¼ nª¥Á®¨º°¸Ä£µ¬µ
°Ê åŤ» n¤¸nµÄonµ¥ æ
800-722-1471 (TTY: 800-842-5357)
Polskie (Polish):
To ogáoszenie moĪe zawieraü waĪne informacje. To ogáoszenie moĪe ɍɤɪɚʀɧɫɶɤɢɣ (Ukrainian):
zawieraü waĪne informacje odnoĞnie PaĔstwa wniosku lub zakresu ɐɟ ɩɨɜɿɞɨɦɥɟɧɧɹ ɦɿɫɬɢɬɶ ɜɚɠɥɢɜɭ ɿɧɮɨɪɦɚɰɿɸ. ɐɟ ɩɨɜɿɞɨɦɥɟɧɧɹ
ĞwiadczeĔ poprzez Premera Blue Cross. Prosimy zwrócic uwagĊ na ɦɨɠɟ ɦɿɫɬɢɬɢ ɜɚɠɥɢɜɭ ɿɧɮɨɪɦɚɰɿɸ ɩɪɨ ȼɚɲɟ ɡɜɟɪɧɟɧɧɹ ɳɨɞɨ
kluczowe daty, które mogą byü zawarte w tym ogáoszeniu aby nie ɫɬɪɚɯɭɜɚɥɶɧɨɝɨ ɩɨɤɪɢɬɬɹ ɱɟɪɟɡ Premera Blue Cross. Ɂɜɟɪɧɿɬɶ ɭɜɚɝɭ ɧɚ
przekroczyü terminów w przypadku utrzymania polisy ubezpieczeniowej lub ɤɥɸɱɨɜɿ ɞɚɬɢ, ɹɤɿ ɦɨɠɭɬɶ ɛɭɬɢ ɜɤɚɡɚɧɿ ɭ ɰɶɨɦɭ ɩɨɜɿɞɨɦɥɟɧɧɿ. ȱɫɧɭɽ
pomocy związanej z kosztami. Macie PaĔstwo prawo do bezpáatnej ɿɦɨɜɿɪɧɿɫɬɶ ɬɨɝɨ, ɳɨ ȼɚɦ ɬɪɟɛɚ ɛɭɞɟ ɡɞɿɣɫɧɢɬɢ ɩɟɜɧɿ ɤɪɨɤɢ ɭ ɤɨɧɤɪɟɬɧɿ
informacji we wáasnym jĊzyku. ZadzwoĔcie pod 800-722-1471 ɤɿɧɰɟɜɿ ɫɬɪɨɤɢ ɞɥɹ ɬɨɝɨ, ɳɨɛ ɡɛɟɪɟɝɬɢ ȼɚɲɟ ɦɟɞɢɱɧɟ ɫɬɪɚɯɭɜɚɧɧɹ ɚɛɨ
(TTY: 800-842-5357). ɨɬɪɢɦɚɬɢ ɮɿɧɚɧɫɨɜɭ ɞɨɩɨɦɨɝɭ. ɍ ȼɚɫ ɽ ɩɪɚɜɨ ɧɚ ɨɬɪɢɦɚɧɧɹ ɰɿɽʀ
ɿɧɮɨɪɦɚɰɿʀ ɬɚ ɞɨɩɨɦɨɝɢ ɛɟɡɤɨɲɬɨɜɧɨ ɧɚ ȼɚɲɿɣ ɪɿɞɧɿɣ ɦɨɜɿ. Ⱦɡɜɨɧɿɬɶ ɡɚ
Português (Portuguese): ɧɨɦɟɪɨɦ ɬɟɥɟɮɨɧɭ 800-722-1471 (TTY: 800-842-5357).
Este aviso contém informações importantes. Este aviso poderá conter
informações importantes a respeito de sua aplicação ou cobertura por meio TiӃng ViӋt (Vietnamese):
do Premera Blue Cross. Poderão existir datas importantes neste aviso. Thông báo này cung cҩp thông tin quan trӑng. Thông báo này có thông
Talvez seja necessário que você tome providências dentro de tin quan trӑng vӅ ÿѫn xin tham gia hoһc hӧp ÿӗng bҧo hiӇm cӫa quý vӏ qua
determinados prazos para manter sua cobertura de saúde ou ajuda de chѭѫng trình Premera Blue Cross. Xin xem ngày quan trӑng trong thông
custos. Você tem o direito de obter esta informação e ajuda em seu idioma báo này. Quý vӏ có thӇ phҧi thӵc hiӋn theo thông báo ÿúng trong thӡi hҥn
e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357). ÿӇ duy trì bҧo hiӇm sӭc khӓe hoһc ÿѭӧc trӧ giúp thêm vӅ chi phí. Quý vӏ có
quyӅn ÿѭӧc biӃt thông tin này và ÿѭӧc trӧ giúp bҵng ngôn ngӳ cӫa mình
miӉn phí. Xin gӑi sӕ 800-722-1471 (TTY: 800-842-5357).
no reviews yet
Please Login to review.
