Common use of Language Assistance Clause in Contracts

Language Assistance. If you have questions about completing this application, please contact Xxxxxx Health Plus Member Services at 0-000-000-0000 (TTY 0-000-000-0000), Monday through Friday from 8 a.m. to 7 p.m. Xxxxxx Health Plus provides translation services and other language assistance services to you free of charge. If you are working with a broker, you may also call him or her for assistance. The broker who helped you read and complete this application must sign the application (see Section H). M-17-096 Section A – Enrollment ‌‌‌‌‌ Is the applicant an existing or former Xxxxxx Health Plus member? Yes No If Yes, please include your Subscriber ID here Enrollment Period Annual Open Enrollment Period Special Enrollment Period Qualifying Event Date (Please complete the Attestation Form for Qualifying Events for Special Enrollment included) Demographic Change Only Name Change Address Change Phone Number Change Enrollment or Change Type New Enrollment Subscriber Only Subscriber and Spouse/Domestic Partner Subscriber and Child(ren) Child Only Family: Subscriber, Spouse/Domestic Partner, Child(ren) Existing Subscriber Change Plan Add Dependent(s) Requested Effective Date Section A1 – Plan Details and Account Information Select the plan you would like Platinum Ml01 HMO* Gold Ml02 HMO* Silver Ml03 HMO* Bronze Ml04 HMO** Sections to Complete If you are applying for coverage for: • Yourself only (subscriber), complete Section B and Section E if applicable • Child only, complete Sections B, D and E If you are applying for any other coverage, complete Sections B and C and Section D if applicable If you are updating or changing name, address or phone, complete Section B for subscriber and Section C for dependents if applicable You need to select a primary care physician (PCP) for yourself and each covered family member. Please include your PCP's name and provider ID in Sections B and C. Section B – Subscriber Information Last Name First Name MI Gender Date of Birth M F Social Security Number (Required) Residential Address City State ZIP Home Phone Mobile Phone Work Phone Email Address Mailing Address (P.O. Box Accepted) same as residential City State ZIP Previous Name (If Any) Primary Spoken Language

Language Assistance. If you have questions about completing this application, please contact Xxxxxx Health Plus Member Services at 0-000-000-0000 (TTY 0-000-000-0000), Monday through Friday from 8 a.m. to 7 p.m. Xxxxxx Health Plus provides translation services and other language assistance services to you free of charge. If you are working with a broker, you may also call him or her for assistance. The broker who helped you read and complete this application must sign the application (see Section H). M-17-096 Section A – Enrollment ‌‌‌‌‌ Is the applicant an existing or former Xxxxxx Health Plus member? Yes No If Yes, please include your Subscriber ID here Enrollment Period Annual Open Enrollment Period Special Enrollment Period Qualifying Event Date (Please complete the Attestation Form for Qualifying Events for Special Enrollment included) Demographic Change Only Name Change Address Change Phone Number Change Enrollment or Change Type New Enrollment Subscriber Only Subscriber and Spouse/Domestic Partner Subscriber and Child(ren) Child Only Family: Subscriber, Spouse/Domestic Partner, Child(ren) Existing Subscriber Change Plan Add Dependent(s) Requested Effective Date Section A1 – Plan Details and Account Information Select the plan you would like Platinum Ml01 HMO* Gold Ml02 HMO* Silver Ml03 HMO* Bronze Ml04 HMO** Sections to Complete If you are applying for coverage for: • Yourself only (subscriber), complete Section B and Section E if applicable • Child only, complete Sections B, D and E If you are applying for any other coverage, complete Sections B and C and Section D if applicable If you are updating or changing name, address or phone, complete Section B for subscriber and Section C for dependents if applicable You need to select a primary care physician (PCP) for yourself and each covered family member. Please include your PCP's name and provider ID in Sections B and C. Section B – Subscriber Information Last Name First Name MI Gender M F Date of Birth M F Social Security Number (Required) Residential Address City State ZIP Home Phone Mobile Phone Work Phone Email Address Mailing Address (P.O. Box Accepted) same as residential City State ZIP Previous Name (If Any) Primary Spoken Language

Language Assistance. If you have questions about completing this application, please contact Xxxxxx Health Plus Member Services at 0-000-000-0000 (TTY 0-000-000-0000), Monday through Friday from 8 a.m. to 7 p.m. Xxxxxx Health Plus provides translation services and other language assistance services to you free of charge. If you are working with a broker, you may also call him or her for assistance. The broker who helped you read and complete this application must sign the application (see Section H). M-17-096 Section A – Enrollment ‌‌‌‌‌ Is the applicant an existing or former Xxxxxx Health Plus member? Yes No If Yes, please include your Subscriber ID here Yes No Enrollment Period Annual Open Enrollment Period Special Enrollment Period Qualifying Event Date (Please complete the Attestation Form for Qualifying Events for Special Enrollment included) Demographic Change Only Name Change Address Change Phone Number Change Enrollment or Change Type New Enrollment Subscriber Only Subscriber and Spouse/Domestic Partner Subscriber and Child(ren) Child Only Family: Subscriber, Spouse/Domestic Partner, Child(ren) Existing Subscriber Change Plan Add Dependent(s) Requested Effective Date Section A1 – Plan Details and Account Information Select the plan you would like Platinum Ml01 HMO* Gold Ml02 HMO* Silver Ml03 HMO* Bronze Ml04 HMO** Sections to Complete If you are applying for coverage for: • Yourself only (subscriber), complete Section B and Section E if applicable • Child only, complete Sections B, D and E If you are applying for any other coverage, complete Sections B and C and Section D if applicable If you are updating or changing name, address or phone, complete Section B for subscriber and Section C for dependents if applicable You need to select a primary care physician (PCP) for yourself and each covered family member. Please include your PCP's name and provider ID in Sections B and C. Section B – Subscriber Information Last Name First Name MI Gender M F Date of Birth M F Social Security Number (Required) Residential Address City State ZIP Home Phone Mobile Phone Work Phone Email Address Mailing Address (P.O. Box Accepted) same as residential City State ZIP Previous Name (If Any) Primary Spoken Language