A46163-VI (10/16) 1

Chp thun cho php S dng hoc Tit l Thng tin Sc khe

A. S dng mu n ny y quyn cho php Blue Shield of California, Blue Shield of California Life & Health Insurance Company, v cc cng ty lin kt kinh doanh ca h (gi chung l "Blue Shield") s dng hoc tit l thng tin sc khe ca bn cho mt c nhn hoc t chc khc.

1. Ngi c thng tin c tit l ("Thnh vin").Tn v a ch Thnh vin:

ID s ng k: Ngy sinh:

2. Ngi c y quyn tip nhn thng tin ca Thnh vin ("Ngi nhn")? Tn v a ch ca ngi nhn:

Quan h ca Ngi nhn vi Thnh vin:

3. Thng tin no c th c tit l cho Ngi nhn? (Chn mt)c Bt k hoc tt c thng tin m Blue Shield lu tr. Thng tin c tit l c

th bao gm thng tin lin quan n chm sc y t, chn on, ngi cung cp dch v chm sc y t, yu cu bi thng/thanh ton bo him hoc phc li v/hoc thng tin ti chnh/ha n. Thng tin c tit l khng bao gm cc Thng tin nhy cm tr khi c chp thun c th di y.

c Ch tit l cc Thng tin hoc cc loi Thng tin do Blue Shield lu di y (ghi r):

4. Ngi nhn c c y quyn tip nhn Thng tin nhy cm ca Thnh vin hay khng?

c KHNG - TIP TC TI PHN 5c C - hon thnh (a) hoc (b) di y - bn khng th chn c hai. Ti c

bit cho php Ngi nhn tip nhn:

H0504_13_133_VI 06252013 S2468_13_133_VI 06252013 Blue

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a. c H s ghi chp v tr liu tm l - Nu bn chn ny, bn c th khng chn bt k no trong phn b. di y. Chp thun cng b h s ghi chp v tr liu tm l khng nht thit phi kt hp vi Chp thun cho php tit l bt k loi thng tin no khc. TIP TC TI PHN 5.

b. c Ch hon thnh phn ny NU bn khng chn 4(a) trn, v bn mun cho php tit l bt k loi Thng tin nhy cm no di y (chn tt c nu cn thit):

c Ph thai c Nghin ru/ma ty c Thng tin di truyn c HIV/AIDS c Sc khe tm thn c Mang thaic Lm dng tnh dc, lm dng th cht

hoc tm thnc Bnh ly truyn qua ng tnh dc

Lu cho ph huynh/ngi gim h hp php ca tr v thnh nin 12 tui: Bn c th khng th khng nhn c hoc khng c php s dng hoc tit l mt s loi Thng tin nhy cm v tr v thnh nin nu khng c y quyn bng vn bn ca tr. Thng tin ni trn c th bao gm cc loi Thng tin nhy cm c lit k trn v thng tin v bnh truyn nhim, tn cng tnh dc/hm hip, v cc bin php t vn/iu tr ngoi tr v sc khe tm thn nht nh. i vi trng hp tr v thnh nin t 17 tui tr ln, vic tit l cc thng tin lin quan n bo lc gia nh v hin mu nhn o i hi phi s chp thun ca tr.

5. Mc ch s dng hoc tit l Thng tin theo yu cu l g?c Thng tin v ti v c s dng hoc tit l theo yu cu ca tic gii quyt tranh chp khiu ni hoc khng coc Mc ch khc (ghi r):

B. Ht hn v thu hiy quyn ny s c hiu lc trong vng mt nm k t ngy bn k (di y) tr khi c ngy khc c quy nh di y: ______/______/___________Bn c quyn thu hi ny y quyn ny bt k lc no bng cch thng bo bng vn bn cho Blue Shield. Vic thu hi y quyn ny s khng nh hng n thng tin chng ti s dng hoc tit l trc khi chng ti nhn c yu cu thu hi ca bn. Nu y quyn ny c cp bi ph huynh hoc ngi gim h hp php thay mt cho tr v thnh nin, y quyn s ht hiu lc vo ngy sinh nht 18 tui ca tr.

A46163-VI (10/16) 3

C. Ch kTi c mu n ny v ti hiu v ng vi cc iu khon quy nh theo y. Ti cho php Blue Shield of California s dng hoc tit l Thng tin cho Ngi nhn theo ch nh trn. Ti hiu rang sau khii Thng tin ca ti c tit l, thng tin c th c Ngi nhn ti tit l v khng cn c bo v bi php lut quyn ring t, bao gm Health Insurance Portability and Accountability Act (o lut v Trch nhim Gii trnh v Cung cp Thng tin Bo him Y t) nm 1996 ca Lin Bang.Ti hiu rng Blue Shield c th khng a ra iu kin thanh ton, ghi danh trong mt k hoch y t, hoc tnh iu kin cho cc li ch trn cho d ti k y quyn ny.

Ch k Ngy

Tn vit in

D. i din hoc Ngi gim h hp php hoc c nhnNu mu n ny do mt ngi khng phi Thnh vin hoc ph huynh ca tr v thnh nin k, chng hn nh mt i din c nhn/hp php, ngi gim h hoc ngi thc thi, bn phi trnh h s php l chng minh thm quyn thay mt cho Thnh vin (hoc ngi k tha ca Thnh vin) cho php s dng hoc tit l Thng tin sc khe ca Thnh vin. Ti liu c th bao gm: 1) Giy y quyn Chm sc Sc khe di hn; 2) Lnh trao quyn gim h ca Ta n c hiu lc hin hnh; hoc 3) Ti liu php l hp l chng minh thm quyn thay mt cho Thnh vin (hoc ngi tha k ca Thnh vin).Xin vui lng in y phn di y:Tn Ngi i din (vit in):Quan h vi Thnh vin:Loi ti liu trnh:

Gi mt bn sao y quyn ny trong h s ca bn.

Gi li mu y quyn in y v c ch k : Blue Shield of California Customer Service P.O. Box 272540 Chico, CA 95927-2540

Blue Shield of California50 Beale Street, San Francisco, CA 94105 blueshieldca.com

Thng Bo Dnh Cho C Nhn V Yu Cu Khng Phn Bit i X V Kh Nng Tip Cn

Phn bit i x l hnh vi vi phm php lutBlueShieldofCaliforniatunthlutdnslinbanghinhnhvkhngphnbitixdatrnsctc,muda,xutx,tuitc,khuyttthocgiitnh.BlueShieldofCaliforniakhngloitrhocixvimtsngimtcchkhcbitdosctc,muda,xutx,tuitc,khuyttthocgiitnh.

Blue Shield of California:

Cungcpshtrvdchvminphchongikhuytttcthgiaotiphiuquvichng tinh:

- Phindchvinngnngkhiunnglc

- Thngtinbngvnbndinhiunhdngkhc(trongcbninkhln,bnghim,nhdngintcthtipcnvccnhdngkhc)

CungcpdchvngnngminphchocccnhnmngnngchnhkhngphiltingAnh, vd:

- Phindchvinnnglc

- Thngtincvitbngccngnngkhc

Nuquvcnccdchvny,hylinhiuPhiVinQuynDnScaBlueShieldofCalifornia.

NuquvchorngBlueShieldofCaliforniakhngcungcpccdchvnyhoccsphnbitixtheocchkhcdatrnvnsctc,muda,xutx,tuitc,khuyttthocgiitnh,quvcthgithanphinvi:

Blue Shield of California Civil Rights Coordinator P.O.Box629007 ElDoradoHills,CA95762-9007in thoi: (844) 831-4133 (TTY: 711) Fax: (916) 350-7405 Email: BlueShieldCivilRightsCoordinator@blueshieldca.com

Quvcthtrctipgithanphinhocgibngth,faxhocemail.Nuquvcntrgiptrongvicnpthanphin,PiuPhiVinQuynDnScachngtisnsngtrgipquv.

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QuvcngcthnpyucuthanphintheonhdngintvquyndnsviU.S.DepartmentofHealthandHumanServices(BYTVDchVNhnSinhHoaK),PhngDnSthngquaCngThngTinThanPhincaPhngDnS,theoachhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf,hocbngthhocquainthoitheoach:

U.S. Department of Health and Human Services 200IndependenceAvenueSW. Room509F,HHHBuilding Washington,DC20201 (800)368-1019;TTY:(800)537-7697

Biumuthanphinctrnwww.hhs.gov/ocr/office/file/index.html.

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. Tambin puede recibir esta carta en su idioma. Para ayuda sin cargo, por favor llame inmediatamente al telfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificacin de Blue Shield o al (866) 346-7198. (Spanish)

Blue Shield ID /

(866) 346-7198(Chinese)

QUAN TRNG: Qu v c th c l th ny khng? Nu khng, chng ti c th nh ngi gip qu v c th. Qu v cng c th nhn l th ny c vit bng ngn ng ca qu v. c h tr min ph, vui lng gi ngay n Ban Dch v Hi vin/Khch hng theo s mt sau th ID Blue Shield ca qu v hoc theo s (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 sanumerong telepono ng Miyembro/Customer Service sa likod ng iyong Blue Shield ID kard, o (866) 346-7198. (Tagalog)

Baa kohwiindzindoo7g7: D77 naaltsoos7sh y77nitago b77n7ghah? Doo b77n7ghahg 7, naaltsoos nich8 yiid0o[tah7g77 a nihee hl=. D77 naaltsoos a[d0 t11 Din4 kehj7 1dooln77[ n7n7zingo b7ighah. Doo b22h 7l7n7g0 sh7k1 adoowo[ n7n7zing0 nihich8 b44sh bee hod7ilnih d00 n1mboo 47 d77 Blue Shield bee n47hod7lzin7g7 bined44 bik11 47 doodag0 47 (866) 346-7198 j8 hod77lnih. (Navajo)

: ? , .

. Blue Shield ID

/ (866) 346-7198 . (Korean)

blueshieldca.com

, , Blue Shield ID , (866) 346-7198 (Armenian)

: ? , . . / , Blue Shield, (866) 346-7198, . (Russian)

Blue Shield ID/(866) 346-7198 (Japanese)

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Blue Shield ID / , (866) 346-7198 (Punjabi)

? / Blue Shield (866) 346-7198 (Khmer)

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(Arabic)).866( 346-7198 Blue Shield

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)

: / Blue Shield (866) 346-7198 (Thai)

: ? , : Blue Shield ID / , (866) 346-7198 (Hindi)

blueshieldca.com

blueshieldca.com

Notice of the Availability of Language Assistance ServicesBlue Shield of California Life & Health Insurance Company