Fillable Authfor Useor DisclosurePH Ito Fam Mbr F 508.ashx (CalOptima)

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Authfor Useor DisclosurePH Ito Fam Mbr F 508.ashx (CalOptima)

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ﺟا هزﺎﻧﺎﻣ ﮫاﺳﺘﻔ هدﺎﯾ ﺎردﺧاﺘﯿ رﺎﺬﮔاﺷﺘ ﻦطاﻼﻋ ﺎ تﺳﻼﻣﺘ ﯽﺮﻣاﻗﺒ ﺖ هﺪﺷ
ﺑ ﮫﻋﻀ ﻮﺧﺎﻧﻮاد هﯾ ﺎدوﺳﺘﮐ ﯽ ﮫد رﻣﺮاﻗﺒ ﺖﻋﻀ ﻮﺷﮐﺮ ﺖدار د
دﻮﺘﺳ راﻟﻌ ﻞﻤ
اﯾ ﻦﻓﺮ م" ﺟاﺎز هﻧﺎﻣ ﮫاﺳﺘﻔﺎد هﯾ ﺎد رﺧاﺘﯿﺎ رﮔﺬاﺷﺘ ﻦاطﻼﻋﺎ تﺳﻼﻣﺘ ﯽﻣﺤﺎﻓ ﺖﻈﺷ هﺪﺑ ﮫﻋ ﻮﻀﺧﺎﻮﻧاهد, دوﺳﺘ ﯽﮐ ﮫد رﻣﺮاﻗﺒ ﺖﻋﻀ ﻮ
ﺷﺮﮐ ﺖاددر" ﺑ ﮫCalOptima ﻤﮐﮏﻣ ﯽﻨﮐﺪﮐﮫﭘﺮﻧوﺪهﺧﺼﻮﺻ ﯽﻤﺷﺎراﻣﺮاﺒﻗ ﺖﻨﮐﺪ. ﻣﺎازﺷﻤﺧ ﺎﻮھاﺶﻣﯽﮐﻨﯿﻢﮐﮫاﯾﻦﻓﺮمر ا
ﺗﮑﯿﻤﻞﮐﯿﻨﺪﺗﺎﻣﺎﺑﺪاﯿﻧ ﻢﻤﺷﺎﻣﯽﺧﻮاﯿھﺪاطﻼﻋﺎتﺳﺘﻣﻼﯽﻣﺤﺎﻓ ﺖﻈﺷﺪهﺧﻮدر اﺘﻨﻣﺸ ﺮﯿﻨﮐﺪ. ﻟﻄﻔ ﺄاطﻼﻋﺎ تذﯾ ﻞر اد راﯾ ﻦﺻﺤﻔ ﮫ
ﺑﺨﻮﯿﻧاﺪوﻓﺮمﺻﻔﺤ ﮫﻌﺑﺪیراﺗﯿﻤﮑ ﻞﯿﻨﮐﺪ.
ردﺻﻮر تداﺷﺘھ ﻦﺮﮔﻮﻧ ﮫﺳﻮا لﯾ ﺎاﮔ ﺮﺑﺮا یﭘ ﺮﮐﺮد ناﯾ ﻦﻓﺮ مﻧﯿﺎ زﺑ ﮫﮐﻤ ﮏدارﯾﺪ ،روھزﺎ یدوﺷﻨﯿ ﮫاﻟﺟ ﯽﻤﻌ ﮫا زﺳﺎﻋ ﺖ8 ﺒﺻ ﺢ
ﺗ ﺎ5:30 ﻌﺑﺪازﮭظﺮﺑﺎادارهﺧﻣﺪﺎتﻣﺘﺸﯾﺮﺎ نCalOptima ﺑ ﮫﺷﻤﺎر هﺗﻠﻔ ﻦ1-714-246-8500 ﺎﯾﺷرﺎﻤهﺗﻠﻔﻦراﯾﺎﮕ ن
1-888-587-8088 ﻤﺗﺎسﺑﯿﮕﯾﺮﺪ. ﻀﻋاﯾﺎﯽﮐﮫدﭼﺎرﻣﺸﮑ ﻞﻨﺷﻮﯾاﯽوﮔﺘﻔﺎریﻣﯽﺑﺎﻨﺷﺪﻣﯽﺗﻮﻨﻧاﺪﺑﺎﺧ ﻂTTY/TDD ﺑﮫﺷرﺎﻤ ه
ﺗﻔﻠ ﻦ1-800-735-2929 ﻤﺗﺎسﺑﯿﮕﻧﺮﺪ. ﻣﺎﮐﺎرﻨﻣﺪﻧاﯽﮐﮫﺑ ﮫﺑزﺎ نﻤﺷﺎﺻﺒﺤﺖﻣ ﯽﻨﻨﮐﺪداﯾر ﻢ.
ﺣﻮﻘ قﻋﻀ ﻮ
•
•
•
•
•
ﻣ ﯽداﻧ ﻢﮐ ﮫﺑﺎﯾ ﺪﯾ ﮏﮐﭙ ﯽا زاﯾ ﻦﺟاﺎز هﻧﺎﻣ ﮫر ادرﯾﺎﻓ ﺖﮐﻨ ﻢ
ﻣﯽداﻧﻢﮐﮫﻣﯽﺗﻮاﻧﻢﮐﭙھ ﯽﺎیاﺿﺎﻓ ﮫ زااﯾﻦازﺎﺟ هﺎﻧﻣﮫر اردﺎﯾﻓﺖﮐﻨ ﻢ
ﻣ ﯽداﻧ ﻢﮐ ﮫﻣ ﯽﺗﻮاﻧ ﻢازاﻣﻀﺎ یاﯾ ﻦﺟاﺎز هﻧﺎﻣﺧ ﮫﻮددار یﮐﻨ ﻢ
ﻣ ﯽداﻧ ﻢﮐھ ﮫ ﺮزﻣﺎ نﻣ ﯽﺗﻮاﻧ ﻢاﯾ ﻦﺟاﺎز هﻧﺎﻣ ﮫر اﺑﺎط ﻞﮐﻨ ﻢ
ﻣ ﯽداﻧ ﻢﮐ ﮫﻧ ﮫدرﻣﺎ نوﻧ ﮫﭘﺮداﺧ ﺖرﺑﻄ ﯽﺑﺧ ﮫﻮددار یا زاﻣﻀﺎ یﺟاﺎز هﻧﺎﻣ ﮫﯾ ﺎﺒﻗﻮ لﻣاﻀﺎ یﯾا ﻦاﺟﺎز هﻧﻣﺎ ﮫﻧﺪار د
ﻖﺣﻮﺘﻣﻗﻒﮐدﺮ ن
ﻣ ﻦﻣ ﯽداﻧ ﻢﮐھ ﮫﺮﻣﻮﺣ ﻊﻗ ﻖﺑﺎط ﻞﮐﺮد ناﯾ ﻦﺟاﺎز هﻧﺎﻣ ﮫر ادار م. ﺮﺑا یاﺑﻄﺎ لاﯾ ﻦﺟاﺎز هﻧﺎﻣ ﮫﻣ ﯽداﻧ ﻢﮐ ﮫﺑﺎﯾ ﺪاﯾ ﻦدﺧرﻮاﺳ ﺖر ا
ﺑﺼﻮر تﮐﺘﺒ ﯽاﺠﻧﺎ مداده وﺑ ﮫوﺿﻮ حذﮐ ﺮﮐﻨ ﻢﮐ ﮫﻣ ﻦاﯾ ﻦﺟاﺎز هﻧﺎﻣ ﮫﺨﺑﺼﻮ صر اﺑﺎط ﻞﻣ ﯽﻨﮐﻢ . د رﺿﻤ ﻦﻣ ﻦﺑﺎﯾ ﺪاﯾ ﻦدﺧرﻮاﺳ ﺖ
رااﻣﻀﺎﮐﺮده وﯾﺎﺑﺎﭘﺴﺖﯾﺎﻓﮑﺲ وﯾﺣ ﺎﻀﻮرأﺑﮫآدرسذﯾ ﻞﺤﺗﻮﯾ ﻞھد ﻢ:
CalOptima
Customer Service Department
505 City Parkway West
Orange, CA 92868
Fax: 1-714-338-3104
ﻣ ﻦﻣ ﯽداﻧ ﻢﮐ ﮫاﺑﻄﺎ لاﯾ ﻦﺟاﺎز هﻧﺎﻣ ﮫد راﯾ ﻦزﻣﺎ ند راﺳﺘﻔﺎد هﯾ ﺎاﻧﺘﺸﺎ رﻗﺒﻠ ﯽاطﻼﻋﺎ تﺳﻼﻣﺘ ﯽﻣﺮاﻗﺒ ﺖﺷﺪ هﺗﻮﺳ ﻂ
CalOptima ﯾو ﺎﯾدﮕﺮا نﺗﯿﺛﺎﺮ یﻧﺨﻮاھ ﺪداﺷﺖ.
ﺪﺤﻣدوﯾﺖھ ﺎ
ﻦ ﻣ زا یﺮﮕﯾد ﮫﻣﺎﻧ هزﺎﺟا ﮫﮐ ﯽﻧﺎﻣز ﺎﺗ ﺪﻧا هﺪﺷ ﺮﺸﺘﻨﻣ ﺎﯾ هدﺎﻔﺘﺳا ﮫﻣﺎﻧ هزﺎﺟا ﻦﯾا یﺎﻀﻣا ﻖﺒط ﮫﮐ ﯽﺘﻣﻼﺳ تﺎﻋﻼطا ﮫﮐ ﻢﻧاد ﯽﻣ ﻦﻣ
.. ﺪ ﻧاد ﯽﻣ یرﺎﺒﺟا ﺎﯾ زﺎﺠﻣ اﺮﻧآ ن ﻮﻧﺎﻗ ﮫﮑﻨﯾا ﺮﮕﻣ ﺪﻨﮐ اﺪﯿﭘ ﮫﻣادا ﺪﯾﺎﺒﻧ ﺖﺳا هﺪﺸﻧ ﺖﻓﺎﯾرد
Rev. 04/2014
ﻄﻟ ﺎﻔ ﻦﯾامﺪﺘﭘﻼﮐﻤﺎﻔﺑﺮس ﺮﻓ ار ﺮﭘ ﯿﻨﮐو ﮫﺑ
ﻗﺴﻤﺖA:
ﺎﻧ مﺎﺧﻧدﻮﮔ ﯽ
اطﻼﻋ تﺎﻋﻀ ﻮ
: ﻧمﺎ:
CalOptima ﺷﻤﺎ هر
ﺗﺎﯾرﺦﺗﻮﻟﺪ
:
ﻀﻋﯾﻮ ﺖ
آد سر
:
:
ﮭﺷﺮ: ﮐﺪﭘﺘﺴﯽ:
ﺗﻠ ﻦﻔﻣﻨﺰل
ﺑزﻧﺎﯽﮐﮫﺗﺮﯿﺟﺢﻣﯽدﯿھ ﺪ
: ﻠﺗﻔ ﻦﻠﺳﻻﻮر)ھﻤﺮها:(
:
ﻗﻤﺴ ﺖB: اﺎﺟ هزداد ن
ﻟﻄﻔ ﺄد رﻣﺮ ﻊﺑﭘﺎﺋﯿ ﻦﮐ ﮫﻣﺮﺑﻮ طﺑ ﮫﺷﻤ ﺎﻣ ﯽﺷﻮ دﻋﻼﻣ ﺖزد هﮐ ﮫﺑ ﮫCalOptima ﺟاﺎز هﺑھﺪﯿ ﺪﮐ ﮫﭘﺮوﻧﺪ هﭘﺰﺷﮑ ﯽﻣﺮاﻗﺒ ﺖﺷﺪ هﺷﻤ ﺎر ا
اﺘﺳﻔﺎد هﻨﮐ ﺪﯾو ﺎﯾاﻦاطﻼﻋﺎتراارﺋا ﮫﻨﮐﺪ.CalOptima ﻣﻤﮑ ﻦاﺳ ﺖاﯾ ﻦاطﻼﻋﺎ تر اﺑﺮرﺳ ﯽﯾ ﺎارﺋا ﮫﻨﮐﺪ:
ھﻤ ﮫﭘﺮوﻧﺪ هﭘﺰﮑﺷﻣ ﯽﺮاﻗﺒ ﺖﺷﺪ هﻣﻦ
ﺳاﺘﻔﺎهداطﻼﻋﺎ ت
ﺎﯾارﺋاﮫآنراﺤﻣﺪدوﺑﮫﻣﻮاردزﯾﻣ ﺮﯽﮐﻨ ﺪ:
ﻗﺴﻤﺖ :C ﺷﺨﺺﯾا ﺎﺷﺨﺎ ﯽﺻﮐﮫ ﯽﻣﺗاﻮﻧﻨا ﺪطﻼﻋﺎتذﮐﺮﺷﺪهدرﻗﺴﻤ ﺖB اردرﯾﺎﻓ ﺖﮐﻨﻨ ﺪ
ﻟﻄﻔ ﺄﻧﺎ مﺷﺨ ﺺﯾ ﺎاﺷﺨﺎﺻ ﯽر اﮐ ﮫاﺟﺎز هدارﻧ ﺪﭘﺮوﻧﺪ هﻣﺮاﻗﺒ ﺖﺷﺪ هﭘﺰﮑﺷ ﯽﺷﻤﺎدرﯾﺎﻓ ﺖﮐﻨﻨ ﺪﺑﻄﻮ رواﺿ ﺢﺑﻨﻮﯾﺴﯿﺪ . ﺳ ﻦاﯾ ﻦﺷﺨ ﺺﯾ ﺎاﺷﺨﺎ صﺑﯾﺎ ﺪﺑﺎﻻ ی18
ﺳﺎلﺑﺷﺎ ﺪ.
ﻗﺴﻤﺖ
D: ﻗﺼا ﺪﺟﺎز هادد ن
ﺑﺮا یاﺘﺳﻔﺎد هﯾ ﺎدراﺧﯿﺘﺎ رﮔﺬاﺘﺷ ﻦ ،طﺒ ﻖدرﺧﻮاﺳ ﺖﻣﻦ ،ﯾﺎ
ﺑﺮ یاﻣﻮا درﺨﺑﺼﻮصذﻞﯾ:
ﻗﻤﺴ ﺖE: ﺗﺎرﯾا ﺦﺑﻄﺎ ل
اﯾ ﻦاﺟﺎز هﻓﻮ أرﻗﺎﺑ ﻞاﺟ اﺮﺧﻮاھﺪﺑدﻮ ود راﯾ ﻦﺗﺎرﯾ ﺦﻤﺗﺎ مﺧﻮاھ ﺪﺷﺪ:
وﯾ ﺎﺳ ﮫﺳﺎ لازﺗﺎرﯾ ﺦاﻣﻀﺎ ءھ ﺮﮐﺪ مازودﺗ ﺮﺳاﺖ. ﺗﺎرﯾ ﺦﯾ ﺎرﯾوﺪاد
ﻗﺴﻤﺖF: ﻣاﻀﺎ ء
اﻀﻣﺎیﻀﻋ ﻮﺗﺎﯾر ﺦ: :
اﻀﻣﺎیواﻟﯾﺪﻦﯾ ﺎﯿﻗ ﻢﻗﻧﺎﻧﻮ ﯽ: ﺗﺎﯾر ﺦ:
ﺳاﺎ سﻗﺎﻧﻮﻧ ﯽاﯾﮑﻨ ﮫوﮐﯿﻠ ﯽا زطﺮ فﺷﻤ ﺎاﯾ ﻦاﺟﺎز هﻧﺎﻣ ﮫر ااﻣﻀﮐ ﺎﻨ ﺪ
ﮔا ﺮ ﮏﯾﻧﻤﺎﻨﯾﺪ هﺷﺼﺨ ﯽا زﺟﺎﻧ ﺐﻋﻀ ﻮاﯾ ﻦﻓﺮ مر ااﻣﻀ ﺎﮐﺮد ها ﺖﺳ ،ﯾ ﮏروﻧﺷﻮ ﺖوﮐﺎﻟﺘﻨﺎﻣ ﮫﭘﺷﺰﮑﯽ ،دﺳﺘﻮ ردادﮔﺎ ه)ﻣﻨﻧﺎ ﺪﻣﻮظ ﻒﮐﺮد نﯾ ﮏﻗﯿﻢ ،ﯾ ﺎ
ﺮﺑﺰﮔﺪﯾنوﯿﮐﻞﺑﺮایاداهراﻣﻮ لاﻋﻀﻮﻣﺣﺮﻮ م( ،ﯾ ﮏﻣﺪر کﻣﻮاﻓﻘ ﺖﻣﺪﯾ ﺮﻣﺮﮐﻣ ﺰﻨﻄﻘ ﮫا یﯾ ﺎﻧﻤﺎﯾﻨﺪ هاو ) طﺒ ﻖﻗﺎﻧﻮ نﺷﻤﺎر هWelfare and 4655
( Institutions Code ﯾﺎﻣﺪارکﻗﺎﻧﻮﻧﯽدﮕﯾﺮیﮐﮫﻧﺸﻧﺎﺪﻨھﺪ هﯾاﻦﺑﺎﺷﺪﮐﮫوﯿﮐﻠﯽازﺟﻧﺎ ﺐﻀﻋﻮﺑﺮﮔﯾﺰﺪهﺷﺪهاﺳﺖﺑﯾﺎﺪﺿﯿﻤﻤ ﮫﯾاﻦﻓﺮمﺷﻮد.
ﻧ مﺎﻧﻤﺎ ﯾهﺪﻗﻧﺎﻧﻮ ﯽ:_______________________________________________________________________________________ ﻨ
ﻧﺒﺴﺖﻗﻧﺎﻧﻮﯽﺑ ﺎﻀﻋ ﻮ_____________________________________________________________________________________:
اﻀﻣ ءﺎﻧﻤﺎ ﯾهﺪﻗﻧﺎﻧﻮﯽ:_____________________________________________________________________________________ ﻨ
ﺗﺎرﯾ ﺦ:_______________________________________________________________________________________________
Rev. 04/2014
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Authfor Useor DisclosurePH Ito Fam Mbr F 508.ashx (CalOptima)

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Completed 11 March 2021

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