NATIONAL CLAIMS ADMINISTRATION

NORTHERN CALIFORNIA
KAISER FOUNDATION HEALTH PLAN, INC
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PO Box 629028
El Dorado Hills, CA 95762-9028 This is not a bill
If you owe anything, you’ll get a bill.
This Explanation of Benefits is a summary of
services you’ve received. It shows the charges,
the date of your visit, and the name of the provider
you visited. Use it to:
Dana T Shriver • Keep track of your expenses and make sure
848 SHERRY CT everything is accurate. ***
HANFORD, CA 93230-1501 • Check your progress – have you reached your
deductible or out-of-pocket maximum? ***
• To reduce clutter and get your next EOB online,
sign up at kp.org/choosepaperless.

Call us if you have questions

Weekdays 8:00 am – 5:00 pm (Pacific Time)
1-800-390-3510 or TTY: 711
kp.org

Track your care

Medical record number: 0017466786 Group identification: 000000003*0001
Plan type: HMO - HMO COMMERCIAL- Account Holder Name and Identification: Dana Shriver,
HMO 110017466786
Plan year: 01/01/2022 through 12/31/2022 Membership Relationship to Subscriber: Self

Explanation of Benefits for Dana T Shriver

Here’s a snapshot of your share of the charges for the services you’ve received.

June 20, 2024

$0.00 Your share

You have one or more services that have been denied. See next page(s) for details.

NC_48687643_1997881482_110017466786_N
NME EOB version 5.10
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Here’s how close you are to reaching your deductibles and out-of-pocket maximums.

Out-of-pocket maximum - Year to date*

Dana T Shriver

$240.00
Tier 1 $0 $1500.00

$476.32
Pharmacy $0 $7600.00

Family totals

$320.00
Tier 1 $0 $3000.00

$511.32
Pharmacy $0 $15200.00

For more information, see next pages.

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What happens when I reach my family out-of-pocket
maximum?
Your out-of-pocket maximum helps limit how much you
pay for care. This can protect you financially if a serious
illness or injury comes up. With some plans if you reach
your out-of-pocket maximum, you won’t have to pay for
covered services for the rest of the year.*
Visit kp.org/outofpocket anytime to see how close you are to reaching your deductible or out-of-pocket maximum.
*Your deductible and out-of-pocket maximum will start over on the new accumulation period. See your Evidence of Coverage or
Member Handbook for your plan details.

Common terms

Charges Out-of-pocket costs

The charges for the services you got. You won’t always Any amounts you pay for covered services, not including
pay these amounts. They’re the full charges before your your monthly premiums.
health plan pays. Your costs will usually be lower.
Out-of-pocket maximum
Claim number The most you’ll pay for covered services each year. For a
A number used to identify a service you received. small number of services, you may need to keep paying
copays or coinsurance after reaching your out-of-pocket
Coinsurance maximum.
A percentage of the charges that you pay for covered
services. For example, a 20% coinsurance on a $200 Paid by other insurance
procedure means you pay just $40. See your Evidence of This is the amount paid by your other health insurance
Coverage or Member Handbook for your actual plan for services you got. It doesn't include any amount
coinsurance amounts. Kaiser Permanente may have paid.

Copay Paid by plan

The set amount you pay for covered services – for This is the amount we paid your care provider for the
example, a $10 copay for an office visit. See your services you got, based on your plan details.
Evidence of Coverage or Member Handbook for your
actual copay amounts. Participating Provider
NON means the provider is not included in the provider
network (non-participating).
PAR means the provider is included in the provider
network (participating).

Plan rate
This is the rate we negotiated with your care provider for
the services you got. The amount you pay will usually be
lower, once any amounts paid by your health plan are
included.
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Have questions about your benefits?
Explanation of Benefits Give us a call at 1-800-390-3510 or visit kp.org

Medical record number: 0017466786 Group identification: 000000003*0001

Plan type: HMO - HMO COMMERCIAL-HMO Account holder identification: 110017466786
Summary of services for Dana T Shriver
June 20, 2024 Your Share of the Charges
Service Location/Provider, Paid by Other Copay/
Description Charges Plan Rate Paid by Plan Not Covered* Deductible
Date Claim No., Reason Code Insurance Coinsurance
11/30/22 MARK MRI scan of arm joint $978.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
ALSON (PAR) (73221) $0.00
833339298 CLD01
Totals $978.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Your share $0.00

For covered emergency services, your out-of-pocket costs are limited to your deductible and copay/coinsurance, if any. For other services, you could be
responsible for some or all of the provider’s charges, depending on the situation. If you have any questions about what you owe, please contact us.

Remember: You can help control your costs by getting care and services from Kaiser Permanente or affiliate providers. If you visit an out-of-network provider,
your costs may be higher. If you are covered by more than one health benefit plan, you should file all your claims with each plan.

Manage your costs online

With My Health Manager at kp.org, it’s easy to track your expenses, pay bills,
view your plan information, and more – 24 hours a day, 7 days a week. If you
haven’t registered on our website, visit kp.org/register to get started.

Reason Code:
CLD01 DENY, TIMELY FILING
 APPEAL RIGHTS
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This Explanation of Benefits provides notice to you of our payment decision regarding your claim for benefits. If we
have denied coverage for certain services or supplies, in whole or in part, then you may request that we review this
decision, also referred to as an “adverse benefit determination.” In addition, you may request that we review our
determination of any cost shares (copayments, deductibles, or coinsurance) or other amounts that you may owe.

Please read the rest of this notice carefully. It explains your right to request review of our initial benefit determination.

Requesting Review of Our Decision

You, or a representative whom you formally appoint in writing, have the right to submit a grievance to appeal our
payment decision by asking that we review it. You can choose any of the following ways to submit a grievance/
appeal:

1. You can speak to a representative at our Member Service Call Center by calling 1-800-464-4000 or (TTY)
711.

2. If it is more convenient, you can visit Member Services at your local medical center.

3. You can use our website at www.members.kp.org.

4. You can submit your appeal in writing by either sending it to:

Kaiser Foundation Health Plan, Inc.

Attention: Health Plan Clinical Review Special Services
P.O. Box 23280
Oakland, CA 94623-0280

Or you can fax the letter to: (510) 625-6124.

In your request, please include (1) your name and your medical record number, (2) the specific reason(s) for your
request that we review our initial payment decision, and (3) any relevant information regarding the claim for payment.

Timeframe for Requesting Review of Our Decision

We must receive your request within 180 days of your receiving the notice of our adverse benefit determination.
Please note that we will count the 180 days starting 5 business days from the date of the notice to allow for mail
delivery time, unless you can prove that you received the notice after that 5 business day period.

Appointment of a Representative

If you would like to have someone act on your behalf during our review, you may appoint an authorized
representative. You must make this appointment in writing. Please contact our Member Service Call Center at
1-800-464-4000 or visit your local Member Services office to obtain an Authorized Representative form to submit to
us.

Your Claim File

If you want to review the information that we have collected regarding the claim for this service, you may request,
and we will provide without charge, copies of all relevant documents, records, and other information. Separately, you
have the right to request any diagnostic and treatment codes and their meanings that may be the subject of your
claim. To make a request, you should contact the Member Service Call Center by calling 1-800-464-4000 or (TTY)
711.

You may send us additional information with your appeal, including comments, documents, or additional medical
records, that you believe supports your claim. If we had asked for additional information before and you did not
provide it, we would still like to have that additional information for our review. Please send all your additional
information to:
 Kaiser Foundation Health Plan, Inc.
Attention: Health Plan Clinical Review Special Services
P.O. Box 23280
Oakland, CA 94623-0280

Or you can fax the letter to: (510) 625-6124.

In addition, you may also give testimony in writing or by telephone. Please send your written testimony to Health
Plan Clinical Review Special Services at the address listed above. To arrange to give testimony by telephone, you
should contact (626) 405-2597. We will add all of the new information to your claim file and we will review it without
regard to whether this information was submitted and/or considered in our initial decision of which we informed you.

We will share any additional information that we collect in the course of our review by sending it to you in advance of
our final decision. If we believe on review that your request should not be granted, before we issue our final decision
we will also share with you in writing any new or additional reasons for that decision. We will send you a letter
explaining the new or additional information and/or reasons. Our letters will tell you how you can respond to the
information provided if you choose to do so. If you do not respond before we must make our final decision, that
decision will be based on the information already in your claim file.

Timeframe for Our Decision Regarding Your Appeal

We must make our decision about your appeal within 30 days from the date that we receive your request for review.

Help With Your Appeal

California's Consumer Assistance Program is available to help you understand your appeal process and other rights.
To obtain this assistance, you may contact the California Department of Managed Health Care Help Center
(http://www.healthhelp.ca.gov) or send them an e-mail at [email protected]. You can also reach them by phone
(1-888-466-2219) or by writing to them at California Department of Managed Health Care Help Center, 980 9th
Street, Suite 500, Sacramento, CA 95814.

External Review

If you are dissatisfied with our decision regarding your appeal, you may have the right to request an independent
external review. You can make your request by contacting the California Department of Managed Health Care. They
can be reached through their Internet website (www.dmhc.ca.gov) or their toll-free telephone number
(1-888-466-2219 or TDD 1-877-688-9891).

This request must be made within no more than 6 months after you receive our notice of adverse benefit
determination. If external review overturns our decision, we will provide coverage of payment for your health care
service or supply as directed. Except when external review is permitted to occur simultaneously with your appeal to
us, you must exhaust all internal appeals before you may file a request for external review unless we have failed to
comply with the requirements related to your claim.

Your Claim After External Review

You may have certain additional rights if you remain dissatisfied after you have exhausted all levels of review
including external review. If you are enrolled through a plan that is subject to the Employee Retirement Income
Security Act (ERISA), you may file a civil action under section 502(a) of the federal ERISA statute. To understand
these rights, you should check with your benefits office or contact the Employee Benefits Security Administration
(part of the U.S. Department of Labor) at 1-866-444-EBSA (3272). Alternatively, if your plan is not subject to ERISA
(for instance, most state or local government plans and church plans, or an individual plan), you may have a right to
request review in state court. The California Department of Managed Health Care Help Center should be able to help
you understand any further review rights available to you.

Department of Managed Health Care Complaint Process

The California Department of Managed Health Care is responsible for regulating health care service plans. If you
have a grievance against your health plan, you should first telephone Kaiser Foundation Health Plan at
1-800-464-4000 and use your health plan's grievance process before contacting the department. Utilizing this
grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need
help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health
plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for
assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR
process will provide an impartial review of medical decisions made by a health plan related to the medical necessity
of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in
nature, and payment disputes for emergency or urgent medical services. The department also has a toll-free
telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The
department's Internet website www.dmhc.ca.gov has complaint forms, IMR application forms, and instructions
online.

You can apply immediately to the Department for review of your urgent grievance request without participating in the
plan's grievance process or prior to such participation.

Binding Arbitration

Except for Small Claims Court cases and certain benefit-related disputes, any dispute between members, their heirs,
or associated parties (on the one hand) and Health Plan, its health care providers, or other associated parties (on
the other hand) for alleged violation of any duty arising out of or related to your Health Plan membership, must be
decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable
law provides for judicial review of arbitration proceedings. This includes claims for medical or hospital malpractice,
for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory. Both
sides give up all rights to a jury or court trial, and both sides are responsible for certain costs associated with binding
arbitration. This is a summary; please refer to your Evidence of Coverage for the complete arbitration provision.

Please be advised that whether your arbitration provisions are enforceable or are unenforceable will be determined
by the application and interpretation of various laws. These include Health & Safety Code Section 1363.1, which
pertains to required disclosures of arbitration provisions. Additional information regarding the California laws
pertaining to arbitration of health care claims can be accessed on the Internet at the California Department of
Managed Health Care's website (www.dmhc.ca.gov).

Further Assistance From Kaiser Permanente

Please contact us at 1-800-464-4000 or (TTY) 711 if you have any questions regarding your appeal rights.
This page is intentionally left blank.
 ¹ Kaiser Permanente
Permanente Medical Group,
is inclusive
and of
theKaiser
Southern
Foundation
California
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Nondiscrimination Notice
Discrimination is against the law. Kaiser Permanente¹ follows State and Federal civil rights laws.

Kaiser Permanente does not unlawfully discriminate, exclude people, or treat them differently
because of age, race, ethnic group identification, color, national origin, cultural background, ancestry,
religion, sex, gender, gender identity, gender expression, sexual orientation, marital status, physical
or mental disability, medical condition, source of payment, genetic information, citizenship, primary
language, or immigration status.

Kaiser Permanente provides the following services:

● No-cost aids and services to people with disabilities to help them communicate better with us,
such as:

♦ Qualified sign language interpreters

♦ Written information in other formats (braille, large print, audio, accessible electronic
formats, and other formats)
● No-cost language services to people whose primary language is not English, such as:

♦ Qualified interpreters

♦ Information written in other languages

If you need these services, call our Member Service Contact Center, 24 hours a day, 7 days a week
(closed holidays). The call is free:

● Medi-Cal: 1-855-839-7613 (TTY 711)

● All others: 1-800-464-4000 (TTY 711)

Upon request, this document can be made available to you in braille, large print, audiocassette, or
electronic form. To obtain a copy in one of these alternative formats, or another format, call our
Member Service Contact Center and ask for the format you need.

How to file a grievance with Kaiser Permanente

You can file a discrimination grievance with Kaiser Permanente if you believe we have failed to
provide these services or unlawfully discriminated in another way. You can file a grievance by phone,
by mail, in person, or online. Please refer to your Evidence of Coverage or Certificate of Insurance for
details. You can call Member Services for more information on the options that apply to you, or for
help filing a grievance. You may file a discrimination grievance in the following ways:

● By phone: Medi-Cal members may call 1-855-839-7613 (TTY 711). All other members may
call 1-800-464-4000 (TTY 711). Help is available 24 hours a day, 7 days a week (closed
holidays)
● By mail: Download a form at kp.org or call Member Services and ask them to send you a form
that you can send back.

¹ Kaiser Permanente is inclusive of Kaiser Foundation Health Plan, Inc, Kaiser Foundation Hospitals, The Permanente
Medical Group, and the Southern California Medical Group
 ● In person: Fill out a Complaint or Benefit Claim/Request form at a member services office
located at a Plan Facility (go to your provider directory at kp.org/facilities for addresses)
● Online: Use the online form on our website at kp.org

You may also contact the Kaiser Permanente Civil Rights Coordinator directly at the addresses
below:

Attn: Kaiser Permanente Civil Rights Coordinator

Member Relations Grievance Operations
P.O. Box 939001
San Diego CA 92193

How to file a grievance with the California Department of Health Care Services Office of Civil Rights
(For Medi-Cal Beneficiaries Only)
You can also file a civil rights complaint with the California Department of Health Care Services Office
of Civil Rights in writing, by phone or by email:

● By phone: Call DHCS Office of Civil Rights at 916-440-7370 (TTY 711)

● By mail: Fill out a complaint form or send a letter to:

Deputy Director, Office of Civil Rights
Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413

Complaint forms are available at: http://www.dhcs.ca.gov/Pages/Language_Access.aspx

● Online: Send an email to [email protected]

How to file a grievance with the U.S. Department of Health and Human Services Office of Civil Rights

You can file a discrimination complaint with the U.S. Department of Health and Human Services
Office for Civil Rights. You can file your complaint in writing, by phone, or online:

● By phone: Call 1-800-368-1019 (TTY 711 or 1-800-537-7697)

● By mail: Fill out a complaint form or send a letter to:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201

Complaint forms are available at:

https://www.hhs.gov/ocr/complaints/index.html
● Online: Visit the Office of Civil Rights Complaint Portal at:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
Language Assistance Services

English: Language assistance is available at no cost to

you, 24 hours a day, 7 days a week. You can request
interpreter services, or materials translated into your
language, or in alternative formats. You can also request
auxiliary aids and devices at our facilities. Call our
Member Service Contact Center for help, 24 hours a day,
7 days a week (closed holidays).
●
Medi-Cal: 1-855-839-7613 (TTY 711)
●
All others: 1-800-464-4000 (TTY 711)
‫ بإمكانك طلب خدمة الترجمة الفورية أو ترجمة‬.‫ خدمات الترجمة الفورية متوفرة لك مجانًا على مدار الساعة كافة أيام الأسبوع‬:Arabic
‫ على‬،‫ اتصل مع مركز اتصال خدمة الأعضاء لدينا‬.‫ يمكنك أيضا ً طلب مساعدات إضافية وأجهزة في مرافقنا‬.‫وثائق للغتك أو لصيغ أخرى‬
.(‫أيام في الأسبوع )العطلات مغلق‬7 ‫ ساعة في اليوم و‬24 ‫مدار‬

(TTY 711) 1-855-839-7613 :Medi-Cal ●

(TTY 711) 1-800-464-4000 :‫● جميع الآخرين‬

Armenian: Ձեզ կարող է անվճար լեզվական աջակցություն տրամադրվել օրը 24 ժամ, շաբաթը
7 օր: Դուք կարող եք պահանջել բանավոր թարգմանչի ծառայություններ, Ձեր լեզվով
թարգմանված կամ այլընտրանքային ձևաչափով պատրաստված նյութեր: Դուք նաև կարող եք
խնդրել օժանդակ օգնություններ և սարքեր մեր հաստատություններում: Օգնության համար
զանգահարեք մեր Անդամների սպասարկման կապի կենտրոն օրը 24 ժամ, շաբաթը 7 օր (տոն
օրերին փակ է):
● Medi-Cal` 1-855-839-7613 (TTY 711)
● Այլ` 1-800-464-4000 (TTY 711)

Chinese: 我们每周 7 天，每天 24 小时免费提供语言帮助。您可以要求提供口译员、或将材料翻

译为您所用语言或其他格式。您还可以在我们的设施中要求使用辅助工具和设备。请打电话给我们
的会员服务联络中心，服务时间为每周 7 天，每天 24 小时（节假日除外）。
● 所有会员：1-800-757-7585 (TTY 711)

،‫ میتوانيد خدمات مترجم شفاهی‬.‫ روز هفته بهصورت رايگان در اختيار شماست‬7 ‫ ساعت شبانهروز و‬24 ‫ خدمات زبانی در‬:Farsi
‫ همچنين میتوانيد دستگاهها و کمکهای ديگر را در مراکز ما‬.‫يا ترجمه مدارک به زبان خود يا به فرمتهای ديگر را درخواست کنيد‬
‫ روز هفته )بهجز تعطيلات( با مرکز تماس خدمات اعضای ما‬7 ‫ ساعت شبانهروز و‬24 ‫ در‬،‫ برای دريافت کمک‬.‫درخواست نماييد‬
.‫تماس بگيريد‬

(TTY 711) 1-855-839-7613 :Medi-Cal ●

(1-800-464-4000 (TTY 711 :‫● ساير‬

Hindi: बिना किसी लागत िे भाषा सहायता, दिन िे 24 घंटे, सप्ताह िे सातों दिन उपलब्ध हैं। आप
िभु ाषषये िी सेवाओं िे ललए, या बिना किसी लागत िे सामग्रियों िो अपनी भाषा में अनव ु ाि िरवाने िे
ललए, या वैिल्पपि प्रारूपों िा अनरु ोध िर सिते हैं। आप हमारे सुषवधा-स्थलों में सहायि साधनों और
उपिरणों िे ललए भी अनरु ोध िर सिते हैं।सहायता िे ललए हमारी सिस्य सेवाओं िे सम्पि्क िेंद्र िो,
दिन िे 24 घंटे, सप्ताह िे सातों दिन (छुद्टियों वाले दिन िंि रहता है ) िॉल िरें ।
● Medi-Cal: 1-855-839-7613 (TTY 711)
● िािी िस
ू रे : 1-800-464-4000 (TTY 711)
Hmong: Muaj kev pab txhais lus pub dawb rau koj, 24 teev tuaj ib hnub twg, 7 hnub tuaj ib lim
tiam twg. Koj thov tau cov kev pab txhais lus, muab cov ntaub ntawv txhais ua koj hom lus, los
yog ua lwm hom. Koj kuj thov tau lwm yam kev pab thiab khoom siv hauv peb tej tsev hauj lwm.
Hu rau peb Qhov Chaw Pab Cov Tswv Cuab 24 teev tuaj ib hnub twg, 7 hnub tuaj ib lim tiam twg
(cov hnub caiv kaw).
● Medi-Cal: 1-855-839-7613 (TTY 711)
● Dua lwm cov: 1-800-464-4000 (TTY 711)

Japanese: 多言語による情報支援を無料で 24 時間年中無休でご利用いただけます。通訳サー

ビス、日本語に翻訳された資料、あるいは別の形式による資料もご所望いただけます。また、当
施設における補助的な支援や機器についてもご所望いただけます。お気軽にご連絡ください（祝
祭日を除き 24 時間週 7 日）。
● Medi-Cal: 1-855-839-7613 (TTY 711)
● その他のご連絡先: 1-800-464-4000 (TTY 711)

Khmer (Cambodian): ជំនួយភាសា គឺឥតគិតថ្លៃដល់អ្នកឡ យយ 24 ឡ៉ងកក្នងកួួយថ្ងៃ 7 ថ្ងៃក្នងកួួយសប្តងហ៍។

អ្នកអាចឡស្នយសំឡសអអ្នកកក្រែក ក្ញឯកសារ្រដលបនកក្រែក ជាភាសា្រ្មែរ ឬទែួក់ជំនួសឡ្ងេកៗឡទតត។ អ្នកក៏អាច
ឡស្នយសំបកករ៍៍និកករក្ខាងរជំនួយ ទំនាក់ទំនកសែ៉ក់អ្នកពិ្ខរឡៅទីតាំករកស់ឡយយក្ក្រដរ។ ទូរស័ព្ទឡៅ
ួជងឈួ៍្ឌល ទំនាក់ទំនកឡសអកួមែស៉ជិករកស់ឡយយកសែ៉ក់ជំនួយ 24 ឡ៉ងកក្នងកួួយថ្ងៃ 7 ថ្ងៃក្នងកួួយសប្តងហ៍
(ថ្ងៃឈក់សែ៉កកិទ)។
● Medi-Cal: 1-855-839-7613 (TTY 711)
● ឡ្ងេកឡទតតំំកសស់: 1-800-464-4000 (TTY 711)

Korean: 요일 및 시간에 관계없이 언어지원 서비스를 무료로 이용하실 수 있습니다. 귀하는 통역

서비스 또는 귀하의 언어로 번역된 자료 또는 대체 형식의 자료를 요청할 수 있습니다. 또한 저희
시설에서 보조기구 및 기기를 요청하실 수 있습니다. 저희 가입자 서비스 연락 센터에 주 7 일,
하루 24 시간(공휴일 휴무) 전화하셔서 도움을 받으십시오.
● Medi-Cal: 1-855-839-7613 (TTY 711)
● 기타 모든 경우: 1-800-464-4000 (TTY 711)

Laotian: ມີການຊວ ່ ຍເຫຼືອດາ້ ນພາສາບໍ່ ເສຍຄາ່ ໃຫແ ້ ກທ່ າ່ ນ, 24 ຊ່ວົ ໂມງຕໍ່ ວ ັນ, 7 ວ ັນຕໍ່ອາທິດ. ທາ່ ນຍ ັງສາມາດຂໍ
ບໍລິການຜູແ ້ ປພາສາ ຫຼ ື ເອກະສານທີ່ ແປເປັ ນ ພາສາຂອງທ າ່ ນ ຫຼື ໃນຮູບແບບອື່ ນໄດ.້ ທາ່ ນຍ ັງສາມາດຂໍອປ ຸ ະກອນ
ຊວ່ ຍເສີ
ມ ແລະ ເຄື່ ອງມື ຢ ສ
່ ູ ະຖານບໍ ລ ກ
ິ ານຂອງພວກເຮົ າ ໄດ .
້ ໂທຫາສູ ນ ຕິ
ດ ຕໍ່ ບໍ ລ ກ
ິ ານສະມາຊິ
ກ ຂອງພວກເຮົ າເພື່ ອຂໍ
ຄວາມຊວ ່ ຍເຫຼ ື ອ , 24 ຊ ່ ວ
ົ ໂມງຕໍ່ ວ ັນ, 7 ວ ັນຕໍ່ ອາທິ ດ (ປິ ດ ໃນວ ັນພ ັກ).
● Medi-Cal: 1-855-839-7613 (TTY 711)
● ອື່ ນໆທັງໝ ົດ: 1-800-464-4000 (TTY 711)

Mien: Mbenc nzoih liouh wangv-henh tengx nzie faan waac bun muangx meih maiv cingv, yietc
hnoi mbenc maaih 24 norm ziangh hoc, yietc norm leiz baaix mbenc maaih 7 hnoi. Meih se haih
tov heuc tengx faan benx meih nyei waac bun muangx, a’fai zoux benx nyungc horngh jaa-sic
zoux benx meih nyei waac. Meih corc haih tov tengx nyungc horngh jaa-dorngx aengx caux jaa-
sic nzie bun yiem njiec zorc goux baengc zingh gorn zangc. Beiv hnangv qiemx zuqc longc
mienh nzie weih nor douc waac lorx taux yie mbuo ziux goux baengc mienh nyei gorn zangc,
yietc hnoi tengx duqv 24 norm ziangh hoc, yietc norm leiz baaix tengx duqv 7 hnoi (simv cuotv
gingc nyei hnoi se guon oc).
● Medi-Cal: 1-855-839-7613 (TTY 711)
● Yietc zungv da’nyeic deix: 1-800-464-4000 (TTY 711)

Navajo: Díí hózhó nízhoní bee hane’ dóó jíik’ah jóóní doonílwo’. Ndik’é yádi naaltsoos bee haz’áanii bee
hane’ dóó yádi nihookaa dóó nádááhágíí yádi nihookaa. Shí éí bee háídínii bibee’ haz’áanii dóó bee t’ah
kodí bízíkinii wo’da’gi doolyé. Ahéhee’ bik’ehgo nohólǫǫn’ígíí, 24 t’áádawołíí, 7 t’áádawołíígo (t’áadoo
t’áálwo’).
● Medi-Cal: 1-855-839-7613 (TTY 711)
 ● Yadilzingo biłk’ehgo bee: 1-800-464-4000 (TTY 711)

Punjabi: ਬਿਨਾਂ ਬਿਸੀ ਲਾਗਤ ਦੇ, ਬਦਨ ਦੇ 24 ਘੰ ਟੇ, ਹਫਤੇ ਦੇ 7 ਬਦਨ, ਭਾਸ਼ਾ ਸਹਾਇਤਾ ਤੁਹਾਡੇ ਲਈ ਉਪਲਿਧ ਹੈ। ਤੁਸੀਂ
ਦੁਭਾਸ਼ੀਏ ਦੀਆਂ ਸੇਵਾਵਾਂ ਲਈ, ਜਾਂ ਸਮੱ ਗਰੀਆਂ ਨੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਬਵੱ ਚ ਅਨੁਵਾਦ ਿਰਵਾਉਣ ਲਈ, ਜਾਂ ਬਿਸੇ ਵੱ ਖ ਫਾਰਮੈਟ ਬਵੱ ਚ
ਪ੍ਰਾਪਤ ਿਰਨ ਲਈ ਿੇਨਤੀ ਿਰ ਸਿਦੇ ਹੋ। ਤੁਸੀਂ ਸਾਡੀਆਂ ਸੁਬਵਧਾਵਾਂ ਬਵੱ ਚ ਵੀ ਸਹਾਇਿ ਸਾਧਨਾਂ ਅਤੇ ਉਪਿਰਣਾਂ ਲਈ ਿੇਨਤੀ
ਿਰ ਸਿਦੇ ਹਾਂ। ਮਦਦ ਲਈ ਸਾਡੀ ਮੈਂਿਰ ਸੇਵਾਵਾਂ ਦੇ ਸੰ ਪਰਿ ਿੇਂਦਰ ਨੂੰ, ਬਦਨ ਦੇ 24 ਘੰ ਟੇ, ਹਫਤੇ ਦੇ 7 ਬਦਨ (ਛੁੱ ਟੀਆਂ ਵਾਲੇ
ਬਦਨ ਿੰ ਦ ਰਬਹੰ ਦਾ ਹੈ) ਿਾੱਲ ਿਰੋ।

● Medi-Cal: 1-855-839-7613 (TTY 711)

● ਹੋਰ ਸਾਰੇ: 1-800-464-4000 (TTY 711)

Russian: Языковая помощь доступна для вас бесплатно круглосуточно, ежедневно. Вы

можете запросить услуги переводчика или материалы, переведенные на ваш язык или в
альтернативные форматы. Вы также можете заказать вспомогательные средства и
приспособления. Для получения помощи позвоните в наш центр обслуживания участников
ежедневно, круглосуточно (кроме праздничных дней).
● Medi-Cal: 1-855-839-7613 (линия TTY 711)
● Все остальные: 1-800-464-4000 (линия TTY 711)

Spanish: Tenemos disponible asistencia en su idioma sin ningún costo para usted 24 horas al
día, 7 días a la semana. Usted puede solicitar los servicios de un intérprete, que los materiales
se traduzcan a su idioma o formatos alternativos. También puede solicitar recursos para
discapacidades en nuestros centros de atención. Llame a nuestra Central de Llamadas de
Servicio a los Miembros para recibir ayuda 24 horas al día, 7 días a la semana (excepto los días
festivos).
● Para todos los demás: 1-800-788-0616 (TTY 711)

Tagalog: May magagamit na tulong sa wika nang wala kayong babayaran, 24 na oras sa isang
araw, 7 araw sa isang linggo. Maaari kayong humiling ng mga serbisyo ng interpreter, o mga
babasahin na isinalin sa inyong wika o sa mga alternatibong format. Maaari rin kayong humiling
ng mga pantulong na gamit at device sa aming mga pasilidad. Tawagan ang aming Center sa
Pakikipag-ugnayan ng Serbisyo sa Miyembro para sa tulong, 24 na oras sa isang araw, 7 araw
sa isang linggo (sarado sa mga pista opisyal).
● Medi-Cal: 1-855-839-7613 (TTY 711)
● Lahat ng iba pa: 1-800-464-4000 (TTY 711)

Thai: มีบริการชว่ ยเหลือด ้านภาษาตลอด 24 ชวั่ โมงทุกวันโดยไม่มค ี า่ ใชจ่้ าย โดยคุณสามารถขอใชบริ้ การ

ล่าม บริการแปลเอกสารเป็ นภาษาของคุณหรือในรูปแบบอืน ่ ๆ ได ้ คุณสามารถขออุปกรณ์และเครือ ่ งมือชว่ ย
เหลือได ้ทีศ
่ น
ู ย์บริการของเราโดยโทรหาเราทีศ
่ น
ู ย์ตด ิ
ิ ต่อฝ่ ายบริการสมาชกของเราเพือ ่ ขอความชว่ ยเหลือ
่ ั ่
ตลอด 24 ชวโมงทุกวัน (ปิ ดทําการในชวงวันหยุด)
● Medi-Cal: 1-855-839-7613 (TTY 711)
● ทีอ
่ น
ื่ ๆทัง้ หมด: 1-800-464-4000 (TTY 711)

Ukranian: Послуги перекладача надаються безкоштовно, цілодобово, 7 днів на тиждень. Ви

можете зробити запит на послуги усного перекладача або отримання матеріалів у
перекладі мовою, якою володієте, чи в альтернативних форматах. Також ви можете зробити
запит на отримання допоміжних засобів і пристроїв у закладах нашої мережі компаній.
Телефонуйте в наш контактний центр для обслуговування клієнтів цілодобово, 7 днів на
тиждень (крім святкових днів).
● Medi-Cal: 1-855-839-7613 (TTY 711)
● Усі інші: 1-800-464-4000 (TTY 711)

Vietnamese: Dịch vụ hỗ trợ ngôn nữ được cung cấp miễn phí cho quý vị 24 giờ mỗi ngày, 7
ngày trong tuần. Quý vị có thể yêu cầu dịch vụ thông dịch, hoặc tài liệu được dịch ra ngôn ngữ
của quý vị hoặc nhiều hình thức khác. Quý vị cũng có thể yêu cầu các phương tiện trợ giúp và
thiết bị bổ trợ tại các cơ sở của chúng tôi. Gọi cho Trung Tâm Liên Lạc ban Dịch Vụ Hội Viên của
chúng tôi để được trợ giúp, 24 giờ mỗi ngày, 7 ngày trong tuần (trừ các ngày lễ).
● Medi-Cal: 1-855-839-7613 (TTY 711)
● Mọi chương trình khác: 1-800-464-4000 (TTY 711)