How to Fill Out Continuity of Care Forms

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)

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 TRỌ NG: Quý v ị có th ể đọc lá thư này không? N ếu không, chúng tôi có thể nh ờ ngư ời giúp quý

vị đọc thư. Quý v ị cũng có th ể nh ận lá thư này được viế t b ằng ngôn ngữ c ủa quý vị. Để đư ợ c h ỗ tr ợ

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 ho ặc theo số (866) 346-7198. (Vietnamese)

MAHALAGA: Nababasa mo ba ang sulat na ito? Kung hindi, maari kam ing 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 y77ni ł ta'go b77n7ghah? Doo b77n7ghahgóó é7, naaltsoos nich'8'

yiid0o[tah7g77 ł a' 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) 346-7198 로 지금 전환하세요. (Korean)

Կ

ԿԱ ԱՐ ՐԵ ԵՎ ՎՈ ՈՐ Ր Է Է ․ ․ 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)

:ﻢﮭﻣ ﯽﻣ ﺎﯾآ ﯽﻣ ،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 نﺎﺗ 7198 - 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 ﻦﻣ Blue Shield ﻢﻗﺮﻟا ﻰﻠﻋ وأ 7198 - 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) 346-71 98 (Thai)

महवप

ू

ण :        



?   ,     



        

 



       



    



  :



       Blue Shield ID 

    



/     ,  (866) 346 - 7198   



 (Hindi)

ສ

ສ

ິິ

່່

ງ ງສ ສ

ໍໍ

າ າຄ ຄ

ັັ

ນ ນ: ທ

່

ານສາມາດອ

່

ານຈ

ົ

ດໝາຍນ

ີ

້

ໄດ

້

ບ

ໍ

? ຖ

້

າອ

່

ານບ

ໍ

່

ໄດ

້

, ພວກເຮ

ົ

າສາມາດໃຫ

້

ບາງຄ

ົ

ນຊ

່

ວຍອ

່

ານໃຫ

້

ທ

່

ານຟ

ັ

ງໄດ

້

.

ທ

່

ານຍ

ັ

ງສາມາດ ຂ

ໍ

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)

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 Dị ch Vụ Tr ợ Giúp Ngôn Ng ữ Mi ễ n Phí. Quý v ị có th ể đượ c nhậ n dị ch vụ thông dị ch. Quý v ị có th ể được

người khác đọc giúp các tài liệu và nh ận một số tài li ệ u b ằ ng tiếng Việt. Để được giúp đỡ, hãy gọi cho chúng tôi

tạ i s ố điện tho ại ghi trên thẻ hội viên của quý vị ho ặc 1 - 866-346- 7198. Để đượ c trợ giúp thêm, xin g ọ i Sở Bả o

Hiể m California tạ i 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 تﺎﻣﺪ ﻧﺎﺠﻣ ﯽ 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 ﺖﻓﺎﯾرد 1-866-346-7198 ﺪﯾﺮﯿﮕﺑ سﺎﻤﺗ . یاﺮﺑ

ﮫﺑ ،ﺮﺘﺸﯿﺑ ﮏﻤﮐ ﺖﻓﺎﯾرد CA Dept. of Insurance ) ﺎﯿﻧﺮﻔﯿﻟﺎﮐ ﮫﻤﯿﺑ هرادا ( هرﺎﻤﺷ ﮫﺑ 1-800-927-4357 ﺪﯿﻨﮐ ﻦﻔﻠﺗ . Persian

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 ﺎﻨﺑ 1-866-346-7198 . ،تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ ﺪﯾﺰﻤﻟا ﻲﻠﻋ لﻮﺼﺤﻠﻟ

ﻢﻗﺮﻟا ﻲﻠﻋ ﺎﯿﻧرﻮﻔﯿﻟﺎﻛ ﺔﯾﻻﻮﻟ ﻦﯿﻣﺄﺘﻟا ةرادﺈﺑ ﻞﺼﺗا 1-800-927-4357.

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- 7198 j8' hod77lnih. H0zh= sh7k1 an11'doowo[ n7n7zingo 47 d77 b4eso 1ch'22h naa'nil bi[ haz'32j8'

1-800-927-4357j8 ' hod77lnih.

Navajo

ບ ບ

ໍໍ

ລ ລ

ິິ

ກ ກາ ານ ນແ ແປ ປພ ພາ າສ ສາ າໂ ໂດ ດຍ ຍບ ບ

ໍໍ

່່

ເ ເສ ສຍ ຍ ຄ ຄ

່່

າ າ. ທ

່

ານສາມາດຂ

ໍ

ເອ

ົ

າຜ

ູ

້

ແປພາສາໄດ

້

. ທ

່

ານສາມາດຂ

ໍ

ໃຫ

້

ອ

່

ານເອກະສານ ໃຫ

້

ທ

່

ານຟ

ັ

ງ

ແລະ ສ

ົ

່

ງເອກະສານບາງ ຢ

່

າງທ

ີ

່

ເປ

ັ

ນພາສາຂອງທ

່

ານ. ສ

ໍ

າລ

ັ

ບຄວາມຊ

່

ວຍເຫ

ຼ

ື

ອ, ໃຫ

້

ໂທຫາພວກ ເຮ

ົ

າຕາມເບ

ີ

ໂທລະສ

ັ

ບທ

ີ

່

ມ

ີ

ໃນບ

ັ

ດປະຈ

ໍ

າຕ

ົ

ວຂອງທ

່

ານ ຫ

ຼ

ື

ໂທ ຫາເບ

ີ

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

grahamvinter.blogspot.com

Source: https://fill.io/Request-for-Continuity-of-Care-Services

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