Fillable Enclosed forms: New Subscriber Enrollment form (Page 2) (Lake Superior State University)

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Enclosed forms: New Subscriber Enrollment form (Page 2) (Lake Superior State University)

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Enclosed forms: New Subscriber Enrollment form (Page 2)
Change
of Status form (Page 6)
Blue Cross Physician Choice/BCN Primary Care Physician Selection form (Page
4) Health Savings and Flexible Spending Account Options form (Page 8)
Please
read the following information before completing the attached forms. The information on these forms and the following conditions are part of
your contract with Blue Cross Blue Shield of Michigan or Blue Care Network of Michigan.
Group representative information: The group confirms that the status change
requested complies with and is permitted under applicable state and federal law,
including the Patient Protection and Affordable Care Act.
Blue Care Network only
I and my enrolled family members agree t
hat all our medical services may be
performed, prescribed, directed or authorized by our designated BCN primary
care physician except in the case of an immediate and unforeseen medical
emergency when the time needed to contact our primary care physician may
mean permanent damage to our health. Unauthorized services that are not an
emergency as described above, received from non-BCN providers, will not be
covered.
I agree to assign to BCN the right to recover from any person or organization the
cost of hospital, medical and prescription services delivered by or paid for by
BCN as a result of accident or disease, including injuries or disease claimed
under workers’ compensation laws or acts, whether by redemption award,
voluntary payment or otherwise.
I authorize any holder of medical or other information about me or my enrolled
family members to release any information needed to determine benefits
coverage to the Centers for Medicare and Medicaid Services, any insurance
company or any HMO and their agents. I request that payment of authorized
Medicare, Medicaid, insurance company or HMO benefits be made payable to
BCN on my behalf for any services that BCN provides to me and my enrolled
family members.
Send completed forms to:
(For Blue Cross Blue Shield of Michigan)
Blue Cross Blue Shield of Michigan
Membership and Billing – M.C. 610I
P.
O. Box 2260
Detr
oit, MI 48226
Fax: 1-866-900-2619
(For Blue Care Network)
Blue Care Network
Membership and Billing – M.C. C300
P.O.
Box 5043
Southfield, MI 48086
Fax: 1-877-218-1466
I am applying for health care coverage with Blue Cross Blue Shield of Michigan
or Blue Care Network, or I am modifying existing coverage for me or my
dependents. Coverage begins on the date determined by Blue Cross or BCN.
When Blue Cross or BCN accepts my application or changes, my covered
dependents and I are bound by the terms of the Blue Cross or BCN certificates,
riders, other coverage documents, policies and these forms. I understand that
submitting false or misleading information or omitting material information on
these forms may result in rejection of my changes or retroactive termination of
my coverage.
Proof of eligibility: I agree to provide proof of my dependents’ eligibility for
coverage when requested by Blue Cross or BCN.
Authorization: I appoint my employer or association to handle all matters of
coverage. My employer may forward any agreed deductions for coverage from
my wages. I am responsible for notifying my employer or association of changes
in my status or my family’s status that affect coverage, such as marriage,
divorce, birth, Medicare entitlements or death of someone covered under the
policy. I authorize Blue Cross or BCN or my primary care physician to obtain the
medical records relating to me and my enrolled family members needed to
coordinate our medical care, administer my Blue Cross or BCN coverage and for
other purposes necessary for Blue Cross or BCN to fulfill its contractual and
statutory obligations.
Health Insurance Portability and Accountability Act: If I lose my eligibility for
coverage, I may be entitled to special enrollment rights under HIPAA. Blue Cross
or BCN reserves the right to request written verification of the date of the event
and reason for loss of eligibility from my previous group or carrier. HIPAA special
enrollment rights do not pre-empt a new-hire waiting period, which must first be
satisfied. Termination of employment may qualify for special enrollment rights,
but voluntary terminations of other health care coverage do not.
Release of health care information: I acknowledge that Blue Cross or BCN
requires me to provide my Social Security number. In applying for coverage, I
and my enrolled dependents agree to permit health care providers and others to
release “protected health information (as defined in the Health Insurance
Portability and Accountability Act of 1996) to Blue Cross or BCN for administering
our coverage. Upon my request, Blue Cross or BCN will tell me where the
information was sent. If I have enrolled in a flexible spending account or health
reimbursement arrangement through my employer, I authorize Blue Cross or
BCN to provide claim information pertaining to me and my covered dependents
to the account administrator to facilitate reimbursement.
Page 1 of 9 WF 3599 MAY 19
New Subscriber Enrollment
(See Page 3 for instructions)
Blue Cross Blue Shield of Michigan Blue Care Network
(Also complete Page 4 for Physician Choice or primary care physician selection)
Blue Cross group number Division BCN group number Subgroup number Class number Employer representative signature
Subscriber information
Date
Non U.S.
citizen
Social Security/TIN number (required) Subscriber legal last name Subscriber legal first name M.I. Marital status
S M
Gender
M F
Subscriber birth date Home street address City State ZIP code
County Country – if other than USA Primary telephone number Home
Work
Cell
Secondary telephone number
Home
Work
Cell
Email
List all persons to be covered:
*Relationship code
(see instructions for
codes)
Legal last name Legal first name MI Gender
Date of
birth
Non U.S.
citizen
Social Security/TIN
number (required)
Spouse
M F
Dep. 1
M F
Dep. 2
M F
Dep. 3
M F
Dep. 4
M F
If the permanent address of the spouse or dependent is different from the address above, please complete the information below:
Spouse or dependent (full name) Street address City State ZIP code
Coordination of benefits information
Do you, your spouse or dependents have other health care coverage? Yes No
If “Yes,” complete below:
Check here if this applies to all members on the contract.
Person covered (full name) Employer or group name Policy number Carrier Address
I have read and understand the conditions of this form.
Subscriber signature: Date:
Health savings, health reimbursement and flexible spending account options for only Blue Cross coverage: See Page 8 for product selections
FSA HRA HSA HSA Opt out
Blue Cross product indicator code
Add Change Cancel
Goal amount:
Employer/group use only
Group name Employer reference ID Department ID Benefit code Plan code Date of hire Effective date
Check coverage if applicable: Check type of enrollment:
Transfer Return from layoff Loss of eligibility (prior coverage) Salary
Average hours worked
per week (required):
Job title
(required)
Medical
Dental
Vision
Pharmacy
New
Rehire
Full time
Part time
Old group division/subgroup
New group division/subgroup
Retiree
Hourly
Surviving spouse
Open enrollment
COBRA enrollment
Check reason:
Termination
Layoff
Reduction of hours
Loss of dependent status
Divorce or legal separation
Deceased subscriber
Previous contract number Original qualifying date
Loss of eligibility (prior coverage)
Yes No
If “Yes,” complete:
Carrier’s name (including Blue Cross and BCN) Contract holder name Policy number Termination date
Are any members listed enrolled in Medicare? Yes No If “Yes,” check reason category Over 65 and working Retired Disabled ESRD Medicare ID:
Medicare primary Subscriber Spouse
Medicare A effective date Medicare B effective date Medicare Part D effective date
Blue Cross or BCN primary Dependent name:
Page 2 of 9 WF 3599 MAY 19
New Subscriber Enrollment and Change of Status Forms
Instructions for completing New Subscriber Enrollment form on Page 2
•
Indicate if enrolling in Blue Cross or Blue Care Network. If enrolling with Blue Cross Physician Choice or with BCN, you are also required to complete the Blue Cross
Physician Choice/BCN Primary Care Physician form on Page 4 to designate your primary care physician.
• Enter Blue Cross group and division number (for example, suffix, section code) or BCN group number, subgroup number and BCN class number. Have your employer's HR
representative sign and date the "Employer Signature" section.
Subscriber information:
• If the responsible individual is not a U.S. citizen, check the box for non-U.S. citizen. Enter a taxpayer identification number in the "Social Security/TIN number" field if the
responsible individual checked the box as a non-U.S. citizen. For a U.S. citizen, enter the nine-digit Social Security number (required for all members) of the responsible
individual (Example xxx-xx-xxxx).
• Enter home address beginning with street address, city, state and ZIP code. Enter email address to receive health and wellness information.
• Enter county name for home address and country name (if other than USA). Enter primary and secondary phone number and indicate if home, work or cell.
• List all persons to be enrolled. Enter names on appropriate line – Spouse, Dependent 1, 2, 3 and 4 as applicable. Complete additional forms if you have more than four
dependents.
• Enter last name, middle initial, male or female and date of birth. If the responsible individual is not a U.S. citizen, check the box for non-U.S. citizen. Enter a taxpayer
identification number in the "Social Security/TIN number" field if the responsible individual checked the box as a non-U.S. citizen. For a U.S. citizen, enter the nine-digit Social
Security number (required for all members) of the responsible individual (Example xxx-xx-xxxx). Enter the relationship code of the member (see below).
Relationship codes:
N – Child (by birth or adoption) A – Child adoption in process** C – Court order coverage (QMCSO)** SP – Spouse
S – Stepchild L – Legal guardianship** D – Disabled child*** DP – Domestic partner
P – Principal support (BCN only)* SD – Sponsored dependent* M – Medicare
* = Attached documentation ** = Attach court order *** = Attach physician statement
• Enter the spouse’s or dependent’s permanent address if different from the address indicated above.
Coordination of benefits information:
• Indicate “Yes” or “No” if you, your spouse or dependent have other health care coverage. If “Yes,” lit complete name of person covered, group name, policy number, carrier
name and address. If other health coverage applies to all members on the contract, check the applicable box.
Health savings, health reimbursement and flexible spending account options:
• Check all applicable options. Blue Cross only: See Page 8 for four-digit product indicator code. Return to Page 2 or 6 and enter the four-digit Blue Cross product indicator code.
Employer/group use only:
• Enter employer or group name and employee reference ID or department number, if applicable. Enter benefit code (service code, package code). For the plan code field, enter
“710” to represent Blue Cross Blue Shield of Michigan. Enter date of hire and effective date.
• Please check all applicable boxes to indicate coverage selected.
• Check type of enrolment (new, rehire, etc.). Indicate the average hours worked per week and the employee’s job title. If enrolled in COBRA, check the reason for COBRA.
Indicate the previous contract number and the original qualifying date. If transfer, please indicate the old group/division/subgroup and new group division/subgroup numbers.
• For loss of eligibility (prior coverage), indicate “Yes” or “No.” If “Yes,” please indicate the carrier name, contract holder name, policy number and termination date. If coverage is
lost from an insurance carrier other than Blue Cross or BCN, then a letter of credible coverage is required.
• Medicare status: Indicate if any members listed are enrolled in Medicare. If “Yes,” check the reason category to explain the member’s enrollment in Medicare. Indicate if
Medicare is primary or if Blue Cross or BC is primary and enter effective date of the Medicare Parts A, B and D coverage. Please attach a copy of the Medicare card.
Please provide all documentation for enrollment.
Page 3 of 9 WF 3599 MAY 19
Blue Cross Physician Choice PPO/BCN Primary Care Physician Selection (see Page 5 for instructions)
Non U.S.
citizen
Subscriber Social Security number/TIN (required) Blue Cross/BCN group number Blue Cross division/BCN subgroup number BCN class number
If you are enrolling in Blue Cross Blue Shield of Michigan Physician Choice PPO or Blue Care Network, you need to select a primary care physician for you and each person on
your contract. List your selections on this form.
You can choose a different primary care physician for each member of your family, or one to care for your entire family. If you elect to have one doctor for your entire family, you
must select a family or general practice physician. You cannot choose a specialist as a primary care physician. You also need to fill out this form if you are already enrolled in Blue
Cross or BCN and have decided to change your primary care physician.
Need information about available primary care physicians?
Our website, bcbsm.com/find-a-doctor, provides the most current information on Blue Cross and BCN-affiliated primary care physicians. You can search for a family practice,
general medicine, internal medicine, pediatrics, preventive medicine, city or hospital group.
Member information
Member’s last name, first name Physician last name, first name Physician’s NPI# Physician address If change PCPs, list reason
Seen in the last
12 months?
Subscriber
Yes No
Spouse
Yes No
Dep. 1
Yes No
Dep. 2
Yes No
Dep. 3
Yes No
Dep. 4
Yes No
Group/Employer’s name: Effective date of change:
I have read and understand the
conditions of this form.
Subscriber signature Date:
Return this form to start your heath care partnership
We encourage you to return this form as soon as you enroll so we can notify hour doctor of your membership.
For Blue Cross Blue Shield of Michigan:
Fax y
our complete form to 1-866-900-2619
Or mail to:
Blue Cross Blue Shield of Michigan
Membership and Billing – M.C. 610I
P.O. Box 2260
Detroit, MI 48226
For Blue Care Network:
Fax your complete form to 1-877-218-1466
Or mail to:
Blue Care Network
Membership and Billing – M.C. C300
P.O. Box 5043
Southfield, MI 48086-5043
All changes become effective two business days after we receive this form – unless you request a later effective date.
You cannot select an earlier date when you change your primary care physician. If you change your primary care physician while you are being treated by a specialist, your new
primary care physician must reauthorize the treatment you are receiving. Your treatment may not be covered until that occurs. You may request to change your primary care
physician effective immediately by calling the Customer Service number on the back of your Blue Cross or BCN ID card.
Page 4 of 9 WF 3599 MAY 19
Instructions for completing the Blue Cross Physician Choice/BCN Primary Care Physician Selection form on Page 4
• If the responsible individual is not a U.S. citizen, check the box for non-U.S. citizen, enter a taxpayer identification number in the Social Security number field if the responsible
individual checked the box as a non-U.S. citizen. For a U.S. citizen, enter the nine-digit Social Security number (required for all members) of the responsible individual
(Example xxx-xx-xxxx).
• Enter each member’s last and first name, physician’s last name and first name, physician’s NPI number, physician’s address and the reason for changing your primary care
physician, if applicable. Indicate if the primary care physician has been seen in the last 12 months. You can find the physician’s NPI number when searching for a doctor on
bcbsm.com/find-a-doctor.
• Enter the employer’s name and the date you changed to this physician.
• In the signature section, sign your full name and enter the date that you signed the form.
Note: Submit the Blue Cross Physician Choice/BCN Primary Care Physician form with your New Subscriber Enrollment form when enrolling with Blue Cross or BCN.
Page 5 of 9 WF 3599 MAY 19
Blue Cross Blue Shield of Michigan Blue Care Network (see instructions on Page 7)
Change of Status
Blue Cross group number Division BCN group number Subgroup number Class number Employer representative signature Date
Subscriber information (*Indicate changes only)
Non U.S.
citizen
Social Security/TIN number (required) Subscriber legal last name Subscriber legal first name M.I.* Date of birth* Marital status*
S M
Gender*
M F
New home street address* City* State* ZIP code* Email*
County*
Country – if other than USA*
New primary phone* Home Work Cell New secondary phone* Home Work Cell
List all persons to be added or deleted:
*Relationship code
(see instructions for
codes)
Legal last name Legal first name M. Gender
Date of
birth
Non U.S.
citizen
Social Security/TIN
number (required)
Spouse
Add Delete
M F
Dep. 1
Add Delete
M F
Dep. 2
Add Delete
M F
Dep. 3
Add Delete
M F
Dep. 4
Add Delete
M F
If the permanent address of the spouse or dependent is different from
the address above, please complete the following information:
Spouse or dependent (full name) Home street address City State ZIP code
Coordination of benefits information
Do you, your spouse or dependents have other health care coverage? Yes No
If “Yes,” complete below:
Check here if this applies to all members on the contract.
Person covered (full name) Employer or group name Policy number Carrier Address
I have read and understand the conditions of this form.
Subscriber signature: Date:
Health savings, health reimbursement and flexible spending account options for only Blue Cross coverage: See Page 8 for product selections
FSA HRA HSA HSA Opt out
Blue Cross product indicator code Add Change Cancel Goal amount:
Employer/group use only
Group name Employer reference ID Department ID Benefit code Plan code
Check reason for change below:
Marriage Loss of eligibility (prior coverage) COBRA enrollment
Dependents Name change Open enrollment Address change
Transfer old group div
ision/subgroup New group division/subgroup
Date of event: Effective date:
Check type of cancellation and reason below. Type: Contract Spouse Dependents
Reason: COBRA Death Left employment
Divorce Dependent over age Other
Retired Other insurance
Last date of coverage:
Loss of eligibility (prior coverage) Yes No If “Yes,” complete below:
Carrier’s name (including Blue Cross and BCN) Contract holder name Policy number Termination date
Are any members listed enrolled in Medicare? Yes No If “Yes,” check reason category Over 65 and working Retired Disabled ESRD
Medicare primary Subscriber Spouse
Medicare A
effective date
Medicare B
effective date
Medicare Part D
effec
tive date
Medicare
ID:
Blue Cross
or BCN primary Dependent name:
Page 6 of 9 WF 3599 MAY 19
Instructions for completing Change of Status form on Page 6
•
Indicate if enrolling in Blue Cross or Blue Care Network. If enrolling with Blue Cross Physician Choice or with BCN, you are also required to complete the Blue Cross
Physician Choice/BCN Primary Care Physician form on Page 4 to designate your primary care physician.
• Enter Blue Cross group and division number (for example, suffix, section code) or BCN group number, subgroup number and BCN class number. Have your employer's HR
representative sign and date the "Employer Signature" section.
Subscriber information:
• If the responsible individual is not a U.S. citizen, check the box for non-U.S. citizen. Enter a taxpayer identification number in the "Social Security/TIN number" field if the
responsible individual checked the box as a non-U.S. citizen. For a U.S. citizen, enter the nine-digit Social Security number (required for all members) of the responsible
individual (Example xxx-xx-xxxx).
• Enter new home address beginning with street address, city, state and ZIP code. Enter email address to receive health and wellness information.
• Enter new county name for home address and country name (if other than USA). Enter new primary phone, if changing, and indicate if home, work or cell. Enter new secondary
phone number and indicate if home, work or cell.
• List all persons to be added or deleted. Enter name(s) on appropriate line – Spouse, Dependent 1, 2, 3 and 4 as applicable. Complete additional forms if all your dependents do
not fit on this form.
• Enter last name, middle initial, male or female and date of birth. If the responsible individual is not a U.S. citizen, check the box for non-U.S. citizen. Enter a taxpayer
identification number in the "Social Security/TIN number" field if the responsible individual checked the box as a non-U.S. citizen. For a U.S. citizen, enter the nine-digit Social
Security number (required for all members) of the responsible individual (Example xxx-xx-xxxx). Enter the relationship code of the member (see below).
Relationship codes:
N – Child (by birth or adoption) A – Child adoption in process** C – Court order coverage (QMCSO)** SP – Spouse
S – Stepchild L – Legal guardianship** D – Disabled child*** DP – Domestic partner
P – Principal support (BCN only)* SD – Sponsored dependent* M – Medicare
* = Attached documentation ** = Attach court order *** = Attach physician statement
• Enter the spouse’s or dependent’s permanent address if different from the address indicated above.
Coordination of benefits information:
• Indicate “Yes” or “No” if you, your spouse or dependent have other health care coverage. If “Yes,” lit complete name of person covered, group name, policy number, carrier
name and address. If other health coverage applies to all members on the contract, check the applicable box.
Health savings, health reimbursement and flexible spending account options:
• Check all applicable options. Blue Cross only: See Page 8 for four-digit product indicator code. Return to Page 2 or 6 and enter the four-digit Blue Cross product indicator code.
Employer/group use only:
• Enter employer or group name and employee reference ID or department number, if applicable. Enter benefit code (service code, package code). For the plan code field, enter
“710” to represent Blue Cross Blue Shield of Michigan. Enter date of hire and effective date.
• Please check all applicable boxes to indicate coverage selected.
• Check type of enrolment (new, rehire, etc.). Indicate the average hours worked per week and the employee’s job title. If enrolled in COBRA, check the reason for COBRA.
Indicate the previous contract number and the original qualifying date. If transfer, please indicate the old group/division/subgroup and new group division/subgroup numbers.
• For loss of eligibility (prior coverage), indicate “Yes” or “No.” If “Yes,” please indicate the carrier name, contract holder name, policy number and termination date. If coverage is
lost from an insurance carrier other than Blue Cross or BCN, then a letter of credible coverage is required.
• Medicare status: Indicate if any members listed are enrolled in Medicare. If “Yes,” check the reason category to explain the member’s enrollment in Medicare. Indicate if
Medicare is primary or if Blue Cross or BC is primary and enter effective date of the Medicare Parts A, B and D coverage. Please attach a copy of the Medicare card.
Please provide all documentation for enrollment.
Page 7 of 9 WF 3599 MAY 19
Blue Cross Blue Shield of Michigan Health Savings and Flexible Spending Account Options
If you are enrolling in a health savings and flexible spending account, please indicate below which options you are selecting by checking all appropriate boxes.
Record your selections and the corresponding product indicator code on Page 2 for new enrollments or on Page 6 for a change of status in the “Health savings
and flexible spending account options” section of the form. If you have selected as FSA product, please indicate your designated goal amount on Page 2 or
Page 6 of the form.
Product selections
Product selected
(Check box)
Product name Product indicator code
Health Savings Account (HSA) 1000
HSA with limited purpose Flexible Spending Account (FSA) 1070
HSA with dependent care FSA 1004
HSA with limited purpose FSA and dependent care FSA 1074
Health Reimbursement Arrangement (HRA) 0100
HRA with limited purpose FSA 0170
HRA with dependent care FSA 0104
HRA with limited purpose FSA and dependent care FSA 0174
HRA with FSA 0110
HRA with FSA and dependent care FSA 0114
Health care FSA 0010
Dependent care FSA 0004
Health care FSA and dependent care FSA 0014
Limited Purpose FSA 0070
Page 8 of 9 WF 3599 MAY 19
 ,      , 
 ,     
      
   ,    
    
We speak your language
If you, or someone you’re helping, needs assistance,
you have the right to get help and information in
your language at no cost. To talk to an interpreter,
call the Customer Service number on the back of
your card.
Si usted, o alguien a quien usted está ayudando,
necesita asistencia, tiene derecho a obtener ayuda e
información en su idioma sin costo alguno. Para
hablar con un intérprete, llame al número telefónico
de Servicio al cliente, que aparece en la parte trasera
de su tarjeta.
إ اذﻛ ﺖﻨأ ﺖﻧأ وﺷ ﺺﺨآﺧ ﺮﺗﺴﺎﻋﺪ هﺑﺤﺎ ﺔﺟﻟﻤﺴﺎﻋﺪة ،ﻠﻓﺪﯾ ﻚﻟاﺤ ﻖ
ﻓ ﻲﻟاﺤﺼﻮ لﻠﻋ ﻰﻟاﻤﺴﺎﻋﺪ ةﻟاوﻤﻠﻌﻮﻣﺎ تﻟاﻀﺮورﯾ ﺔﻠﺑﻐﺘ ﻚدو نأ ﺔﯾ
ﻠﻟﺘﺤ ثﺪﻟإﻰﻣﺘﺟﺮﻢاﺗ ﻞﺼﺑﺮﻗ ﻢﺪﺧﻣﺔاﻟﻌﻤﻼءاﻟﻤﺟﻮدﻮﻋﻠﻰ . ﺗﻠﻜﺔﻔ
ظﮭ ﺮﺑﻄﻗﺎﺘﻚ.
Jeśli Ty lub osoba, której pomagasz, potrzebujecie
pomocy, masz prawo do uzyskania bezpłatnej
informacji i pomocy we własnym języku. Aby
porozmawiać z tłumaczem, zadzwoń pod numer
działu obsługi klienta, wskazanym na odwrocie
Twojej karty.
Falls Sie oder jemand, dem Sie helfen, Unterstützung
benötigt, haben Sie das Recht, kostenlose Hilfe und
Informationen in Ihrer Sprache zu erhalten. Um mit
einem Dolmetscher zu sprechen, rufen Sie bitte die
Nummer des Kundendienstes auf der Rückseite Ihrer
如果您，或是您正在協助的對象，需要協助，您
Karte an.
Kung ikaw, o ang iyong tinutulungan, ay
nangangailangan ng tulong, may karapatan ka na
makakuha ng tulong at impormasyon sa iyong wika
ng walang gastos. Upang makausap ang isang
tagasalin, tumawag sa numero ng Customer Service
sa likod ng iyong tarheta.
Important disclosure
Blue Cross Blue Shield of Michigan and Blue Care
Network comply with Federal civil rights laws and do
not discriminate on the basis of race, color, national
origin, age, disability, or sex. Blue Cross Blue Shield
of Michigan and Blue Care Network provide free
auxiliary aids and services to people with disabilities
to communicate effectively with us, such as qualified
sign language interpreters and information in other
formats. If you need these services, call the
Customer Service number on the back of your card.
If you believe that Blue Cross Blue Shield of Michigan
有權利免費以您的母語得到幫助和訊息。要洽詢
Se tu o qualcuno che stai aiutando avete bisogno di
or Blue Care Network has failed to provide services
一位翻譯員，請撥在您的卡背面的客戶服務電話
assistenza, hai il diritto di ottenere aiuto e
or discriminated in another way on the basis of race,
informazioni nella tua lingua gratuitamente. Per
color, national origin, age, disability, or sex, you can
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 
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،
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,
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.
.
،
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parlare con un interprete, rivolgiti al Servizio
file a grievance in person, by mail, fax, or email with:
Assistenza al numero indicato sul retro della tua
Office of Civil Rights Coordinator, 600 E. Lafayette
scheda.
Blvd., MC 1302, Detroit, MI 48226, phone: 888-605-
6461, TTY: 711,
ご本人様、またはお客様の身の回りの方で支援
fax: 866-559-0578, email:
CivilRights@bcbsm.com. If
you need help filing a grievance, the Office of Civil
を必要とされる方でご質問がございましたら、
ご希望の言語で
サポートを受けたり、情報を入
Rights Coordinator is available to help you.
手したりするこ
とができます。料金はかかりま
せん。通訳とお
話される場合はお持ちのカード
の裏面に記載さ
れたカスタマーサービスの電話
You can also file a civil rights complaint with the U.S.
Department of Health & Human Services Office for
Civil Rights electronically through the Office for Civil
番号までお電話ください。
Rights Complaint Portal available at
Если вам или лицу, которому вы помогаете,
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by
нуж
на помощь, то вы имеете право на бесплатное
mail, phone, or email at: U.S. Department of Health
полу
чение помощи и информации на вашем
языке
. Для разговора с переводчиком позвоните
& Human Services, 200 Independence Ave, S.W.,
Washington, D.C. 20201, phone: 800-368-1019, TTD:
по телефону отдела обслуживания клиентов,
800-537-7697,
указ
анному на обратной стороне вашей карты.
email:
OCRComplaint@hhs.gov. Complaint forms are
Ukoliko Vama ili nekome kome Vi pomažete treba
available at
pomoć, i
mate pravo da besplatno dobijete pomoć i
http://www.hhs.gov/ocr/office/file/index.html.
informacije na Vašem jeziku. Da biste razgovarali sa
prevodiocem, pozovite broj korisničke službe sa
zadnje strane kartice.
Nếu quý vị, hay người mà quý vị đang giúp đỡ, cần
trợ giúp, quý vị sẽ có quyền được giúp và có thêm
thông tin bằng ngôn ngữ của mình miễn phí. Để nói
chuyện với một thông dịch viên, xin gọi số Dịch vụ
Khách hàng ở mặt sau thẻ của quý vị.
Nëse ju, ose dikush që po ndihmoni, ka nevojë për
asistencë, keni të drejtë të merrni ndihmë dhe
informacion falas në gjuhën tuaj. Për të folur me një
përkthyes, telefononi numrin e Shërbimit të Klientit
në anën e pasme të kartës tuaj.
만약 귀하 또는 귀하가 돕고 있는 사람이 지원이
필요하다면 , 귀하는 도움과 정보를 귀하의 언어로
비용 부담 없이 얻을 수 있는 권리가 있습니다 .
통역사와 대화하려면 귀하의 카드 뒷면에 있는
고객 서비스 번호로 전화하십시오 .
Page 9 of 9 WF 3599 MAY 19
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