Fillable Request for Continuity of Care Services (Blue Shield of California)

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Request for Continuity of Care Services (Blue Shield of California)

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C13095 Request for Continuity of Care Services Form Page 1 of 6
Request for Continuity of Care Services
Blue Shield of California provides continuity of care services to new and current members of a
Blue Shield of California plan. As of January 1, 2018, there are eligibility limitations that apply to new
enrollees of a Blue Shield Individual and Family Plan (IFP). You may call the Member Services or
Customer Care number on your Blue Shield member ID card for more information.
Initial criteria must be met:
• Current Blue Shield members – You are now receiving care and your provider is no longer in the
plan’s network.
If you are a current Blue Shield member, you are eligible for continuity of care services when a
Blue Shield provider from whom you are receiving services for a specified course of treatment
leaves the network. If your provider has left the network after your effective date of coverage
or you need assistance finding a provider, please call the Member Services number on your
Blue Shield member ID card.
• Newly enrolled members – You are currently receiving care and your previous provider does not
accept your new health plan.
Individual and Family Plan (IFP) members newly enrolled on Blue Shield policies effective January
1, 2018, and later, may be eligible for continuity of care services when the previous provider is
outside the Blue Shield IFP network.
• Any Maternal Mental Health conditions
Secondary criteria must be met:
• Acute condition – A medical condition that involves a sudden onset of symptoms due to an
illness, injury, or other medical problem that requires prompt medical attention and has a
limited duration.
• Scheduled surgery/procedure – Surgery or another procedure that was recommended and
documented by your provider and scheduled to take place within 180 days of your effective
date of coverage or provider termination date and authorized for continued care by Blue Shield.
• Newborn/infants – Newborn to 36 months old, general pediatric or specialist care until the earlier
of 12 months from the effective/provider termination date or the date the child is 36 months old.
• Pregnancy – The duration of the pregnancy and the immediate postpartum care.
• Serious chronic condition – A medical condition due to a disease, illness, or other medical
problem or medical disorder that is serious in nature and that persists without full cure or worsens
over time or requires ongoing treatment to maintain remission or prevent deterioration.
• Terminal illness – An incurable or irreversible condition that has a probability of causing death
within one year or less. Terminal illness is covered for the duration of the terminal illness.
• Maternal Mental Health Condition – A mental health condition that can impact a woman during
pregnancy, peri or postpartum, or that arises during pregnancy, in the peri or postpartum
period, up to one year after delivery.
C13095 Request for Continuity of Care Services Form Page 2 of 6
Attention: The following information must be included to process this request. For the request to
be considered complete, it must meet the above criteria and include the patient and provider
information below:
Documents required:
• Initial Consult Report from the treating provider(s)
• Current treatment plan
• Last three progress notes
• If a former Kaiser member, please provide the Kaiser Medical Record Number
• Any and all ICD-10 and CPT codes
C13095 Request for Continuity of Care Services Form Page 3 of 6
Subscriber information
Subscriber’s name:
Address:
City: State: ZIP code:
Date of birth: Subscriber ID number:
Home phone number: Cell phone number:
Employer group name:
Name of previous health insurance company and plan:
Date coverage ended:
Was the previous health coverage plan you indicated above no longer being offered? c Yes or c No
Patient information
Member’s name (if different):
Address:
City: State: ZIP code:
Date of birth: Relationship to subscriber:
Home phone number: Cell phone number:
Name of previous health insurance company and plan:
Date coverage ended:
Was the previous health coverage plan you indicated above no longer being offered? c Yes or c No
Provider information 1
Requesting provider first and last name: NPI:
Provider address:
City: State: ZIP code:
Provider specialty:
Provider phone number: Provider fax number:
Condition/diagnosis being treated, including ICD-10 and/or CPT codes:
Original start date with provider:
Date of last office visit/treatment:
Date of next appointment/treatment:
Please note: Before Blue Shield can approve continuity of care for you or your dependent,
Blue Shield must receive a signed agreement from the treating provider, agreeing to:
1) Accept Blue Shield's standard participating provider contracted rate
2) Only collect Blue Shield member's standard copayment/coinsurance
3) Refrain from balance billing Blue Shield members for any amounts resulting from
financial disagreements
C13095 Request for Continuity of Care Services Form Page 4 of 6
Provider information 2
Requesting provider first and last name: NPI:
Provider address:
City: State: ZIP code:
Provider specialty:
Provider phone number: Provider fax number:
Condition/diagnosis being treated, including ICD-10 and/or CPT codes:
Original start date with provider:
Date of last office visit/treatment:
Date of next appointment/treatment:
Please note: Before Blue Shield can approve continuity of care for you or your dependent,
Blue Shield must receive a signed agreement from the treating provider, agreeing to:
1) Accept Blue Shield's standard participating provider contracted rate
2) Only collect Blue Shield member's standard copayment/coinsurance
3) Refrain from balance billing Blue Shield members for any amounts resulting from
financial disagreements
Provider information 3
Requesting provider first and last name: NPI:
Provider address:
City: State: ZIP code:
Provider specialty:
Provider phone number: Provider fax number:
Condition/diagnosis being treated, including ICD-10 and/or CPT codes:
Original start date with provider:
Date of last office visit/treatment:
Date of next appointment/treatment:
Please note: Before Blue Shield can approve continuity of care for you or your dependent,
Blue Shield must receive a signed agreement from the treating provider, agreeing to:
1) Accept Blue Shield's standard participating provider contracted rate
2) Only collect Blue Shield member's standard copayment/coinsurance
3) Refrain from balance billing Blue Shield members for any amounts resulting from
financial disagreements
C13095 Request for Continuity of Care Services Form Page 5 of 6
Provider information 4
Requesting provider first and last name: NPI:
Provider address:
City: State: ZIP code:
Provider specialty:
Provider phone number: Provider fax number:
Condition/diagnosis being treated, including ICD-10 and/or CPT codes:
Original start date with provider:
Date of last office visit/treatment:
Date of next appointment/treatment:
Please note: Before Blue Shield can approve continuity of care for you or your dependent,
Blue Shield must receive a signed agreement from the treating provider, agreeing to:
1) Accept Blue Shield's standard participating provider contracted rate
2) Only collect Blue Shield member's standard copayment/coinsurance
3) Refrain from balance billing Blue Shield members for any amounts resulting from
financial disagreements
Medical information
If pregnant, what is the expected delivery date?
Name of delivering hospital: Name of OB/GYN:
Is member currently hospitalized? c Yes or c No
Name of hospital:
Is member currently receiving home health care or hospice? c Yes or c No
Name of home healthcare provider or hospice:
Healthcare provider or hospice Tax ID:
Phone number:
Does the member have a terminal condition? c Yes or c No
ICD-10:
Additional information to be considered
Please list any additional information to be considered:
C13095 Request for Continuity of Care Services Form Page 6 of 6
Member certification, authorization, and signature
I certify that all statements on this and all accompanying documents are true, correct, and
complete to the best of my knowledge and belief. I hereby authorize a physician, healthcare
facility, and other provider of health care, insurance carrier, hospital, or medical service plan to
provide Blue Shield, or its agents or employees, all information pertaining to any illness which this
patient received at any time. This information is collected to evaluate and process this request.
Name of member responding:
Member signature Date of signature
Phone number where we may reach you:
Return this form by mail to:
Blue Shield of California
Attn: Continuity of Care Team
P.O. Box 629005
El Dorado Hills, CA 95762
Send this form by fax to:
(855) 895-3506
This facsimile transmission may contain protected and privileged, highly confidential medical
information, Personal and Health Information (PHI), and/or legal information. The information is
intended only for the use of the individual or entity named above.
If you are not the intended recipient of this material, you may not use, publish, discuss, disseminate, or
otherwise distribute it. If you are not the intended recipient, or if you have received this transmission in
error, please notify the sender immediately and confidentially destroy the information that was faxed
in error.
Thank you for your help in maintaining appropriate confidentiality.
Revised: 9/2020 Effective: 01/2018
Blue Shield of California is an independent member of the Blue Shield Association C13095-MEM-FF (8/20)
Blue Shield of California
Notice Informing Individuals about Nondiscrimination
and Accessibility Requirements
Discrimination is against the law
Blue Shield of California complies with applicable state laws and federal civil rights laws, and does
not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status,
gender, gender identity, sexual orientation, age, or disability. Blue Shield of California does not
exclude people or treat them differently because of race, color, national origin, ancestry, religion,
sex, marital status, gender, gender identity, sexual orientation, age, or disability.
Blue Shield of California:
• Provides aids and services at no cost to people with disabilities to communicate effectively
with us such as:
- Qualified sign language interpreters
- Written information in other formats (including large print, audio, accessible electronic
formats, and other formats)
• Provides language services at no cost to people whose primary language is not English such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact the Blue Shield of California Civil Rights Coordinator.
If you believe that Blue Shield of California has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status,
gender, gender identity, sexual orientation, age, or disability, you can file a grievance with:
Blue Shield of California
Civil Rights Coordinator
P.O. Box 629007
El Dorado Hills, CA 95762-9007
Phone: (844) 831-4133 (TTY: 711)
Fax: (844) 696-6070
Email: BlueShieldCivilRightsCoordinator@blueshieldca.com
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our
Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the
U.S. Department of Health and Human Services, Office for Civil Rights electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
(800) 368-1019; TTY: (800) 537-7697
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
Blue Shield of California
601 12
th
Street, Oakland CA 94607
Blue Shield of California is an independent member of the Blue Shield Association
A20275 (12/19)
blueshieldca.com
Notice of the Availability of Language Assistance Services
Blue Shield of California
IMPORTANT: Can you read this letter? If not, we can have somebody help you read it.
You may also be able to get this letter written in your language. For help at no cost, please
call right away at the Member/Customer Service telephone number on the back of your
Blue Shield ID card, or (866) 346-7198.
IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla.
También puede recibir esta carta en su idioma. Para ayuda sin cargo, por favor llame
inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de
su tarjeta de identificación de Blue Shield o al (866) 346-7198. (Spanish)
重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閱讀。這封信也可以 用您所講的語言書寫。
如需免费幫助，請立即撥打登列在您的Blue Shield ID卡背面上的 會員/客戶服務部的電話，或者撥打
電話 (866) 346-7198。(Chinese)
QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý
vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ
miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield
của quý vị hoặc theo số (866) 346-7198. (Vietnamese)
MAHALAGA: Nababasa mo ba ang sulat na ito? Kung hindi, maari kaming kumuha ng
isang tao upang matulungan ka upang mabasa ito. Maari ka ring makakuha ng sulat na
ito na nakasulat sa iyong wika. Para sa libreng tulong, mangyaring tumawag kaagad sa
numerong telepono ng Miyembro/Customer Service sa likod ng iyong Blue Shield ID kard,
o (866) 346-7198. (Tagalog)
Baa’ ákohwiindzindoo7g7: D77 naaltsoos7sh y77niłta’go b77n7ghah? Doo b77n7ghahgóó é7, naaltsoos nich’8’
yiid0o[tah7g77 ła’ nihee hól=. D77 naaltsoos a[d0’ t’11 Din4 k’ehj7 1dooln77[ n7n7zingo b7ighah. Doo b22h 7l7n7g0
sh7k1’ adoowo[ n7n7zing0 nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 Blue Shield bee n47ho’d7lzin7g7
bine’d44’ bik11’ 47 doodag0 47 (866) 346-7198 j8’ hod77lnih. (Navajo)
중요: 이 서신을 읽을 수 있으세요? 읽으실 수 경우, 도움을 드릴 수 있는 사람이 있습니다. 또한 다른
언어로 작성된 이 서신을 받으실 수도 있습니다. 무료로 도움을 받으시려면 Blue Shield ID 카드 뒷면의
회원/고객 서비스 전화번호 또는 (866) 346-7198로 지금 전환하세요. (Korean)
Կ
ԿԱԱՐՐԵԵՎՎՈՈՐՐ ԷԷ․․ Կարողանում ե՞ք կարդալ այս նամակը։ Եթե ոչ, ապա մենք կօգնենք ձեզ։ Դուք պետք է
նաև կարողանաք ստանալ այս նամակը ձեր լեզվով։ Ծառայությունն անվճար է։ Խնդրում ենք
անմիջապես զանգահարել Հաճախորդների սպասարկման բաժնի հեռախոսահամարով, որը նշված է
ձեր Blue Shield ID քարտի ետևի մասում, կամ (866) 346-7198 համարով։ (Armenian)
ВАЖНО:
Не можете прочесть данное письмо? Мы поможем вам, если необходимо. Вы также можете
получить это письмо написанное на вашем родном языке. Позвоните в Службу клиентской/членской
поддержки прямо сейчас по телефону, указанному сзади идентификационной карты Blue Shield, или
по телефону (866) 346-7198, и вам помогут совершенно бесплатно. (Russian)
重重要要：：お客様は、この手紙を読むことができますか？ もし読むことができない場合、弊社が、お客様
をサポートする人物を手配いたします。 また、お客様の母国語で書かれた手紙をお送りすることも可
能です。 無料のサポートを希望される場合は、Blue Shield IDカードの裏面に記載されている会員/お客
様サービスの電話番号、または、(866) 346-7198にお電話をおかけください。 (Japanese)
blueshieldca.com
:ﻢﮭﻣ ﯽﻣ ﺎﯾآﯽﻣ ،ﺖﺳا ﯽﻔﻨﻣ نﺎﺘﺨﺳﺎﭘ ﺮﮔا ؟ﺪﯿﻧاﻮﺨﺑ ار ﮫﻣﺎﻧ ﻦﯾا ﺪﯿﻧاﻮﺗﯽﻣ ﯽﺘﺣ .ﻢﯿھد راﺮﻗ نﺎﺗرﺎﯿﺘﺧا رد ﺎﻤﺷ ﮫﺑ ﮏﻤﮐ یاﺮﺑ ار ﯽﺴﮐ ﻢﯿﻧاﻮﺗ ﮫﺨﺴﻧ ﺪﯿﻧاﻮﺗ
زا ﺖﻗو تﻮﻓ نوﺪﺑ
ً
ﺎﻔﻄﻟ ،نﺎﮕﯾار ﮏﻤﮐ ﺖﻓﺎﯾرد یاﺮﺑ .ﺪﯿﻨﮐ ﺖﻓﺎﯾرد نﺎﺗدﻮﺧ نﺎﺑز ﮫﺑ ار ﮫﻣﺎﻧ ﻦﯾا بﻮﺘﮑﻣ ﯽﺳﺎﻨﺷ ترﺎﮐ ﺖﺸﭘ رد ﮫﮐ ﯽﻨﻔﻠﺗ هرﺎﻤﺷ ﻖﯾﺮط
Blue Shield ﻦﻔﻠﺗ هرﺎﻤﺷ ﻖﯾﺮط زا ﺎﯾ و ﺖﺳا هﺪﺷ جرد نﺎﺗ7198-346 )866.ﺪﯾﺮﯿﮕﺑ سﺎﻤﺗ یﺮﺘﺸﻣ/ﺎﻀﻋا تﺎﻣﺪﺧ ﺎﺑ ( (Persian)
:        ?               
                     
Blue Shield ID     /    ,  (866) 346-7198    (Punjabi)
 ?   
  
 /   Blue Shield
  (866) 346-7198 (Khmer)
: ﻢﮭﻤﻟا اﺬھ ﻰﻠﻋ لﻮﺼﺤﻟا ﻰﻟإ
ً
ﺎﻀﯾأ جﺎﺘﺤﺗ ﺪﻗ .ﮫﺗءاﺮﻗ ﻲﻓ كﺪﻋﺎﺴﯿﻟ ﺎﻣ ﺺﺨﺷ رﺎﻀﺣإ ﺎﻨﻨﻜﻤﯾ ،ﮫﺗءاﺮﻗ ﻊﻄﺘﺴﺗ ﻢﻟ نأ ؟بﺎﻄﺨﻟا اﺬھ ةءاﺮﻗ ﻊﯿﻄﺘﺴﺗ ﻞھ
ﺎﺠﻟا ﻰﻠﻋ نوﺪﻤﻟا ءﺎﻀﻋﻷا ﺪﺣأ/ءﻼﻤﻌﻟا ﺔﻣﺪﺧ ﻒﺗﺎھ ﻢﻗر ﻰﻠﻋ نﻵا لﺎﺼﺗﻻا ﻰﺟﺮﯾ ،ﺔﻔﻠﻜﺗ نوﺪﺑ ةﺪﻋﺎﺴﻤﻟا ﻰﻠﻋ لﻮﺼﺤﻠﻟ .ﻚﺘﻐﻠﺑ
ً
ﺎﺑﻮﺘﻜﻣ بﺎﻄﺨﻟا ﻲﻔﻠﺨﻟا ﺐﻧ
ﺔﯾﻮﮭﻟا ﺔﻗﺎﻄﺑ ﻦﻣBlue Shield ﻢﻗﺮﻟا ﻰﻠﻋ وأ7198-346 )866.((Arabic)
TSEEM CEEB: Koj pos tuaj yeem nyeem tau tsab ntawv no? Yog hais tias nyeem tsis tau, peb tuaj yeem nrhiav ib tug
neeg los pab nyeem nws rau koj. Tej zaum koj kuj yuav tau txais muab tsab ntawv no sau ua koj hom lus. Rau kev pab
txhais dawb, thov hu kiag rau tus xov tooj Kev Pab Cuam Tub Koom Xeeb/Tub Lag Luam uas nyob rau sab nraum nrob
qaum ntawm koj daim npav Blue Shield ID, los yog hu rau tus xov tooj (866) 346-7198. (Hmong)
สําคัญ: 



 Blue Shield 
(866) 346-7198 (Thai)
महवप
ू
ण:       
?  ,    
        

     
   
:
       Blue Shield ID 
   
/   ,  (866) 346-7198   
(Hindi)
ສ
ສ
ິິ
່່
ງງສສ
ໍໍ
າາຄຄ
ັັ
ນນ: ທ
່
ານສາມາດອ
່
ານຈ
ົ
ດໝາຍນ
ີ
້
ໄດ
້
ບ
ໍ
? ຖ
້
າອ
່
ານບ
ໍ
່
ໄດ
້
, ພວກເຮ
ົ
າສາມາດໃຫ
້
ບາງຄ
ົ
ນຊ
່
ວຍອ
່
ານໃຫ
້
ທ
່
ານຟ
ັ
ງໄດ
້
.
ທ
່
ານຍ
ັ
ງສາມາດຂ
ໍ
ໃຫ
້
ແປຈ
ົ
ດໝາຍນ
ີ
້
ເປ
ັ
ນພາສາຂອງທ
່
ານໄດ
້
.ສ
ໍ
າລ
ັ
ບຄວາມຊ
່
ວຍເຫ
ຼ
ື
ອແບບບ
ໍ
່
ເສຍຄ
່
າ, ກະລ
ຸ
ນາ
ໂທຫາເບ
ີ
ໂທຂອງຝ
່
າຍບ
ໍ
ລ
ິ
ການສະມາຊ
ິ
ກ/ລ
ູ
ກຄ
້
າໃນທ
ັ
ນທ
ີ
ເບ
ີ
ໂທລະສ
ັ
ບຢ
ູ
່
ດ
້
ານຫ
ຼ
ັ
ງບ
ັ
ດສະມາຊ
ິ
ກ Blue Shield ຂອງທ
່
ານ,
ຫ
ຼ
ື
ໂທໄປຫາເບ
ີ
(866) 346-7198. (Laotian)
blueshieldca.com
Notice of the Availability of Language Assistance Services
Blue Shield of California Life & Health Insurance Company
No Cost Language Services. You can get an interpreter. You can get documents read to you
and some sent to you in your language. For help, call us at the number listed on your ID card or
1-866-346-7198. For more help call the CA Dept. of Insurance at 1-800-927-4357.
English
Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le
envíen algunos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de
identificación o al 1-866-346-7198. Para obtener más ayuda, llame al Departamento de Seguros de
CA al 1-800-927-4357.
Spanish
免
免費費語語言言服服務務。您可獲得口譯員服務。可以用中文把文件唸給您聽，有些文件有中文的版本，也可以把這些文
件寄給您。欲取得協助，請致電您的保險卡所列的電話號碼，或撥打
1-866-346-7198
與我們聯絡。欲取得其他
協助，請致電
1-800-927-4357
與加州保險部聯絡。
Chinese
Các Dịch Vụ Trợ Giúp Ngôn Ngữ Miễn Phí. Quý vị có thể được nhận dịch vụ thông dịch. Quý vị có thể được
người khác đọc giúp các tài liệu và nhận một số tài liệu bằng tiếng Việt. Để được giúp đỡ, hãy gọi cho chúng tôi
tại số điện thoại ghi trên thẻ hội viên của quý vị hoặc 1-866-346-7198. Để được trợ giúp thêm, xin gọi Sở Bảo
Hiểm California tại số 1-800-927-4357.
Vietnamese
무료
통역
서비스
.
귀하는
한국어
통역
서비스를
받으실
수
있으며
한국어로
서류를
낭독해주는
서비스를
받으실
수
있습니다
.
도움이
필요하신
분은
귀하의
ID
카드에
나와있는
안내
전화
: 1-866-346-7198
번으로
문의해
주십시오
.
보다
자세한
사항을
문의하실
분은
캘리포니아
주
보험국
,
안내
전화
1-800-927-4357
번으로
연락해
주십시오
.
Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at
maipababasa mo sa Tagalog ang mga dokumento. Para makakuha ng tulong, tawagan kami sa
numerong nakalista sa iyong ID card o sa 1-866-346-7198. Para sa karagdagang tulong, tawagan
ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
Անվճար
Լեզվական
Ծառայություններ։
Դուք
կարող
եք
թարգման
ձեռք
բերել
և
փաստաթղթերը
ընթերցել
տալ
ձեզ
համար
հայերեն
լեզվով։
Օգնության
համար
մեզ
զանգահարեք
ձեր
ինքնության
(ID)
տոմսի
վրա
նշված
կամ
1-866-346-7198
համարով։
Լրացուցիչ
օգնության
համար
1-800-927-4357
համարով
զանգահարեք
Կալիֆորնիայի
Ապահովագրության
Բաժանմունք։
Armenian
Беслпатные услуги перевода. Вы можете воспользоваться услугами переводчика, и ваши
документы прочтут для вас на русском языке. Если вам требуется помощь, звоните нам по
номеру, указанному на вашей идентификационной карте, или 1-866-346-7198. Если вам
требуется дополнительная помощь, звоните в Департамент страхования штата Калифорния
(Department of Insurance), по телефону 1-800-927-4357.
Russian
無無料料のの言言語語ササーービビスス 日本語で通訳をご提供し、書類をお読みします。サービスをご希望の方は、ＩＤカー
ド記載の番号または
1-866-346-7198
までお問い合わせください。更なるお問い合わせは、カリフォルニア州
保険庁、
1-800-927-4357
までご連絡ください。
Japanese
ﺧ تﺎﻣﺪﻧﺎﺠﻣﯽ نﺎﺑز ﮫﺑ طﻮﺑﺮﻣ. ﺪﻧﻮﺷ هﺪﻧاﻮﺧ نﺎﺘﯾاﺮﺑ ﯽﺳرﺎﻓ نﺎﺑز ﮫﺑ کراﺪﻣ ﺪﯿﺋﻮﮕﺑ و ﺪﯿﻨﮐ هدﺎﻔﺘﺳا ﯽھﺎﻔﺷ ﻢﺟﺮﺘﻣ ﮏﯾ تﺎﻣﺪﺧ زا ﺪﯿﻧاﻮﺘﯿﻣ. ی ا ﺮ ﺑ
هرﺎﻤﺷ ﻦﯾا ﺎﯾ و ﺖﺳا هﺪﺷ ﺪﯿﻗ ﺎﻤﺷ ﯽﺋﺎﺳﺎﻨﺷ ترﺎﮐ یور ﮫﮐ ﯽﻨﻔﻠﺗ هرﺎﻤﺷ ﻖﯾﺮط زا ﺎﻣ ﺎﺑ،ﮏﻤﮐ ﺖﻓﺎﯾرد1-866-346-7198 ﺪﯾﺮﯿﮕﺑ سﺎﻤﺗ. یاﺮﺑ
ﮫﺑ ،ﺮﺘﺸﯿﺑ ﮏﻤﮐ ﺖﻓﺎﯾردCA Dept. of Insurance ) ﺎﯿﻧﺮﻔﯿﻟﺎﮐ ﮫﻤﯿﺑ هرادا ( هرﺎﻤﺷ ﮫﺑ1-800-927-4357 ﺪﯿﻨﮐ ﻦﻔﻠﺗ.Persian
blueshieldca.com
ਮੁਫ਼ਤ
ਭਾਸ਼ਾ
ਸੇਵਾਵਾਂ
:





























(ID)

'



'


1-866-346-7198 '

'











1-800-927-4357 '



Punjabi





    

1-866-346-7198

   

1-800-927-4357
Khmer
ﺔﻘﻠﻜﺗ نوﺪﺑ ﺔﻤﺟﺮﺗ تﺎﻣﺪﺧ. ﻐﻠﻟﺎﺑ ﻚﻟ ﻖﺋﺎﺛﻮﻟا ةءاﺮﻗ و ﻢﺟﺮﺘﻣ ﻲﻠﻋ لﻮﺼﺤﻟا ﻚﻨﻜﻤﯾﺔﯿﺑﺮﻌﻟا ﺔ . ﻞﺼﺗا ،ةﺪﻋﺎﺴﻤﻟا ﻲﻠﻋ لﻮﺼﺤﻠﻟ
ﻢﻗﺮﻟا ﻲﻠﻋ وأ ﻚﺘﯾﻮﻀﻋ ﺔﻗﺎﻄﺑ ﻲﻠﻋ ﻦﯿﺒﻤﻟا ﻢﻗﺮﻟا ﻲﻠﻋ ﺎﻨﺑ1-866-346-7198 . ،تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ ﺪﯾﺰﻤﻟا ﻲﻠﻋ لﻮﺼﺤﻠﻟ
ﻢﻗﺮﻟا ﻲﻠﻋ ﺎﯿﻧرﻮﻔﯿﻟﺎﻛ ﺔﯾﻻﻮﻟ ﻦﯿﻣﺄﺘﻟا ةرادﺈﺑ ﻞﺼﺗا1-800-927-4357.
Arabic
Cov Kev Pab Txhais Lus Tsis Them Nqi. Koj yuav thov tau kom muaj neeg los txhais lus rau koj thiab kom
neeg nyeem cov ntawv ua lus Hmoob. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj nyob
hauv koj daim yuaj ID los sis 1-866-346-7198. Yog xav tau kev pab ntxiv hu rau CA lub Caj Meem Fai
Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357
Hmong
 










1-866-346-7198



 

1-800-927-4357
Thai


































,

ID






,

1-866-346-7198











(CA Dept. of Insurance)

1-800-927-4357



Hindi
Doo b11h 7l7n7g0 saad bee y1t’i’ bee an1’1wo’. D77 sh1 ata’halne’doo7g7 h0l=-doo n7n7zingo 47 b7ighah. Naaltsoos
naanin1h1jeeh7g7 shich’8’ y7idooltah 47 doodag0 [a’ shich’8’ 1dooln77[ n7n7zingo b7ighah. Sh7k1 a’doowo[ n7n7zingo
nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 ninaaltsoos doot[‘7zh7g7 bee n47ho’d7lzin7g7 bine’d44’ bik11’ 47 doodag0
47 (866)346-7198j8’ hod77lnih. H0zh= sh7k1 an11’doowo[ n7n7zingo 47 d77 b4eso 1ch’22h naa’nil bi[ haz’32j8’
1-800-927-4357j8’ hod77lnih.
Navajo
ບບ
ໍໍ
ລລ
ິິ
ກກາານນແແປປພພາາສສາາໂໂດດຍຍບບ
ໍໍ
່່
ເເສສຍຍຄຄ
່່
າາ. ທ
່
ານສາມາດຂ
ໍ
ເອ
ົ
າຜ
ູ
້
ແປພາສາໄດ
້
. ທ
່
ານສາມາດຂ
ໍ
ໃຫ
້
ອ
່
ານເອກະສານໃຫ
້
ທ
່
ານຟ
ັ
ງ
ແລະ ສ
ົ
່
ງເອກະສານບາງຢ
່
າງທ
ີ
່
ເປ
ັ
ນພາສາຂອງທ
່
ານ. ສ
ໍ
າລ
ັ
ບຄວາມຊ
່
ວຍເຫ
ຼ
ື
ອ, ໃຫ
້
ໂທຫາພວກເຮ
ົ
າຕາມເບ
ີ
ໂທລະສ
ັ
ບທ
ີ
່
ມ
ີ
ໃນບ
ັ
ດປະຈ
ໍ
າຕ
ົ
ວຂອງທ
່
ານ ຫ
ຼ
ື
ໂທຫາເບ
ີ
1-866-346-7198. ສ
ໍ
າລ
ັ
ບຄວາມຊ
່
ວຍເຫ
ຼ
ື
ອເພ
ີ
່
ມເຕ
ີ
ມໂທຫາ ພະແນກ ປະກ
ັ
ນໄພຂອງ
ລ
ັ
ດຄາລ
ີ
ຟ
ໍ
ເນຍໄດ
້
ທ
ີ
່
ເບ
ີ
1-800-927-4357.
Laotian
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