non-state-specific-enrollform-eng.pdf

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1 Ü»² Û² ± ³»² Ú± ³ ÍÛÝÌ ÑÒ ßæ ÙÛÒÛÎßÔ ÒÚÑÎÓßÌ ÑÒ øð»»»½ º ݱ²½± ¼ ß½½» ݱ²½± ¼ Ý ± ½» ݱ²½± ¼ Ú» ݱ²½± ¼ лº»»¼ ݱ²½± ¼ Í»»½ Ñ» ÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁ øð»»»½ º ݱ²½± ¼ Ð «Ñ» ÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁ øüøóñ ±² Ý ²½» ß Ý±ª» ¹» øû³ ±»» ú ß Ü»»²¼»² Ý ²½» Ü»»²¼»² ø Ѳ øô ¼»»²¼»² ± ¾» ½ ²½»»¼ ² Í»½ ±² Ü Ý ²½» Í ± Ѳ øô ± ± ¾» ½ ²½»»¼ ² Í»½ ±² Ü ß¼¼ Ü»»²¼»² ø»ò¹òô ±ô ¼±³» ½ ²» ô ½ ¼ô» ½ò Ý ²¹» ß¼¼» λ ²» ݱª» ¹» Ý ²¹» Ù ±«Ò«³¾» Ý ²¹» Ð ±ª ¼» Ý ²¹» Ò ³» ̱ ÝÑÞÎß Ù ±«Ñ» ÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁÁ ø³³¼¼ ÍÛÝÌ ÑÒ Þæ ÛÓÐÔÑÇÛÎ ËÍÛ ÑÒÔÇ ÍÛÝÌ ÑÒ Ýæ ÛÓÐÔÑÇÛÛ ÒÚÑÎÓßÌ ÑÒ Ð»» ² ½» ±»»¼» ± ò øí±½ Í»½«Ò«³¾» ø³³¼¼ ø³³¼¼ ÍÛÝÌ ÑÒ Üæ ÜÛÐÛÒÜÛÒÌ ÒÚÑÎÓßÌ ÑÒ Ð»»» ¼¼»¼½ ²½»»¼ ¼»»²¼»² ²»½ ±²ò Ú± ³±» ² ¼»»²¼»² ½ ¼»²ô ½±³»» ²¼ ½ ² ¼¼ ±² º± ³ò º ¼»»²¼»² ½ ¼»²»¼ ²»½ ±²» ¼ ¾»¼ ± º«ó ³» «¼»² ¹» ïç ± ±ª» ô»»»» ±«¹ ±«¼³ ² ± º± Ü»»²¼»² Ý» º ½ ±² Ú± ³ô ½ ±«¼ ¾» ½±³»»¼ ²¼» «²»¼» Ü»² Û² ± ³»² Ú± ³ò ëððð øðëïð

2 ÍÛÝÌ ÑÒ Ûæ ÑÌØÛÎ ÜÛÒÌßÔ ÝÑÊÛÎßÙÛ Ü± ±«± ±«¼»»²¼»² ø ª» ±» Ù ±«Ü»² ݱª» ¹»á Ç» Ò± º ±«²»» ô»» ½±³»»» º± ± ²¹ ²º± ³ ±²ò øú ô Óò òô Ô ø³³¼¼»»»² ²º± ³ ±² ¼ ² ½ ±² ²¼ ½±»½ ò ß²» ±² ± µ²± ²¹ ô ²¼ ²»² ± ¼»º «¼ ² ² «²½» ²º± ³ ±² ½±²½» ² ²¹ ² º ½ ³»»» ±ô ½±³³ º «¼² ² «²½» ½ ô ½ ½ ³»ò

3 Ð ±¹ ³ ߪ ¾ ¼±» ²± ª»»¹«± ±ª ò Í» Ó ²¼»¼ Ð ±ª ±² Ýßæ ÚÔæ ßÆô Ùßô ÕÇô ÒÛ ú ÒØæ ÕÍæ Ý º± ² ± ¾ ² Ø Ê» º ±³ ¾» ²¹» ¼ ± ¼ ¾» ² «²½» ½±³ ²» ½±²¼ ±² ±º ±¾ ² ²¹» ² «²½» ½±ª» ¹»ò ß²» ±² ± µ²± ²¹ ô ²¼ ²»² ± ² ô ± ² ½ ±² ½±² ² ²¹ ² º»ô ²½±³»» ± ³» ¼ ²¹ ²º± ³ ±² ¹«±º º» ±² ±º» ¼ ¼»¹»»ò ß»³»² ³ ¼» ¾ б ½ ± ¼» ± ¾ ² ² ¼ Ó»³¾» ¾» ¼»»³»¼»»»² ±² ²¼ ²± ²» ô ²¼ ²±»³»² ³ ¼» º±» «±» ±º б ½ ± ¼» ò ß²» ±² ± µ²± ²¹ ²¼ ²»² ± ¼»º «¼ô»¼ ±² ß ½ ±²ô ³ ¾» ½±³³ ²¹ º «¼² ² «²½» ½ ½ ³ ¾» ½ ³»ò ÒÇæ ÑÎæ ÑÎæ ÌÒæ ß²» ±² ± µ²± ²¹ ²¼ ²»² ± ¼»º «¼ ² ² «²½» ±»³»² ±º ½ ³ ½±² ² ²¹ ² ³» º» ²º± ³ ±²ô ± ½±²½» º±» «±» ±º ³» ¼ ²¹ô ²º± ³ ±² ½±²½» ² ²¹ ² º ½ ³»»» ±ô ½±³³ º «¼² ² «²½» ½ ô ½ ½ ³» ²¼ ± ¾» ²¼»»¼ ª ±º» ½ ³ º±» ½ «½ ª ± ±²ò ß²» ±² ± µ²± ²¹ ²¼ ²»² ± ¼»º «¼ô»¼ ±² ß ½ ±²ô ³ ¾» ½±³³ ²¹ º «¼² ² «²½» ½ ½ ³ ¾» ½ ³»ò ݱ²» ¾ ³»¼ ± ±»»¼ ²» Ù ±«Ð± ½ ò ½ ³» ± µ²± ²¹ ±ª ¼» º»ô ²½±³»» ± ³» ¼ ²¹ ²º± ³ ±² ± ² ² «²½» ½±³ ² º±» «±» ±º ¼»º «¼ ²¹» ½±³ ² ò л²» ²½ «¼» Ôßæ ÒÖæ ß²» ±² ± µ²± ²¹»»² º» ± º «¼²»»² º» ²º± ³ ±² ² ² ½ ±² º± ² «²½» ß»³»² ³ ¼» ¾ ½ ²» ²¼ ½±³»» ±» ¾» ±º» ½ ² µ²±»¼¹» ²¼ ¾»»ºò ß²» ±² ± ²½ «¼» ² º» ± ³» ¼ ²¹ ²º± ³ ±² ±² ² ½ ±² º± ² ² «²½» ± ½ «¾»½ ± ½ ³ ² ²¼ ½ ª»²» ò ËÌæ Êßæ ß² ³» ² ¼ ¾»»»² ±«²¼» ½±³ ² ³ ¾» «¾»½ ± ¾ ±² ²» ² ª» ± ½±«½ ±² ««² ±» Î ±º ø» ß³» ½ ² ß ¾ ±² ß ±½ ±² ± ±»»½±¹²»¼ ¾ ± ô ½± ±º ½ ª ¾» ±²» º ±³» ½±³ ² ò ß² ¼»½ ±²» ½»¼ ¾ ¾ ±² ¾» ¾ ²¼ ²¹ «±² ¾± ±«²¼» ½±³ ² ò Ì» ¾ ±² ¼ ³ ²½ «¼» ± ²» º»» º ±»¼ ¾» ²¼ ³ ¾»»²»»¼ «¼¹»³»² ² ² ½±«±º ±» «¼ ½ ±²ò ß²» ±² ± ²» ²»² ± ¼»º «¼ ± µ²± ²¹» º ½ ²¹ º «¼ ¹ ² ² ² ô «¾³ ²»³»² ³ ª» ª ±»¼»» ò ˲»¼ ݱ²½± ¼ ±»» ± ± ²»¼ «¾ ¼ «²¼»» ² ³»»¼ ¾» ± ²» º± ± ²¹» æ ÝÌô ÚÔô Ùßô Ø ô ßô Üô Òô ÕÍô Ôßô Óßô ÓÜô ÓÛô Ó ô ÓÒô ÓÍô ÓÌô ÒÛô Ôô ÕÇô ÓÜô ÓÑô ÒÝô ÒÖô Ðß

4 Discrimination is Against the Law The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex assigned at birth, gender identity or recorded gender. Furthermore, the Plan will not deny or limit coverage to any health service based on the fact that an individual s sex assigned at birth, gender identity, or recorded gender is different from the one to which such health service is ordinarily available. The Plan will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual. The Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact the Civil Rights Coordinator. If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: , TTY: 711, Fax: , CivilRightsCoordinator@highmark.com. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the 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 or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at

5 English Espaol (Spanish) ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: Si habla espaol, le ofrecemos servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). (Chinese) Ti ng Vi t (Vietnamese) (Korean) Tagalog (Tagalog - Filipino) (Russian) (Arabic) Kreyòl Ayisyen (French Creole) (TTY: 711) CHÚ Ý: N u quý v nói Ti ng Vi t, chúng tôi có các d ch v h tr ngôn ng mi n phí dành cho quý v. G i s (TTY: 711). :, (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). :, ( : 711) (TTY: 711) ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis èd nan lang ki disponib gratis pou ou. Rele nimewo (TTY: 711). Français (French) sont proposés gratuitement. Appelez le (ATS: 711). Polski (Polish) (TTY: 711). Português (Portuguese) ATENÇÃO: se você fala português, encontram-se disponíveis serviços linguísticos gratuitos. Ligue para (TTY: 711). Italiano (Italian) linguistica gratuiti. Chiamare il numero (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlose Dienste für die sprachliche Unterstützung zur Verfügung. Rufnummer: (TTY: 711). (Japanese) TTY: 711 (Farsi) (TTY: 711)