HEALTH NET LIFE INSURANCE COMPANY 1. You do not need more than one Supplement plan. 2. If you elect this plan, you may want to evaluate your existing health coverage and decide if you need multiple coverages. 3. You may be eligible for benefits under Medi-Cal and may not need a Medicare Supplement plan. 4. If after electing this plan you become eligible for Medi-Cal, the benefits and the amount you pay under your Medicare Supplement plan can be suspended, if requested, during your entitlement to benefits under Medi-Cal for 24 months. You must request this suspension within 90 days of becoming eligible for Medi-Cal. If you are no longer entitled to Medi-Cal, your suspended Medicare Supplement plan or, if that is no longer available, a substantially equivalent plan will be reinstituted if requested within 90 days of losing Medi-Cal eligibility. If the Medicare Supplement plan provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your plan was suspended, the reinstituted plan will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. 5. If you are eligible for, and have enrolled in, a Medicare Supplement plan by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and the amount you pay under your Medicare Supplement plan can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare Supplement plan under these circumstances and later lose your employer or union-based group health plan, your suspended Medicare Supplement plan or, if that is no longer available, a substantially equivalent plan will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare Supplement plan provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your plan was suspended, the reinstituted plan will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. 6. Counseling services are available in this state to provide advice concerning your election of Medicare Supplement insurance and concerning medical assistance through the Medi-Cal program, including benefits as a qualified Medicare beneficiary (QMB) and a specified low-income Medicare beneficiary (SLMB). If you want to discuss electing Medicare Supplement insurance with a trained insurance counselor, call the California Department of Insurance toll-free telephone number at 1-800-927-HELP, and ask how to contact your local Counseling and Advocacy Program (HICAP) office. HICAP is a service provided free of charge by the State of California. A rate guide is available that compares the plans sold by different insurers. You can obtain a copy of this rate guide by calling the Department of Insurance consumer toll-free telephone number at 1-800-927-HELP, by calling the Health Insurance Counseling and Advocacy Program (HICAP) toll-free number at 1-800-434-0222 or by accessing the Department of Insurance Internet website at www.insurance.ca.gov.

Health Net Life Insurance Company is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved. FRM011524ED00 (1/17) HEALTH NET LIFE INSURANCE Effective date: ______/ / Plan/Group ID: ______COMPANY ENROLLMENT FORM Reason for application: Open enrollment FOR A GROUP MEDICARE Loss of prior coverage date: ______ / / SUPPLEMENT PLAN Qualifying event: ______Qualifying event date: ______/ / Reason for change:  Plan change Change address/name Employer, union or trust name: ______O t h e r : ______Please follow these enrollment form instructions: 1. Complete your enrollment form, provide any supporting information requested, and sign and date it where indicated. 2. Submit your enrollment form to your employer group administrator. Conditions of membership in Health Net Life Insurance Company (Health Net Life) Medicare Supplement: 1. This enrollment form, together with the Health Net Life Certificate of Insurance and any endorsements, appendices and attachments thereto, will collectively constitute the entire agreement for coverage. 2. I alone am responsible for the accuracy and completeness of this enrollment form and have answered all of the questions to the best of my knowledge and belief. I understand that Health Net may cancel or non-renew the coverage for either (a) the nonpayment of premium or (b) a misrepresentation of the risk by the applicant that is shown by Health Net to be material to the acceptance for coverage within the first two years of a policy.

Signature: ______Date: ______/ / (MM/DD/YYYY) Print name: ______Your personal information: First name: Middle initial: Last name: Primary residence street address (PO Box is not allowed): City: State: County: ZIP: Mailing address (if different from your primary residence address): City: State: County: ZIP: Home telephone: ( ) - Email address: Gender: Male Female Date of birth: ______/ / Preferred language: English Other: ______(MM/DD/YYYY) Which Health Net Life Medicare Supplement Plan are you applying for? Are you the primary retiree? Yes ____ No ____ If yes, retirement date: ______/ / If no, name of primary retiree: ______(MM/DD/YYYY) Your requested start date: the 1st of month ______of year ______Medicare claim/HIC #: Social Security #:

You are entitled to: ______/ / ______/ / Medicare Part A (hospital) effective: (MM/DD/YYYY) Medicare Part B (medical) effective: (MM/DD/YYYY) 1 of 3 White – Health Net Yellow – Writing Agent/Employer Pink – Member FRM011524ED00 (1/17) Current health plan information Please answer all of the questions below by marking “yes” or “no” with an “X”. To the best of your knowledge: 1. YES NO a. Did you turn 65 years of age in the last six months? YES NO b. Did you enroll in Medicare Part B (medical) in the last 6 months? If “Yes,” what was the effective date? ______/ / (MM/DD/YYYY) 2. YES NO Are you covered for medical assistance through California’s Medi-Cal program? Note to applicant: If you are eligible for Medi-Cal benefits with a “share of cost” and have not met your share of cost, please answer “No” to this question. If you have answered “Yes” to the above question, answer the following two questions: YES NO a. Will Medi-Cal pay your premiums for this Medicare Supplement plan? YES NO b. Do you receive benefits from Medi-Cal OTHER THAN payment toward your Medicare Part B premium? 3. YES NO a. If you have had coverage from any Medicare plan other than Medicare within the past 63 days (for example, a Medicare Advantage plan or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under the plan, leave the END DATE blank. Start date: ______/ / End date: ______/ / (MM/DD/YYYY) (MM/DD/YYYY) YES NO b. If you are still covered under the Medicare plan, do you intend to replace your current coverage with this Health Net Life Plan? YES NO If yes, have you received and completed the Notice to Applicant Regarding Replacement of Medicare Supplement Coverage or Medicare Advantage form? YES NO c. Is this your first time in this type of Medicare plan? YES NO d. Did you drop a Medicare Supplement plan to enroll in the Medicare Plan? 4. YES NO a. Do you have another Medicare Supplement plan in force? b. If so, with what company and what plan? ______YES NO c. If so, do you intend to replace your current Medicare Supplement plan with this plan? YES NO If so, have you received and completed the Notice to Applicant Regarding Replacement of Medicare Supplement Coverage or Medicare Advantage form? 5. YES NO a. Have you had coverage under any other health insurance coverage within the past 63 days (for example, an employer, union or individual plan)? b. If so, with what companies and what kind of plan? ______c. What are your dates of coverage under the other plan? (If you are still covered under the other plan, leave “End date” blank.) Start date: ______/ / End date: ______/ / (MM/DD/YYYY) (MM/DD/YYYY) California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

2 of 3 White – Health Net Yellow – Writing Agent/Employer Pink – Member FRM011524ED00 (1/17) Signature section AUTHORIZATION TO OBTAIN OR RELEASE MEDICAL INFORMATION I authorize the United States Department of Health and Human Services, the Centers for Medicare & Services, and any health care provider, hospital, or medical facility to furnish to any agent, designee, employee, or representative of Health Net Life any and all records pertaining to claims payments or rejections, medical history, services rendered, or treatment given to myself for purposes of review, investigation or evaluation of a claim. I also authorize Health Net Life and its employees, participating providers, agents, and representatives to disclose to any health care provider, health care service plan, insurer, or self-insurer any such medical information obtained if such disclosure is necessary to allow the processing of a claim or if requested pursuant to legal process. This authorization shall become effective immediately and shall remain in effect for the term of coverage under the plan. I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the State where the individual resides) on this enrollment form means that I have read and understand the contents of this enrollment form. If signed by an individual (as described previously), the signature certifies that: 1. The person is authorized under State law to complete this enrollment form on behalf of the named applicant, and 2. Documentation of the authority is available upon request by Health Net Life Insurance Company or another authorized regulatory agency. Note: Health Net Life requests that a copy of the authorization form, Durable Power of Attorney for Health Care or similar document be included with this enrollment form.

BINDING ARBITRATION I, the applicant, understand and agree that any and all disputes or disagreements between me (including any of my heirs or personal representatives) and Health Net Life regarding the construction, interpretation, performance, or breach of the Health Net Life Group Medicare Supplement Certificate of Insurance, but not as to professional negligence (medical malpractice), must be submitted to final and binding arbitration in lieu of a jury or court trial. I understand that, by agreeing to submit all disputes to final and binding arbitration, all parties, including Health Net Life, are giving up their constitutional right to the extent permitted by law to have their dispute decided in a court of law before a jury. A more detailed arbitration provision is included in the Certificate of Insurance. My signature below indicates that I understand the terms of this Binding Arbitration Clause and agree to submit disputes to binding arbitration.

Signature: ______Date: ______/ / (MM/DD/YYYY) Print name: ______If you are the authorized representative, you must provide the following information: First name: Middle initial: Last name: Home address: City: State: ZIP: Relationship to applicant: Phone number: ( ) -

3 of 3 White – Health Net Yellow – Writing Agent/Employer Pink – Member FRM011524ED00 (1/17) English 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 employer group applicants please call 1-800-522-0088 (TTY: 711). Individual & Family Plan (IFP) applicants please call 1-877-609-8711 (TTY: 711). For more help: If you are enrolled in a PPO or EPO insurance policy from Health Net Life Insurance Company, call the CA Dept. of Insurance at 1-800-927-4357. If you are enrolled in an HMO or HSP plan from Health Net of California, Inc., call the DMHC Helpline at 1-888-HMO-2219. Arabic خدمات اللغة مجانية. يمكنك الحصول على مترجم فوري. ويمكنك الحصول على وثائق مقروءة لك. للحصول على المساعدة، اتصل بنا على الرقم الموجود على بطاقة الهوية، أو يرجى من مقدمي طلبات مجموعة أصحاب العمل االتصال بمركز االتصال TTY: 711( 1-800-522-0088(.. يرجى من مقدمي طلبات خطة األفراد والعائلة )IFP( االتصال على الرقم TTY: 711( 1-877-609-8711(. وللحصول على المساعدة: في حال كنت مسجالً في بوليصة تأمين المنظمة المزودة المفضلة PPO أو المنظمة المزودة الحصرية EPO من Health Net Life Insurance Company ، اتصل على قسم التأمين في كاليفورنيا على الرقم 4357-927-800- .1 في حال كنت مسجالً في منظمة المحافظة على الصحة HMO أو خطة التوفير الصحية HSP من شركة Health Net of California, Inc. , اتصل على خط المساعدة في قسم الرعاية الصحية المدارة DMHC على الرقم .1-888-HMO-2219.

Armenian Անվճար լեզվական ծառայություններ: Դուք կարող եք բանավոր թարգմանիչ ստանալ: Փաստաթղթերը կարող են կարդալ ձեզ համար ձեր լեզվով: Օգնության համար զանգահարեք մեզ ձեր ID քարտի վրա նշված հեռախոսահամարով, իսկ գործատուի խմբի դիմորդներին խնդրում ենք զանգահարել 1-800-522-0088 (TTY: 711) հեռախոսահամարով: Անհատական և Ընտանեկան Ծրագրի անգլերեն հապավումը՝ (IFP) դիմորդներին խնդրում ենք զանգահարել 1-877-609-8711 (TTY: 711) հեռախոսահամարով: Լրացուցիչ օգնության համար. եթե անդամագրված եք Health Net Life Insurance Company-ի PPO կամ EPO ապահովագրությանը, զանգահարեք Կալիֆորնիայի Ապահովագրության բաժին՝ 1-800-927-4357 հեռախոսահամարով: Եթե անդամագրված եք Health Net of California, Inc.-ի HMO կամ HSP ծրագրին, զանգահարեք DMHC օգնության գիծ՝ 1-888-HMO-2219 հեռախոսահամարով.

Chinese 免費語言服務。您可使用口譯員。您可請人使用您的語言將文件內容唸給您聽，並請我們將有 您語言版本的部分文件寄給您。如需協助，請致電您會員卡上所列的電話號碼與我們聯絡， 雇主團體申請人請致電 1-800-522-0088（TTY：711）。個人與家庭計畫 (IFP) 申請人請致電 1-877-609-8711（TTY：711）。如需進一步協助：如果您透過 Health Net Life Insurance Company 投保 PPO 或 EPO 保單，請致電 1-800-927-4357 與加州保險局聯絡。如果您透過 Health Net of California, Inc. 投保 HMO 或 HSP 計畫，請致電 DMHC 協助專線 1-888-HMO-2219。 Hindi बिना लागत की भाषा सेवाएँ। आप एक दभाु षिया ꥍरप्त कर सकते हℂ। आपको दस्तवेज अपनी भाषा मᴂ प褼 कर सुनाए जा सकते हℂ। मदद के लिए, आपके आईडी कार㔡 पर दिए गए सूचीबद्ध नंबर पर हमᴂ कॉल करᴂ, या नियो啍त समूह आवेदक कृपया 1-800-522-0088 (TTY: 711) संपर् कᴂद्र पर कॉल करᴂ। कृपया व्यकगत और पारिवारिक प्쥈न (IFP) के आवेदक 1-877-609-8711 (TTY: 711) पर कॉल करᴂ। अधिक मदद के लिए: यदि आप Health Net Life Insurance Company PPO या ईपीओ EPO बीमा पॉलिसी मᴂ नामांकित हℂ, तो कै लिफोर्नया बीमा विभाग को 1-800-927-4357 पर कॉल करᴂ। यदि आप Health Net of California, Inc., एचएमओ HMO या एचएसपी HSP प्쥈न मᴂ नामांकित हℂ, तो डीएमएचसी DMHC हेल्लाइन के 1-888-HMO-2219 पर कॉल करᴂ। Hmong Kev Pab Txhais Lus Dawb. Koj xav tau neeg txhais lus los tau. Koj xav tau neeg nyeem cov ntaub ntawv kom yog koj hom lus los tau xav tau kev pab, hu peb tau rau ntawm tus xov tooj nyob ntawm koj daim npav, los yog tias koj yog tus neeg tso npe xav tau kev pab kho mob los ntawm koj txoj hauj-lwm thov hu rau 1-800-522-0088 (TTY: 711). Yog koj yog tus tso npe xav tau kev pab kho mob rau Ib Tug Neeg & Tsev Neeg Individual & Family Plan (IFP) thov hu 1-877-609-8711 (TTY: 711). Xav tau kev pab ntxiv: Yog koj tau tsab ntawv tuav pov hwm PPO los yog EPO los ntawm Health Net Life Insurance Company, hu mus rau CA Dept. of Insurance ntawm 1-800-927-4357. Yog koj tau txoj kev pab kho mob HMO los yog HSP los ntawm Health Net of California, Inc., hu mus rau DMHC tus xov tooj pab Helpline ntawm 1-888-HMO-2219. Japanese 無料の言語サービス。通訳をご利用いただけます。日本語で文書をお読みします。援助が必要な場 合は、IDカードに記載されている番号までお電話いただくか、雇用主を通じた団体保険の申込者の 方は、 1-800-522-0088、(TTY: 711) までお電話ください。個人および家族向けプラン (IFP) の申込者の方は、 1-877-609-8711 (TTY: 711) までお電話ください。さらに援助が必要な場合: Health Net Life Insurance CompanyのPPOまたはEPO保険ポリシーに加入されている方は、カリフォル ニア州保険局 1-800-927-4357 まで電話でお問い合わせください。Health Net of California, Inc.のHMO またはHSPに加入されている方は、DMHCヘルプライン 1-888-HMO-2219 まで電話でお問い合わせ ください。

Khmer សេ玶徶羶ដោយឥតគិតថ្濃។ អ䮓ក讶ចទទួល厶នអ䮓កបកប្រ埒䞶ល់掶ត់។ អ䮓ក讶ចស⮶ ប់គេ讶នឯក羶រឱ䮙អ䮓ក នៅក侻្ង徶羶របស់អ䮓ក។ សម្ប់ជនួយំ សូម䞶ក់ទងយ�ើងខ្ញុ㾶មរយៈលេខទូរសព្ទែល掶ននៅល�ើζតសមஶ ល់ខលនរប្ ស់អ䮓ក ឬ បេក䮁ជនក្殻មនិយោជក 讶ច䞶ក់ទងទៅមជ䮈មណ䮌លទំ侶ក់ទំនង家ណិ ជ䮇កម䮘នៃក្殻មហ៊ុន 1-800-522-0088 (TTY: 711)។ បេក䮁ជនផែនζរគ្殽羶រ និងបេក䮁ជនផែនζរបុគ្ល សូមទូរសព្ទៅលេខ 1-877-609-8711 (TTY: 711)។ សម្ប់ជនួយបំ ន្䏂ម ៖ ប�ើសិនអ䮓ក厶នចុះ ឈ្មោះក侻ង្ គោលζរណ៍䮶侶រ➶ប់រង PPO ឬ EPO Health Net Life Insurance Company សូម䞶ក់ទងទៅ侶 យកដ⾶ ន䮶侶រ➶ប់រង CA 㾶មរយៈទូរសព្ទលខ 1-800-927-4357។ ប�ើសិនអ䮓ក厶នចុះឈ្មោះក侻ង្ ផែនζរ HMO ឬ HSP ពីក្殻មហ៊ុន

Health Net នៃរដ្ζលីហ្珐រញ➶ សូម䞶ក់ទងលេខទូរសព្ជនួយំ DMHC ៖ 1-888-HMO-2219។ Korean 무료 언어 서비스. 통역 서비스를 받을 수 있습니다. 귀하가 구사하는 언어로 문서의 낭독 서비스를 받으실 수 있습니다. 도움이 필요하시면 보험 ID 카드에 수록된 번호로 전화하시거나 고용주 그룹 신청인의 경우 1-800-522-0088 (TTY: 711) 번으로 전화해 주십시오. Individual & Family Plan (IFP) 신청인의 경우, 1-877-609-8711 (TTY: 711) 번으로 전화해 주십시오. 추가 도움이 필요하시면, Health Net Life Insurance Company의 PPO 또는 EPO 보험에 가입되어 있으시면 캘리포니아 주 보험국에1-800-927-4357번으로 전화해 주십시오. Health Net of California, Inc.의 HMO 또는 HSP 플랜에 가입되어 있으시면 DMHC 도움라인에 1-888-HMO-2219번으로 전화해 주십시오. Navajo Saad Bee !k1 E’eyeed T’11 J77k’e. Ata’ halne’7g77 h0l=. T’11 h0 hazaad k’ehj7 naaltsoos hach’8’ w0ltah. Sh7k1 a’doowo[ n7n7zingo naaltsoos bee n47ho’d0lzin7g77 bik1a’gi b44sh bee hane’7 bik11’ 1aj8’ hod77lnih 47 doodaii’ employer group-j7 ninaaltsoos si[tsoozgo 47 1-800-522-0088 (TTY: 711). T’11 h0 d00 ha’1[ch7n7 bi[ hak’4’4sti’7g77 (IFP woly4h7g77) 47 koj8’ hojilnih 1-877-609-8711 (TTY: 711).Sh7k1 an11’doowo[ jin7zingo: PPO 47 doodaii’ EPO-j7 Health Net Life Insurance Company woly4h7j7 b4eso 1ch’33h naa’nil biniiy4 hwe’iina’ bik’4’4sti’go 47 CA Dept. of Insurance bich’8’ hojilnih 1-800-927-4357. HMO 47 doodaii’ HSP-j7 Health Net of California-j7 b4eso 1ch’33h naa’nil biniiy4 hats’77s bik’4’4sti’go 47 koj8’ hojilnih DMHC Helpline 1-888-HMO-2219. Persian (Farsi) خدمات زبان به طور رايگان. می توانيد يک مترجم شفاهی بگيريد. می توانيد درخواست کنيد که اسناد به زبان شما برايتان قرائت شوند. برای دریافت راهنمایی، با ما به شماره ای که روی کارت شناسایی شما درج شده تماس بگیرید، یا درخواست کنندگان گروه کارفرما لطفاً با مرکز تماس بازرگانیTTY: 711( 1-800-522-0088( تماس بگیرید. درخواست کنندگان برنامه انفرادی یا خانواده )IFP( لطفاً با شمارهTTY: 711( 1-877-609-8711( تماس بگیرید. برای دریافت راهنمایی بیشتر: اگر در بیمه نامه PPO یا EPO از سوی Health Net Life Insurance Companyعضویت دارید، با CA Dept. of Insurance به شماره 4357-927-800-1 تماس بگیرید. اگر در برنامه HMO یا HSP از سوی Health Net of California, Inc. عضویت دارید، با خط راهنمایی تلفنی DMHC به شماره HMO-2219-888-1 تماس بگیرید.

Panjabi (Punjabi) ਬਿਨ拓 ਕਿਸੇ ਲਾਗਤ ਤ⸂ ਭਾਸ਼ ਸੇਵਾਵ拓। ਤੁਸȂ ਇੱਕ ਦੁਭਾਸ਼ਆ ਪ੍ਰਪਤ ਕਰ ਸਕਦੇ ਹੋ। ਤੁਹਾਨੂੰ ਦਸਤਾਵੇ爼 ਤੁਹਾਡੀ ਭਾਸ਼ ਵਿੱਚ ਪੜ㘹 ਕੇ ਸੁਣਾਏ ਜਾ ਸਕਦੇ ਹਨ। ਮਦਦ ਲਈ, ਆਪਣੇ ਆਈਡੀ ਕਾਰਡ ਤੇ ਦਿੱਤੇ ਨੰ ਬਰ ਤੇ ਸਾਨੂੰ ਕਾਲ ਕਰੋ ਜ拓 ਕਿਰਪਾ ਕਰਕੇ 1-800-522-0088 (TTY: 711) ’ਤੇ ਕਾਲ ਕਰੋ। ਵਿਅਕਤੀਗਤ ਅਤੇ ਪਾਰਿਵਾਰਕ ਪਲੈਨ (IFP) ਦੇ ਆਵੇਦਕ ਕਿਰਪਾ ਕਰਕੇ 1-877-609-8711 (TTY: 711) ’ਤੇ ਕਾਲ ਕਰੋ। ਵਧੇਰੀ ਮਦਦ ਲਈ: ਜੇ Health Net Life Insurance Company ਤ⸂ ਇੱਕ ਪੀਪੀਓ PPO ਜ拓 ਈਓਪੋ EPO ਬੀਮਾ ਪਾਲਿਸੀ ਵਿੱਚ ਨਾਮ拓ਕਿਤ ਹੋ, ਤ拓 ਕੈਲੀਫੋਰਨੀਆਂ ਬੀਮਾ ਵਿਭਾਗ ਨੂੰ 1-800-927-4357 ’ਤੇ ਕਾਲ ਕਰੋ। ਜੇ ਤੁਸȂ ਹੈਲਥ ਨੈੱਟ ਆ긼 ਕੈਲੀਫ਼ਰਨੀਆਂ, ਇੰ ਕ ਤ⸂ ਇੱਕ ਐਚਐਮਓ HMO ਜ拓 ਐਚਐਸਪੀ HSP ਪਲੈਨ ਵਿੱਚ ਨਾਮ拓ਕਿਤ ਹੋ ਤ拓 ਡੀਐਮਐਚਸੀ DMHC ਹੈਲਪਲਾਈਨ ਨੂੰ 1-888-HMO-2219 ’ਤੇ ਕਾਲ ਕਰੋ। Russian Бесплатная помощь переводчиков. Вы можете получить помощь устного переводчика. Вам могут прочитать документы в переводе на ваш родной язык. За помощью обращайтесь к нам по телефону, приведенному на вашей идентификационной карточке участника плана. Если вы хотите стать участником группового плана, предоставляемого работодателем, звоните в коммерческий контактный центр компании 1-800-522-0088 (TTY: 711). Если вы хотите стать участником плана для семей и частных лиц (IFP), звоните по телефону 1-877-609-8711 (TTY: 711). Дополнительная помощь: Если вы включены в полис PPO или EPO от страховой компании Health Net Life Insurance Company, звоните в Департамент страхования штата Калифорния CA Dept. of Insurance, телефон 1-800-927-4357. Если вы включены в план HMO или HSP от страховой компании Health Net of California, Inc., звоните по контактной линии Департамента управляемого медицинского обслуживания (DMHC), телефон 1-888-HMO-2219. Spanish Servicios de idiomas sin costo. Puede solicitar un intérprete. Puede obtener el servicio de lectura de documentos y recibir algunos en su idioma. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación. Los solicitantes del grupo del empleador deben llamar al 1-800-522-0088 (TTY: 711). Los solicitantes de planes individuales y familiares deben llamar al 1-877-609-8711 (TTY: 711). Para obtener más ayuda, haga lo siguiente: Si está inscrito en una póliza de seguro PPO o EPO de Health Net Life Insurance Company, llame al Departamento de Seguros de California, al 1-800-927-4357. Si está inscrito en un plan HMO o HSP de Health Net of California, Inc., llame a la línea de ayuda del Departamento de Atención Médica Administrada, al 1-888-HMO-2219. Tagalog Walang Bayad na Mga Serbisyo sa Wika. Makakakuha kayo ng isang interpreter. Makakakuha kayo ng mga dokumento na babasahin sa inyo sa inyong wika. Para sa tulong, tawagan kami sa nakalistang numero sa inyong ID card, o para sa grupo ng mga aplikante ng employer, mangyaring tawagan ang 1-800-522-0088 (TTY: 711). Para sa mga aplikante ng Plano para sa Indibiduwal at Pamilya Individual & Family Plan, (IFP), mangyaring tawagan ang 1-877-609-8711 (TTY: 711). Para sa higit pang tulong: Kung nakatala kayo sa insurance policy ng PPO o EPO mula sa Health Net Life Insurance Company, tawagan ang CA Dept. of Insurance sa 1-800-927-4357. Kung nakatala kayo sa HMO o HSP na plan mula sa Health Net of California, Inc., tawagan ang Helpline ng DMHC sa 1-888-HMO-2219. Thai ไม่มีค่าบริการด้านภาษา คุณสามารถใช้ล่ามได้ คุณสามารถให้อ่านเอกสารให้ฟงเป็นภาษาของคุณได้ั ส�ำหรับความช่วยเหลือ โทรหาเราตามหมายเลขที่ให้ไว้บนบัตรประจ�ำตัวของคุณ หรือ ผู้สมัครกลุ่มนายจ้าง กรุณาโทรหาศูนย์ติดต่อเชิงพาณิชย์ของ 1-800-522-0088 (TTY: 711) ผู้สมัครแผนบุคคลและครอบครัว Individual & Family Plan (IFP) กรุณาโทร 1-877-609-8711 (TTY: 711) ส�ำหรับความช่วยเหลือเพิ่มเติม หากคุณสมัครท�ำกรมธรรม์ประกันภัย PPO หรือ EPO กับ Health Net Life Insurance Company โทรหากรมการประกันภัยรัฐแคลิฟอร์เนียได้ที่ 1-800-927-4357 หากคุณสมัครแผน HMO หรือ HSP กับ Health Net of California, Inc. โทรหาสายด่วนความช่วยเหลือของ DMHC ได้ที่ 1-888-HMO-2219. Vietnamese Các Dị̣ch Vụ Ngôn Ngữ Miễn Phí. Quý vị có thể có một phiên dịch viên. Quý vị có thể yêu cầu được đọc cho nghe tài liệu bằng ngôn ngữ của quý vị. Để nhận trợ giúp, hãy gọi cho chúng tôi theo số được liệt kê trên thẻ ID của quý vị, hoặc người nộp đơn vào chương trình theo nhóm của chủ sử dụng lao động vui lòng gọi 1-800-522-0088 (TTY: 711). Người nộp đơn thuộc Chương Trình Cá Nhân & Gia Đình viết tắt trong tiếng Anh là (IFP) vui lòng gọi số 1-877-609-8711 (TTY: 711). Để nhận thêm trợ giúp: Nếu quý vị đăng ký hợp đồng bảo hiểm PPO hoặc EPO từ Health Net Life Insurance Company, vui lòng gọi Sở Y Tế CA theo số 1-800-927-4357. Nếu quý vị đăng ký vào chương trình HMO hoặc HSP từ Health Net of California, Inc., vui lòng gọi Đường Dây Trợ Giúp DMHC theo số 1-888-HMO-2219.

CA Commercial Applicant Notice of Language Assistance

FLY007791EL00 (06/16)