Fillable 2020 Requestfor Accountingof Disclosures A 508.ashx (CalOptima)

Fill Online, Printable, Fillable, Blank 2020 Requestfor Accountingof Disclosures A 508.ashx (CalOptima) Form

Use Fill to complete blank online CALOPTIMA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

2020 Requestfor Accountingof Disclosures A 508.ashx (CalOptima)

On average this form takes 4 minutes to complete

The 2020 Requestfor Accountingof Disclosures A 508.ashx (CalOptima) form is 2 pages long and contains:

  • 0 signatures
  • 3 check-boxes
  • 15 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your CalOptima forms online.

BROWSE CALOPTIMA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MCAL MM–18–98_DHCS Approved 01.29.19_Accounting of Disclosures_A
Page 1 of 2
تﺎﺣﺎﺼﻓﻺﻟ ﺔﺒﺳﺎﺤﻣ جذﻮﻤﻧ ﺐﻠط
ﺦﯾرﺎﺗ بﻠطﻟا:
:ﻮﻀﻌﻟا ﻢﺳا :دﻼﯿﻤﻟا ﺦﯾرﺎﺗ __________________________
مﻗر فﯾرﻌﺗ :ﻮﻀﻌﻟا____________________________ مﻗر ﻟافﺗﺎﮭ: ___________________________
ﻒﯿﻛ لﻮﺣ ﺮﯾﺮﻘﺗ ﻰﻠﻋ لﻮﺼﺤﻟا ﻲﻓ ﺐﻏرأ ﻢﺗ ﻹاحﺎﺼﻓ ) ﺔﯿﻤﺤﻤﻟا ﺔﯿﺤﺼﻟا ﻲﺗﺎﻣﻮﻠﻌﻣ ﻦﻋPHI ﺔﻄﺳاﻮﺑ (CalOptima
ً
ﺎﻘﻓو ، .نﻮﻧﺎﻘﻟا ﮫﯿﻀﺘﻘﯾ ﺎﻤﻟ
نأ كردأCalOptima ﯾ ﻻﻮﺘ ﺐﺟإ ﺎﮭﯿﻠﻋﻣﻼﻋ:ﺔﯿﻟﺎﺘﻟا تﺎﺣﺎﺼﻓﻹا عاﻮﻧأ ﻦﻋ ﻲ
1. ،جﻼﻌﻟا ضاﺮﻏﻷ تﺎﺣﺎﺼﻓﻹاو،ﻊﻓﺪﻟا .ﺔﯿﺤﺼﻟا ﺔﯾﺎﻋﺮﻟا تﺎﯿﻠﻤﻋو
2. وأ
ّ
ﻲﻟإ تﺎﺣﺎﺼﻓﻹاحﺮﺼﻣ ﺎﮭﺑ ﻲﻨﻣﺺﺨﺸﻟ (صﺎﺨﺷأ) .ﺮﺧآ
3. تﺎﺣﺎﺼﻓﻹا ﻰﻟإ.ﻲﺘﯾﺎﻋر ﻲﻓ ﻦﯿﻛرﺎﺸﻤﻟا صﺎﺨﺷﻷا
4. ﻲﺘﻟا تﺎﺣﺎﺼﻓﻹا ﻞﺒﻗ ﺎھؤاﺮﺟإ ﻢﺗ14 ﻞﯾﺮﺑأ2003.
ﻀﯾأ ﻢﮭﻓأ
ً
ﺎ ﺮﯾرﺎﻘﺗ ﻲﻓ ﻲﻘﺣ ﻖﯿﻠﻌﺗ ﻢﺘﯾ ﺪﻗ ﮫﻧأ ﺑ ﺔﺻﺎﺧ ﺾﻌﺒ وأﺑ.تﻻﺎﺤﻟا ﺾﻌﺑ ﻲﻓ تﺎﺣﺎﺼﻓﻹا ﻊﯿﻤﺠ
ﻢﮭﻓأ نأCalOptima لﻼﺧ تﺎﺣﺎﺼﻓﻹا ﺮﯾﺮﻘﺗ ﻲﻟ مﺪﻘﺗ نأ ﺐﺠﯾ60 ﻣﻮﯾ
ً
ﺎ ﻰﻟإ ﺔﺟﺎﺣ كﺎﻨھ نﺄﺑ ﻲﻨﻐﻠﺒﺗ نأ وأ ﻲﺒﻠط ﻦﻣ30 ﻣﻮﯾ
ً
ﺎ (ﻞﻗأ وأ)
.ﺎھداﺪﻋﻹ
ﮫﻧأ ﻢﮭﻓأ ﺪﺣاو ﻲﻧﺎﺠﻣ ﺮﯾﺮﻘﺗ ﻢﯾﺪﻘﺘﺑ ﺢﻤﺴ
ُ
ﯾ ﻲﻟ ﻞﻛ تﺎﺣﺎﺼﻓﻹا ﻦﻋ12 ﺮﮭﺷ
ً
ا ـﻟا لﻼﺧ ﺪﺣاو ﺮﯾﺮﻘﺗ ﻦﻣ ﺮﺜﻛأ ﺖﺒﻠط اذإ
ّ
ﻲﻠﻋ مﻮﺳر ضﺮﻓ ﻢﺘﯾ ﺪﻗ .12
ﺮﮭﺷ
ً
ا .ﺎﮭﺴﻔﻧ
ﺒﻠط ﺲﯿﻟ اﺬھ نأ ﺔﻈﺣﻼﻣ ﻰﺟﺮﯾ
ً
ﺎ ) ﺔﯿﻤﺤﻤﻟا ﺔﯿﺤﺼﻟا تﺎﻣﻮﻠﻌﻤﻟا ﻰﻟإ لﻮﺻﻮﻠﻟPHI وأ ﺔﯿﺒﻄﻟا تﺎﺒﻟﺎﻄﻤﻟا ﻞﺜﻣ تﻼﺠﺳ ﻰﻠﻋ ﻞﺼﺤﺗ ﻦﻟ .(
تﺎﻣﻮﻠﻌﻤﻟا ﻰﻟإ لﻮﺻﻮﻠﻟ يدﺮﻔﻟا ﺐﻠﻄﻟا ءﻞﻣ ﻰﺟﺮﯿﻓ ،تﻼﺠﺴﻟا ﻦﻣ عﻮﻨﻟا اﺬھ ﻲﻓ ﺐﻏﺮﺗ ﺖﻨﻛ اذإ .جذﻮﻤﻨﻟا اﺬھ ماﺪﺨﺘﺳﺎﺑ ﺔﻟﺪﯿﺼﻟا تﺎﺒﻟﺎﻄﻣ
ﺔﻨﯿﻌﻤﻟا تﻼﺠﺴﻟا ﺔﻋﻮﻤﺠﻣ جذﻮﻤﻧ ﻲﻓ ﺔﯿﻤﺤﻤﻟا ﺔﯿﺤﺼﻟا )Designated Record Set(.
دﯾزﻣﻟ نﻣ تﺎﻣوﻠﻌﻣﻟا لوﺣ قوﻘﺣ ﺔﯾﺻوﺻﺧﻟا ﺔﺻﺎﺧﻟا ،كﺑ ﻰﺟرﯾ ةرﺎﯾزﻧﻌﻗوﻣﺎ ﻰﻠﻋ www.caloptima.org وأ مﺳﻘﺑ لﺎﺻﺗﻻاﺔﻣدﺧ
ءﻼﻣﻌﻟا ﻲﻓ CalOptima مﻗرﻟا ﻰﻠﻋ ﻲﻧﺎﺟﻣﻟا 1-888-587-8088. نﻛﻣﯾ ءﺎﺿﻋﻸﻟ نﯾذﻟا فﻌﺿ مﮭﯾدﻟ ﻊﻣﺳﻟا ﻲﻓ وأ ﻖطﻧﻟا لﺎﺻﺗﻻا ﻰﻠﻋ
طﺧ TDD/TTY ﻲﻧﺎﺟﻣﻟا ﻰﻠﻋ مﻗرﻟا 1-800-735-2929 .ﺎﻧﯾدﻟ مﻗﺎط ثدﺣﺗﯾ كﺗﻐﻟ.
MCAL MM–18–98_DHCS Approved 01.29.19_Accounting of Disclosures_A
Page 2 of 2
Rev. 08/2019
ﻲﻓ ﺐﻏرأ ﻰﻠﻋ لﻮﺼﺤﻟا ﻞﺠﺳﺑ:ﺔﯿﻟﺎﺘﻟا ﺔﯿﻨﻣﺰﻟا ةﺮﺘﻔﻟا ﻲﻄﻐﺗ ﻲﺘﻟا تﺎﺣﺎﺼﻓﻹﺎ
ﻦﻣ: إ:ﻰﻟ
) ﺔﺘﺳ ﻦﻋ ﺔﯿﻨﻣﺰﻟا ةﺮﺘﻔﻟا ﺪﯾﺰﺗ ﻻ ﺪﻗ :ﺔﻈﺣﻼﻣ6 ﻞﺒﻗ ﺦﯾراﻮﺘﻟا ﻞﻤﺸﺗ ﻻ ﺪﻗو ،تاﻮﻨﺳ (14 ﻞﯾﺮﺑأ2003.
:(ةﺪﺣاو ﺮﺘﺧا) ﺔﺑﻮﻠﻄﻤﻟا ﻢﯿﻠﺴﺘﻟا ﺔﻘﯾﺮط
مﻼﺘﺳﻻاﯿﺼﺨﺷ"
ً
ﺎ ﻲﻓ "CalOptima )ﺔﯾﻮﮭﻟا ﻒﯾﺮﻌﺗ ﺖﻗو ﻲﻓ بﻮﻠﻄﻣمﻼﺘﺳﻻا(
:ﺪﯾﺮﺒﻟا
ﻟاناﻮﻨﻌ/ﺔﻘﺸﻟا ﻢﻗر ﺔﻨﯾﺪﻤﻟا ﺔﯾﻻﻮﻟا يﺪﯾﺮﺒﻟا ﺰﻣﺮﻟا
ﯿﻧوﺮﺘﻜﻟإ
ً
ﺎ :ﻰﻟإ ﻦﻣآ ﻲﻧوﺮﺘﻜﻟإ ﺪﯾﺮﺑ ﺮﺒﻋ ﺎﮭﻟﺎﺳرإ ﻢﺘﯾ ،
ﻊﯾﻗوﺗ وﺿﻌﻟا: ﻟا :ﺦﯾرﺎﺘ
اذإ نﺎﻛ لﺛﻣﻣﻟا ضوﻔﻣﻟا )ﻰﺟرﯾ نﯾﻣﺿﺗ ﻖﺋﺎﺛوﻟا ﺔﯾﻧوﻧﺎﻘﻟا:(
ﻊﺑطا مﺳﻻا: ﺔﻗﻼﻌﻟا وﺿﻌﻟﺎﺑ:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

2020 Requestfor Accountingof Disclosures A 508.ashx (CalOptima)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document