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(PROTECTED HEALTH INFORMATION, PHI) (DESIGNATED RECORD SET, DRS) (CalOptima)

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MCAL MM-18-142_Individual Request for Access to PHI Contained in DRS_A
ﺔﺤﻔﺻ 1 ﻦﻣ3 Rev. 09/18
ﺔﯿﺤﺼﻟا تﺎﻣﻮﻠﻌﻤﻟا ﻰﻟإ لﻮﺻﻮﻠﻟ يدﺮﻓ ﺐﻠط ﺔﯿﻤﺤﻤﻟا(PROTECTED HEALTH INFORMATION, PHI)
ﺔﻋﻮﻤﺠﻣ ﻲﻓ ﺔﻨﻤﻀﺘﻤﻟا ﺔﺼﺼﺨﻤﻟا تﻼﺠﺴﻟا(DESIGNATED RECORD SET, DRS)
ﻖﺤﯾﻟ ﻚﺺﺤﻓ ﺗﺎﻣﻮﻠﻌﻣﻚ ﺔﯿﻤﺤﻤﻟا ﺔﯿﺤﺼﻟاPHI ) ﺔﺼﺼﺨﻤﻟا تﻼﺠﺴﻟا ﺔﻋﻮﻤﺠﻣ ﻲﻓ ﺔﻨﻤﻀﺘﻤﻟاDRS.(
ً
ﺎﻀﯾأ ﻚﯾﺪﻟ هﺬھ ﻦﻣ ﺦﺴﻧ ﺐﻠط ﻲﻓ ﻖﺤﻟا
.تﻼﺠﺴﻟا
ً
ادر ﻲﻘﻠﺘﺗ فﻮﺳ ﻠﻋﻰ نﻮﻀﻏ ﻲﻓ ﻚﺒﻠط30
ً
ﺎﻣﻮﯾ ﺪﻌﺑأ .ﻞﻤﺘﻜﻤﻟا جذﻮﻤﻨﻟا ﻰﻘﻠﺘﻧ ن ةﺮﻓﻮﺘﻣ ﺮﯿﻏ تﺎﻣﻮﻠﻌﻤﻟا ﺖﻧﺎﻛ اذإﺔﻟﻮﮭﺴﺑ ىﺪﻟ نﻮﻜﯾ ﺪﻘﻓ ،
CalOptima ﻰﺘﺣ 60 ﻲﻘﻠﺗ ﺦﯾرﺎﺗ ﻦﻣ
ً
ﺎﯿﻤﯾﻮﻘﺗ
ً
ﺎﻣﻮﯾCalOptima ﻟ ﻚﻟ ﺮﻓﻮﺗ ﻲﻜﺗﺎﻣﻮﻠﻌﻣﻚ ﺔﯿﻤﺤﻤﻟا ﺔﯿﺤﺼﻟا نأ ﻦﻜﻤﻤﻟا ﻦﻣ .ﺗ مﻮﻘCalOptima
ﺔﻤﯿﻘﺑ مﻮﺳر ﻊﺿﻮﺑ$0.10 .ﺪﯾﺮﺒﻟﺎﺑ ﻚﯿﻟإ تﻼﺠﺴﻟا لﺎﺳرإ ﺖﺒﻠط اذإ ﺔﯾﺪﯾﺮﺑ مﻮﺳر ﺔﯾأو ﺔﺤﻔﺻ ﻞﻜﻟ
ﻚﺗﺎﻣﻮﻠﻌﻣ ﻦﻣ ﺔﺨﺴﻧ ﺐﻠﻄﻟPHI ﻲﻓ ﺔﻨﻤﻀﺘﻤﻟاDRS:
1. ﻢﻗ ﺑ ﻞﻣﺎﻜﻟﺎﺑ جذﻮﻤﻨﻟا ﺔﺌﺒﻌﺘ ﻊﻣ ﻞﻜﺸﺑ ﺔﺑﺎﺘﻜﻟاةءاﺮﻘﻟا ﻞﮭﺳ .قﺎﻓرإ ﺐﺠﯾ ،ﻚﺒﻠط داﺪﻋإ ﻞﺟأ ﻦﻣ ) ﻒﯾﺮﻌﺗ ﺔﻘﯿﺛو ﻦﻣ لﻮﻌﻔﻤﻟا ﺔﯾرﺎﺳ ﺔﺨﺴﻧID (
.ﺐﻠﻄﻟا جذﻮﻤﻧ ﻊﻣ ﻊﯿﻗﻮﺗ ﻊﻣ ةرﻮﺻ ﺎﮭﯿﻠﻋ
2. ﺺﺨﺷ ﻦﯿﯿﻌﺗ ﺪﯾﺮﺗ ﺖﻨﻛ اذإ ﺮﺧآﻰﻟإ لﻮﺻﻮﻟا ﻦﻣ ﻦﻜﻤﺘﯿﻟ ضﻮﻔﻣ ﻞﺜﻤﻤﻛ ﻲﻘﻠﺗ وأ ﻚﺗﺎﻣﻮﻠﻌﻣPHI ﺾﯾﻮﻔﺗ جذﻮﻤﻧ ﺔﺌﺒﻌﺗ
ً
ﺎﻀﯾأ ﻚﯿﻠﻋ ﺐﺠﯾ ﺎھﺪﻨﻋ ،
CalOptima ﻲﺘﻟا تﺎﺒﻠﻄﻟا .ﺔﯿﻤﺤﻤﻟا ﺔﯿﺤﺼﻟا تﺎﻣﻮﻠﻌﻤﻟا ﻦﻋ حﺎﺼﻓﻺﻟ ﻲﺼﺨﺸﻟا ﻚﻠﺜﻤﻣ ﺎﮭﻣﺪﻘﯾﻟ ﺔﻌﺿﺎﺧ.ﻖﻘﺤﺘﻠ
3. ﻰﺟﺮ
ُ
ﯾ رﺎﯿﺘﺧاعﻮﻧ ﻲﺘﻟا تﻼﺠﺴﻟاﺗﺟﺎﺘﺤ ﺎﮭ ﺎﻤﻣ ﺪﻛﺄﺘﻣ ﺮﯿﻏ ﺖﻨﻛ اذإ .ﺔﻘﻓﺮﻤﻟا ﺔﻤﺋﺎﻘﻟا ﻦﻣﮫﺟﺎﺘﺤﺗ ،ﻰﺟﺮ
ُ
ﯾ ءﻼﻤﻋ ﺔﻣﺪﺧ ﻊﻣ لﺎﺼﺗﻻاCalOptima
ﻲﻧﺎﺠﻤﻟا ﻢﻗﺮﻟا ﻰﻠﻋ1-888-587-8088 .ةﺪﻋﺎﺴﻤﻠﻟ
4. اذإ
ً
ﺎﻌﺑﺎﺗ ﺖﻨﻛ ﻟ ﻞﺜﻣ) ﺔﯿﺤﺻ ﺔﻜﺒﺸMonarch وأAltaMed ﻟا ﻦﻣ ةﺮﺘﻓ يأ لﻼﺧ (.ﺦﻟإ قﺎﻄﻨﻟا ﻲﻨﻣﺰ ﻚﻠﺗ ﻊﻣ لﺎﺼﺗﻻا
ً
ﺎﻀﯾأ ﺐﺠﯿﻓ ،بﻮﻠﻄﻤﻟا
.ﺔﯿﺤﺼﻟا ﺔﻜﺒﺸﻟا ﻻﺗ ﻆﻔﺘﺤCalOptima ﺑ ﻦﻣ ﺔﻠﻣﺎﻛ ﺦﺴﻨﺗﻼﺠﺳ ﻚﺔﯿﺒﻄﻟا . ﻲﻓ ﺐﻏﺮﺗ ﺖﻨﻛ اذإﺔﻌﺟاﺮﻣ لﻮﺼﺤﻟا وأﻰﻠﻋ ﺨﺴﻧﺔ ﻦﻣ ﺗﻼﺠﺳ ﻚ
ﺔﯿﺒﻄﻟا ،.ةدﺎﯿﻌﻟا وأ ﺐﯿﺒﻄﻟﺎﺑ لﺎﺼﺗﻻا ﻰﺟﺮ
ُ
ﯾ
5. تﺎﻈﻔﺤﺗ وأ ﺔﻠﺌﺳأ ﺔﯾأ ﻚﯾﺪﻟ ﺖﻧﺎﻛ اذإﻚﺒﻠط لﻮﺣ ،ﻰﺟﺮ
ُ
ﯾ ءﻼﻤﻋ ﺔﻣﺪﺧ ﻊﻣ لﺎﺼﺗﻻاCalOptima ﻲﻧﺎﺠﻤﻟا ﻢﻗﺮﻟا ﻰﻠﻋ1-888-587-8088 ﻦﻣ ،
ﺔﻋﺎﺴﻟا ﻦﻣ ﺔﻌﻤﺠﻟا ﻰﻟإ ﻦﯿﻨﺛﻹا8 ﻰﻟإ
ً
ﺎﺣﺎﺒﺻ5:30 .
ً
ءﺎﺴﻣ ﻲﻣﺪﺨﺘﺴﻤﻟ ﻦﻜﻤﯾTDD/TTY لﺎﺼﺗﻻاﻰﻠﻋ ﻲﻧﺎﺠﻤﻟا ﻢﻗﺮﻟا1-800-735-2929 .
ﻐﻟ ثﺪﺤﺘﯾ ﻢﻗﺎط ﺎﻨﯾﺪﻟ.ﻚﺘ
6. ﻦﻜﻤﯾﻚﺗﻼﺠﺳ ﺬﺧأ ﺐﺘﻜﻣ ﻦﻣCalOptima .ﻞﺠﺴﻤﻟا ﺪﯾﺮﺒﻟﺎﺑ وأ ﻲﻧوﺮﺘﻜﻟﻹا ﺪﯾﺮﺒﻟا ﺔﻄﺳاﻮﺑ ﺎﮭﻟﺎﺳرإ ﻦﻜﻤﯾ وأ ﺐﺠﯾأﺔﻘﻓاﻮﻤﻟا ﻢﺘﺗ ن ﻰﻠﻋ تﺎﺒﻠط
لﺎﺳرإ ﺲﻛﺎﻔﻟﺎﺑ تﻼﺠﺴﻟاﻦﻣ CalOptimaﺮﻔﺸﻣ) ﺔﻨﻣآ ﺔﻘﯾﺮﻄﺑ ﺎﮭﻟﺎﺳرإ ﻢﺘﯿﺳ ﻲﻧوﺮﺘﻜﻟﻹا ﺪﯾﺮﺒﻟا ﺮﺒﻋ ﺎﮭﻟﺎﺳرإ ﻢﺘﯾ ﻲﺘﻟا تﻼﺠﺴﻟا .ة ناﻮﻨﻋ ﻰﻟإ (
ﺪﯾوﺰﺗ ﻢﺘﯾ يﺬﻟا ﻲﻧوﺮﺘﻜﻟﻹا ﺪﯾﺮﺒﻟاCalOptima ،ﻚﻟذ ﻊﻣو ؛ﮫﺑنﺈﻓ CalOptima ﺮﯿﻏﻟوﺆﺴﻣﺔ ﻚﺗﺎﻣﻮﻠﻌﻣ ناﺪﻘﻓ ﻦﻋPHI ﻰﻠﻋ ﺪﯾﺮﺒﻟا تﺎﺑﺎﺴﺣ
ﻲﻧوﺮﺘﻜﻟﻹاﺔﯿﺼﺨﺸﻟا.
MCAL MM-18-142_Individual Request for Access to PHI Contained in DRS_A
ﺔﺤﻔﺻ 2 ﻦﻣ3 Rev. 09/18
ﺔﯿﻤﺤﻤﻟا ﺔﯿﺤﺼﻟا تﺎﻣﻮﻠﻌﻤﻟا ﻰﻟإ لﻮﺻﻮﻠﻟ يدﺮﻓ ﺐﻠط(PHI) ﺔﺼﺼﺨﻣ تﻼﺠﺳ ﺔﻋﻮﻤﺠﻣ ﻲﻓ ﺔﻨﻤﻀﺘﻤﻟا(DRS)
:ﻮﻀﻌﻟا ﻢﺳا :دﻼﯿﻤﻟا ﺦﯾرﺎﺗ
(ﺔﻨﺴﻟا/مﻮﯿﻟا/ﺮﮭﺸﻟا)
:ﻒﺗﺎﮭﻟا ﻲﻓ ﻮﻀﻌﻟا ﻢﻗرCalOptima :
ﻦﻣ
ً
اءﺰﺟ ﺮﺒﺘﻌﺗ هﺎﻧدأ ﺔﺟرﺪﻤﻟا تﻼﺠﺴﻟا عاﻮﻧأ نإDRS ﻲﺘﻟاﺗ ﺎﮭﺑ ﻆﻔﺘﺤCalOptima .ﻰﺟﺮ
ُ
ﯾ رﺎﯿﺘﺧاعاﻮﻧأ عﻼطﻻﺎﺑ ﺐﻏﺮﺗ ﻲﺘﻟا تﻼﺠﺴﻟا
ﺎﮭﯿﻠﻋ وأﺎﮭﺨﺴﻧ ﻰﻟإ ﺔﻓﺎﺿﻹﺎﺑﻟا قﺎﻄﻨﻟاﻲﻨﻣﺰ:
نوذﻻا
☐ ﻟا (تا)ﺐﻠطﺢﯾﺮﺼﺘ ﻲﺒﻄﻟا
☐ ﻟاﺢﯾﺮﺼﺘ) ﺔﻟﺪﯿﺼﻠﻟ ﻖﺒﺴﻤﻟا (تا)PA(
☐ ﻞﻤﻌﻟﺎﺑ (تا)رﺎﻌﺷا
ﻞﺠﺳ (تا) ﺔﯿﻛﻮﻠﺴﻟا ﺔﺤﺼﻟا
☐ ﺾﻓرﺢﯾﺮﺼﺗ (تا) ﺔﯿﻛﻮﻠﺴﻟا ﺔﺤﺼﻟا
☐ تﺎﻈﺣﻼﻣإرادة ﺔﯾﺎﻋﺮﻟا
ةرادإ تﻻﺎﺤﻟا
☐ ﻈﺣﻼﻣﺔ ﻹ (تﺎﻈﺣﻼﻣ)ةراد تﻻﺎﺤﻟا
☐ ﺔﻄﺧ (ﻂﻄﺧ)ﺔﯾﺎﻋر ةرادإ تﻻﺎﺤﻟا
☐ ﻢﯿﯿﻘﺗةرادإ (تا) تﻻﺎﺤﻟا
ﺮﺗﻮﻔﻟا/تﺎﺒﻟﺎﻄﻤﻟاة
☐ ﻞﺠﺳ (تا)ﺔﯿﺒﻄﻟا تﺎﺒﻟﺎﻄﻤﻟا
☐ ﻞﺠﺳ (تا)ﺔﻟﺪﯿﺼﻟا تﺎﺒﻟﺎﻄﻣ
ﻣﺪﺧﺔ ءﻼﻤﻌﻟا
☐ ﻀﻌﻟا تﺎﻤﻟﺎﻜﻣ تﻼﺠﺳﻮ
ﺔﯿﻠھﻷا
☐ ﻞﺠﺳ (تا)ﺔﯿﻠھﻷا
☐ ﻟاﻟا ﻦﯿﯿﻌﺘﻲﺋﺎﻘﻠﺘ تاﺮﯿﯿﻐﺗوﻟاﻜﺒﺸﺔ ﺤﺼﻟاﯿﺔ
☐ ﻟا (جذﺎﻤﻧ) جذﻮﻤﻧﻞﯿﺠﺴﺘ ﻖﺒﻄﻨﯾ ﻻ)ﻰﻠﻋ ءﺎﻀﻋأ
Medi-Cal(
) تﺎﻓﺎﻨﺌﺘﺳﻻاو تﺎﻤﻠﻈﺘﻟاGARS(
☐ ﻞﺠﺳ(تا) ﻒﻠﻣ تﺎﻤﻠﻈﺗﻟاﻟﺎﺤ ﺔ
☐ ﻞﺠﺳﻒﻠﻣ (تا) فﺎﻨﺌﺘﺳا ﻟاﻟﺎﺤﺔ
و ﻲﺤﺼﻟا ﻒﯿﻘﺜﺘﻟاةرادإ ﻷاضاﺮﻣ
☐ ﺔﻄﺧ ﺔﯾﺎﻋﺮﻟا (ﻂﻄﺧ)
☐ ﻢﯿﯿﻘﺘﻟا(تا)
☐ تﺎﻈﺣﻼﻣ ﻷا ةرادإو ﻲﺤﺼﻟا ﻒﯿﻘﺜﺘﻟاضاﺮﻣ
تﺎﻣﺪﺨﻟا ﻢﻋﺪﻟاوﻠﯾﻮطﻲ ) ﻞﺟﻷاLTSS(
☐ ﻢﯿﯿﻘﺘﻟا(تا)
☐ ﻟاﺢﯾﺮﺼﺘ (تا)
☐ تﺎﻈﺣﻼﻣةرادإ تﻻﺎﺤﻟا
) ضاﺮﻏﻷا ةدﺪﻌﺘﻣ ﺎﯿﻠﻌﻟا تﺎﻣﺪﺨﻟا ﺞﻣﺎﻧﺮﺑMSSP(
☐ ﻢﯿﯿﻘﺘﻟا(تا)
☐ ﺔﻄﺧ ﺔﯾﺎﻋﺮﻟا (ﻂﻄﺧ)
☐ (جذﺎﻤﻧ) جذﻮﻤﻧﺔﻟﺎﺣﻹا
☐ مﺪﻘﺘﻟا تﺎﻈﺣﻼﻣ
☐ ﺐﻠﻄﻟا ةرﺎﻤﺘﺳا
ﻻا (تﺎﺴﻠﺟ) ﺔﺴﻠﺟﺔﯾﻻﻮﻟﺎﺑ عﺎﻤﺘﺳ
☐ ﻞﺠﺳ(تا) ﺔﯾﻻﻮﻟﺎﺑ عﺎﻤﺘﺳﻻا تﺎﺴﻠﺟ
:ﺔﯿﻟﺎﺘﻟا تﺎﻣﺪﺨﻟا ﺦﯾراﻮﺗ ﻦﻣ ﺦﺴﻧ ﻰﻠﻋ لﻮﺼﺤﻟا ﺐﻠطأ ﻰﻟإ
(ﺔﻨﺴﻟا/مﻮﯿﻟا/ﺮﮭﺸﻟا) (ﺔﻨﺴﻟا/مﻮﯿﻟا/ﺮﮭﺸﻟا)
.ﺔﻠﻤﺘﻜﻣ ﺮﯿﻏ ﺮﺒﺘﻌﺗ فﻮﺳ ﻲﻨﻣز قﺎﻄﻧ نوﺪﺑ ﺎﮭﻤﯾﺪﻘﺗ ﻢﺘﯾ ﻲﺘﻟا تﺎﺒﻠﻄﻟا
ﺔﻘﯾﺮطﺘﻟاﺴﻠﻢﯿ :(ةﺪﺣاو ﺮﺘﺧا) ﺔﺑﻮﻠﻄﻤﻟا
☐ مﻼﺘﺳﻻا”ﯿﺼﺨﺷ
ً
ﺎ“ ﻦﻣCalOptima )ﺘﻟاﺤﻦﻣ ﻖﻘ ﺖﻗو ﻲﻓ بﻮﻠﻄﻣ ﺔﯾﻮﮭﻟا (مﻼﺘﺳﻻا
☐ :ﺪﯾﺮﺒﻟﺎﺑ
MCAL MM-18-142_Individual Request for Access to PHI Contained in DRS_A
ﺔﺤﻔﺻ 3 ﻦﻣ3 Rev. 09/18
ةﺪﺣﻮﻟا ﻢﻗر/عرﺎﺸﻟا ﺔﻨﯾﺪﻤﻟا ﺔﯾﻻﻮﻟا ﺰﻣﺮﻟا يﺪﯾﺮﺒﻟا
☐ ﺲﻛﺎﻔﻟﺎﺑ)ﺪﻨﻋ ﻟا(ﺔﻘﻓاﻮﻤ : ☐ :ﻲﻧوﺮﺘﻜﻟﻹا ﺪﯾﺮﺒﻟﺎﺑ
تﺎﻣﻮﻠﻌﻣ ﻒﯾﺮﻌﺘﻟا ﺑﻮﻠﻄﻣﺔ ﺮﺘﺧا):(ةﺪﺣاو
☐ (.ﺦﻟإ ﺎﯾاﺰﻤﻟا ﻰﻠﻋ لﻮﺼﺤﻟا ﻒﯾﺮﻌﺗ ﺔﻗﺎﻄﺑ وأ دﻼﯿﻣ ةدﺎﮭﺷ وأ لﻮﻌﻔﻤﻟا ﺔﯾرﺎﺳ ةدﺎﯿﻗ ﺔﺼﺧر ﻞﺜﻣ) ﻒﯾﺮﻌﺘﻟا ﻦﻣ ﺔﺨﺴﻧ ﻖﻓﺮﻣ
☐ ﺐﺠﯿﻓ ،ﻒﯾﺮﻌﺗ قﺎﻓرإ ﻢﺘﯾ ﻢﻟ اذإﻖﺛﻮﯾ نأ .ﻚﻌﯿﻗﻮﺗ
ﻣﺛﻮ :ﻞﺒﻗ ﻦﻣ ﻖ
:لﺪﻌﻟا ﺐﺗﺎﻛ ﻢﻗر
:ﺦﯾرﺎﺘﻟا
ﺮﻈﺣ:ﻊﯿﻗﻮﺘﻟا
) ﺔﯾﻮھ ﺔﻗﺎﻄﺑ ﻦﻣ لﻮﻌﻔﻤﻟا ﺔﯾرﺎﺳ ﺔﺨﺴﻧ قﺎﻓرإ ﺐﺠﯾ ،ﻲﺒﻠط ﺔﺠﻟﺎﻌﻣ ﻢﺘﯿﻟ ﮫﻧﺄﺑ ﻢﮭﻓأ ﺎﻧأ)ID ﻖﺋﺎﺛو ﻦﻣ ﺔﺨﺴﻧ وأ ،ﺔﯿﻣﻮﻜﺣ ﺔﮭﺟ ﻦﻋ ةردﺎﺻ (
.(ﻲﺒﻠط جذﻮﻤﻧ ﻊﻣ ﻖﺛﻮﻣ ﻊﯿﻗﻮﺗ وأ ،ﺔﯿﻧﻮﻧﺎﻘﻟا ﺔﻄﻠﺴﻟا
.ﮫﯿﻨﻌﯾ ﺎﻣ ﻢﮭﻓأو جذﻮﻤﻨﻟا اﺬھ ةءاﺮﻘﺑ ﺖﻤﻗ ﺪﻘﻟ ،هﺎﻧدأ ﻊﯿﻗﻮﺘﻟﺎﺑ
ﻲﺼﺨﺸﻟا ﻞﺜﻤﻤﻟا/ﻮﻀﻌﻟا ﻊﯿﻗﻮﺗ
ﻟاﺦﯾرﺎﺘ
:ﻲﺻﻮﻟا/ﺪﻟاﻮﻟا ﻊﯿﻗﻮﺗ
ﺦﯾرﺎﺘﻟا:
عﻮﺒﻄﻤﻟا ﻢﺳﻻا:ﻲﺻﻮﻟا/ﺪﻟاﻮﻠﻟ ﺔﻠﺼﻟا:
ﻆﻔﺘﺤﺗCalOptima ﻦﻋ ﺔﺑﺎﯿﻨﻟﺎﺑ ﻊﻗﻮﯾ يﺬﻟا ﻲﺻﻮﻟا/ﺪﻟاﻮﻟا ﻦﻣ (ﻚﻟذ ﻰﻟإ ﺎﻣو ،ﺔﻤﻜﺤﻣ ﺮﻣأ وأ ،دﻼﯿﻣ ةدﺎﮭﺷ ﻞﺜﻣ) ﺔﯿﻧﻮﻧﺎﻗ ﻖﺋﺎﺛو ﺐﻠط ﻲﻓ ﻖﺤﻟﺎﺑ
.لﺎﻌﻣ ﻮﻀﻋ
نﻮﯿﺼﺨﺸﻟا نﻮﻠﺜﻤﻤﻟا —
ُ
ﯾ ﻦﻣ ﻖﻘﺤﺘﻠﻟ ﺔﯿﻧﻮﻧﺎﻘﻟا ﻖﺋﺎﺛﻮﻟا قﺎﻓرإ ﻰﺟﺮأﯿﺻﻮﻟ ﺬﻔﻨﻤﻟا ،ﻲﺻﻮﻟا ﻚﻧﺔ ﻄﻠﺳ ﻚﯾﺪﻟ وأ ،ﻲﻓﻮﺘﻣﺔ ﺔﯿﺒﻄﻟا تاراﺮﻘﻟا ذﺎﺨﺗا
.دﺮﻔﻠﻟ
مﺪﻗ جذﻮﻤﻧ ﻰﻟإ ﻊﻗﻮﻤﻟاو ﻞﻤﺘﻜﻤﻟا ﺐﻠﻄﻟاCalOptima
ً
ﺎﯿﺼﺨﺷ، ﺪﯾﺮﺒﻟﺎﺑ وأ، .ﺲﻛﺎﻔﻟﺎﺑ وأ
CalOptima
Attn: Office of Compliance (Privacy)
505 City Parkway West, Orange, CA 92868
Fax: 1-714-481-6457
ﺮﯿﻏ ﻲﻤﺳر ﺎﻣ ﻢﻟ ﻢﺘﯾ ﮫﻘﯾﺪﺼﺗ ﻦﻣ ﻞﺒﻗ ﺐﺗﺎﻛ لﺪﻌﻟا
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(PROTECTED HEALTH INFORMATION, PHI) (DESIGNATED RECORD SET, DRS) (CalOptima)

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Completed 11 March 2021

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