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CalOptima )PHI - Protected Health Information ( (CalOptima)

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MCAL MM-19-659_HH.3004 Attachment A_F
ﮫﺤﻔﺻ1 زا2
تﺎﻋﻼطا حﻼﺻا ﺖﮭﺟ ﻮﻀﻋ ﺖﺳاﻮﺧردﯽﻧﺎﻣرد ﮫﻧﺎﻣﺮﺤﻣ )PHI (
:ﺖﺳاﻮﺧرد ﺦﯾرﺎﺗ ____________________________
:ﻮﻀﻋ مﺎﻧ _____________________________ :ﺪﻟﻮﺗ ﺦﯾرﺎﺗ _________________________
) ﺖﯾﻮﻀﻋ هرﺎﻤﺷCIN(: ______________________________ :ﻦﻔﻠﺗ هرﺎﻤﺷ ____________________
ﺪﯿﻠﯾﺎﻣ ﮫﮐ ﺪﯿﯾﻮﮕﺑ ﺎﻣ ﮫﺑ
ً
ﺎﻔﻄﻟCalOptima تﺎﻋﻼطا ماﺪﮐﯽﻧﺎﻣرد ﮫﻧﺎﻣﺮﺤﻣ )PHI - Protected Health Information ﺎﻤﺷ ﻖﺑاﻮﺳ ﺎﯾ (
:ﺪھد ﺮﯿﯿﻐﺗ ار
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
.ﺪﯿﯾﻮﮕﺑ ﺎﻣ ﮫﺑ ار ﺮﯿﯿﻐﺗ ﻦﯾا ﻞﯿﻟد
ً
ﺎﻔﻄﻟ ﻞﯿﻟد ﮏﯾ
ً
ﺎﻤﺘﺣ ﺪﯾﺎﺑ ﺎﻤﺷﺪﯿھد ﮫﺋارا:
_____________________________________________________________________________________
_____________________________________________________________________________________
:ﮫﯿﻣﻼﻋا
،ﺪﻧﻮﺷ مﺎﺠﻧا ﺎﻤﺷ ﺖﺳاﻮﺧرد ﻖﺑﺎﻄﻣ تاﺮﯿﯿﻐﺗ ﺮﮔاCalOptima تﺪﻣ فﺮظ ﺖﺴﯾﺎﺑ ﯽﻣ60 ﺎﯾ ﺪﯾﺎﻤﻧ مﻼﻋا ﺎﻤﺷ ﮫﺑ ار ﮫﻠﺌﺴﻣ ﯽﻤﯾﻮﻘﺗ زور
ﺎﺗ) ﺮﺘﺸﯿﺑ نﺎﻣز ﮫﺑ یﺮﯿﮔ ﻢﯿﻤﺼﺗ یاﺮﺑ ﮫﮐ ﺪﯾﺎﻤﻧ مﻼﻋا30 .دراد زﺎﯿﻧ (ﺮﺘﺸﯿﺑ ﯽﻤﯾﻮﻘﺗ زور ﮫﻣﺎﻧ نآ ﮫﺑ ﺪﯿﻠﯾﺎﻣ ﮫﮐ ﯽﺳردآ ار ﺎﻤﺷ ﻢﯿﻨﮐ لﺎﺳرا
ﯾا ردﺎﺠﻨ :ﺪﯿﻨﮐ ﺮﮐذ
:سردآ _______________________________________ :نﺎﻤﺗرﺎﭘآ هرﺎﻤﺷ__________
:ﺮﮭﺷ _______________________ :ﺖﻟﺎﯾا______ :ﯽﺘﺴﭘﺪﮐ _____________
ﺮﮔاCalOptima زا ﺶﯿﭘ ﮫﮐ ﯽﺼﺨﺷ ﺮھ ﮫﺑ ﺮﯿﯿﻐﺗ ﻦﯾا ،ﺪھد ﺮﯿﯿﻐﺗ ﺎﻤﺷ ﺖﺳاﻮﺧرد ﻖﺑﺎﻄﻣ ار ﻖﺑاﻮﺳ ﮫﮐ دﺮﯿﮕﺑ ﻢﯿﻤﺼﺗ تﺎﻋﻼطا ﺮﯿﯿﻐﺗ
.ﺪﺷ ﺪھاﻮﺧ لﺎﺳرا ،دﺮﮐ ﯽﻣ ﺖﻓﺎﯾرد ار ﺎﮭﻧآ.ﺪﯿﻨﮐ مﻼﻋا ﺎﻣ ﮫﺑ ﺪﻧراد زﺎﯿﻧ ﮫﺘﻓﺎﯾ ﺮﯿﯿﻐﺗ تﺎﻋﻼطا ﮫﺑ ﯽﺻﺎﺨﺷا ﺮﮔا
ً
ﺎﻔﻄﻟ
ﺮﯿﺧ
ﮫﻠﺑ :ﺪﯿﻨﮐ ﺮﮐذ ار صﺎﺨﺷا ﻦﯾا سردآ و مﺎﻧ
ً
ﺎﻔﻄﻟ
_________________________________________ _______________________________________
_________________________________________ _______________________________________
_________________________________________ _______________________________________
یﺮﮕﯾد صﺎﺨﺷا یاﺮﺑ ار تاﺮﯿﯿﻐﺗ ﻦﯾا ﺎﻣ ﮫﮐ ﻢﯿﻧاﺪﯿﻣ ﺪﻧا هدﺮﮐ ﯽﻣ ﺖﻓﺎﯾرد ﺮﯿﯿﻐﺗ زا ﺶﯿﭘ و ﺪﻨھاﻮﺧ دﺎﻨﺘﺳا هﺪﻨﯾآ رد ﺎﯾ و هدﺮﮐ دﺎﻨﺘﺳا ﺎﮭﻧآ ﮫﺑ
دﺮﮐ.دﺮﮐ ﻢﯿھاﻮﺧ لﺎﺳرا ﻢھ ؟ﺪﯿﺘﺴھ ﻖﻓاﻮﻣ ﺎﯾآ
ﺮﯿﺧ
ﮫﻠﺑ
ﮫﺤﻔﺻ رد ﮫﻣادا2
MCAL MM-19-659_HH.3004 Attachment A_F
ﮫﺤﻔﺻ2 زا2
:ﺎھ ﺖﯾدوﺪﺤﻣ
CalOptima :ﺪھد ﺮﯿﯿﻐﺗ ار ﺎﻤﺷ ﻖﺑاﻮﺳ ﺪﯾﺎﺒﻧ ﺮﯾز ﻂﯾاﺮﺷ رد
CalOptima .ﺖﺳا هدﺮﮑﻧ دﺎﺠﯾا ار تﺎﻋﻼطا
.ﺪﻨﺘﺴھ ﻞﻣﺎﮐ و ﻖﯿﻗد ﻖﺑاﻮﺳ رد دﻮﺟﻮﻣ تﺎﻋﻼطا
تﺎﻋﻼطا ﮫﺑ ﯽﺳﺮﺘﺳد ﯽﻧﻮﻧﺎﻗ ﻖﺣ ﺎﻤﺷﯽﻧﺎﻣرد ﮫﻧﺎﻣﺮﺤﻣ )PHI.ﺪﯾراﺪﻧ ار ﺪﯿﺘﺴھ ﺎﮭﻧآ ﺮﯿﯿﻐﺗ ﮫﺑ ﻞﯾﺎﻣ ﮫﮐ (
تﺎﻋﻼطاﯽﻧﺎﻣرد ﮫﻧﺎﻣﺮﺤﻣ )PHI ﮫﺑ ﻞﯾﺎﻣ ﮫﮐ ( ﻂﺳﻮﺗ ﮫﮐ ﯽﺗﺎﻋﻼطا وﺰﺟ ﺪﯿﺘﺴھ ﺎﮭﻧآ ﺮﯿﯿﻐﺗCalOptima دﻮﺷ ﯽﻣ یراﺪﮭﮕﻧ
تﺎﻋﻼطا یﻮﺘﺤﻣ ﻖﺑاﻮﺳ و ﺎھ بﺎﺴﺤﺗرﻮﺻ ﻖﺑاﻮﺳ ،ﺖﯾﻮﻀﻋ تﺎﻋﻼطا ﻞﻣﺎﺷ ﻦﯾا ؛ﻮﻀﻋ صﻮﺼﺨﻣ ﻖﺑاﻮﺳ ﮫﻋﻮﻤﺠﻣ) ﺖﺴﯿﻧ
ﯽﻧﺎﻣرد ﮫﻧﺎﻣﺮﺤﻣ )PHI.(.دﻮﺷ ﯽﻣ هدﺎﻔﺘﺳا ﺎﮭﻧآ زا ﺎﻤﺷ درﻮﻣ رد یﺮﯿﮔ ﻢﯿﻤﺼﺗ یاﺮﺑ ﮫﮐ ﺖﺳا (
:ﺎﻤﺷ قﻮﻘﺣ
ً
ﺎﻔﻄﻟﻧﺎﻣﺮﺤﻣ قﻮﻘﺣ هرﺎﺑرد ﺮﺘﺸﯿﺑ تﺎﻋﻼطا ﺐﺴﮐ ﺖﮭﺟ ﮫ ﮫﺑ دﻮﺧﻆﻔﺣ شور ﮫﯿﻋﻼطا ﯽﺻﻮﺼﺧ ﻢﯾﺮﺣCalOptima ﺪﯾراد رﺎﯿﺘﺧا رد ﮫﮐ
ﺪﯿﯾﺎﻤﻧ ﮫﻌﺟاﺮﻣ رد ار ﮫﯿﻋﻼطا ﻦﯾا ﺪﯿﻧاﻮﺘﯿﻣ ﺎﻤﺷ ﺎﻣ ﺖﯾﺎﺳ بوwww.caloptima.org ﺪﯿﯾﺎﻤﻧ هﺪھﺎﺸﻣ ﺑ ﮫﮑﻨﯾا ﺎﯾﺎ تﺎﻣﺪﺧ ﺶﺨﺑنﺎﯾﺮﺘﺸﻣ
CalOptima ﻂﺳﻮﺗ هرﺎﻤﺷ1-714-246-8500 نﺎﮕﯾار هرﺎﻤﺷ ﺎﯾ1-888-587-8088 رد ﮫﻌﻤﺟ ﺎﺗ ﮫﺒﻨﺷود یﺎھزور تﺎﻋﺎﺳ ﻦﯿﺑ8
ﺎﺗ ﺢﺒﺻ5:30 .ﺪﯾﺮﯿﮕﺑ سﺎﻤﺗ ﺮﮭظ زا ﺪﻌﺑ ﮫﮐ ﯽﯾﺎﻀﻋالﻼﺘﺧا ﻦﻔﻠﺗ ﺎﺑ ﺪﻨﻧاﻮﺗ ﯽﻣ ﺪﻧراد ﯽﯾاﻮﻨﺷ ﺎﯾ یرﺎﺘﻔﮔTDD ﺎﻣﻂﺳﻮﺗ هرﺎﻤﺷ ﻦﻔﻠﺗ
1-714-246-8523 ﺎﯾهرﺎﻤﺷ نﺎﮕﯾار 1-800-735-2929 .ﺪﻧﺮﯿﮕﺑ سﺎﻤﺗرﺎﮐ ﺎﻣﯽﻧاﺪﻨﻣ ﺖﺒﺤﺻ ﺎﻤﺷ نﺎﺑز ﮫﺑ ﮫﮐ ﻢﯾراد ﯽﻣ.ﺪﻨﻨﮐ
ﻧﺎﻣﺮﺤﻣ قﻮﻘﺣ ﺪﯿﻨﮐ ﯽﻣ رﻮﺼﺗ ﺮﮔا ﮫ ﺪﯿﻧاﻮﺗ ﯽﻣ ،هﺪﺷ ﮫﺘﺷاﺬﮔ ﺎﭘ ﺮﯾز ﺎﻤﺷﮫﺑ ار دﻮﺧ ﺖﯾﺎﮑﺷ ﻦﻔﻠﺗ هرﺎﻤﺷ1-714-246-8500 ﮫﺑ
CalOptima ﺎﯾ ﺪﯿﯾﺎﻤﻧ ﮫﺋارا سردآ ﺎﺑ ﺮﯾز :ﺪﯿﻨﮐ ﮫﺒﺗﺎﮑﻣ
CalOptima
Customer Service Department
505 City Parkway West
Orange, CA 92868
ﻧﺎﻣﺮﺤﻣ قﻮﻘﺣ زا ﺎﯾ و ﺪﯿﻨﮐ ﺖﯾﺎﮑﺷ ﮫﮐ ﯽﺗرﻮﺻ رددﻮﺧ ﮫ ،ﺪﯿﯾﺎﻤﻧ هدﺎﻔﺘﺳاCalOptima ﯽﻧﺎﻣرد یﺎھ ﺖﺒﻗاﺮﻣ یﺎﯾاﺰﻣ زا ار ﺎﻤﺷ ﺪﻧاﻮﺗ ﯽﻤﻧ
ﯽﺒﯿﺳآ ﺎﻤﺷ ﮫﺑ ﺎﯾ دزﺎﺳ موﺮﺤﻣ نﺎﺗﺪﻧﺎﺳﺮﺑ .
:ﺎﻀﻣا
:ﻮﻀﻋ یﺎﻀﻣا _____________________________________
:(ﺪﯿﻨﮐ ﮫﻤﯿﻤﺿ ار ﮫطﻮﺑﺮﻣ کراﺪﻣ
ً
ﺎﻔﻄﻟ) ﺪﯿﺘﺴھ ﯽﻤﺳر هﺪﻨﯾﺎﻤﻧ ﺮﮔا
:ﺢﺿاو و ﺖﺷرد فوﺮﺣ ﺎﺑ مﺎﻧ ___________________________ ﺖﺒﺴﻧ :ﻮﻀﻋ ﺎﺑ __________________________
ﮫﺑ لﺎﺳراCALOPTIMA:
ﻞﯿﻤﮑﺗ زا ﺲﭘ ار مﺮﻓ ﻦﯾاﺮﯾز سردآ ﮫﺑ :ﺪﯿﯾﺎﻤﻧ لﺎﺳرا
CalOptima Privacy Officer
505 City Parkway West
Orange, CA 92868
Fax: 714-338-3166
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CalOptima )PHI - Protected Health Information ( (CalOptima)

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Completed 11 March 2021

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