Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: Beginning on or after 01/01/2021

: Platinum 90 HMO 0/20 + Child Dental Coverage for: Individual / Family | Plan Type: HMO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan
would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided
separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage,
www.kp.org/plandocuments or call 1-800-278-3296 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance,
copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at http://www.healthcare.gov/sbc-glossary or call
1-800-278-3296 (TTY: 711) to request a copy.

Important Questions Answers Why This Matters:

What is the overall

$0 See the Common Medical Events chart below for your costs for services this plan covers.
deductible?

This plan covers some items and services even if you haven’t yet met the deductible amount.
Are there services
But a copayment or coinsurance may apply. For example, this plan covers certain preventive
covered before you Not Applicable.
services without cost-sharing and before you meet your deductible. See a list of covered
meet your deductible?
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.
services?
What is the out-of- The out-of-pocket limit is the most you could pay in a year for covered services. If you have
pocket limit for this Medical: $4,500 Individual / $9,000 Family other family members in this plan, they have to meet their own out-of-pocket limits until the
plan? Child Dental: $350 Child / $700 Children overall family out-of-pocket limit has been met.
Premiums, health care this plan doesn’t
What is not included in
cover, and services indicated in chart Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
the out-of-pocket limit?
starting on page 2.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
Will you pay less if you Yes. See www.kp.org or call 1-800-278- network. You will pay the most if you use an out-of-network provider, and you might receive
use a network 3296 (TTY: 711) for a list of network a bill from a provider for the difference between the provider’s charge and what your plan
provider? providers. pays (balance billing). Be aware your network provider might use an out-of-network provider
for some services (such as lab work). Check with your provider before you get services.
Do you need a referral Yes, but you may self-refer to certain This plan will pay some or all of the costs to see a specialist for covered services but only if
to see a specialist? specialists. you have a referral before you see the specialist.

Plan ID: 13297 / 13298_2021

1 of 6
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Services You May Limitations, Exceptions, & Other Important
Event Need Plan Provider Non-Plan Provider Information
(You will pay the least) (You will pay the most)
Primary care visit to
$20 / visit Not covered None
treat an injury or illness
If you visit a health Specialist visit $30 / visit Not covered None
care provider’s You may have to pay for services that aren’t
office or clinic Preventive
preventive. Ask your provider if the services needed
care/screening/ No charge Not covered
are preventive. Then check what your plan will pay
immunization
for.
Diagnostic test (x-ray, X-ray: $30 / encounter
Not covered None
blood work) Lab tests: $20 / encounter
If you have a test
Imaging (CT/PET
$100 / procedure Not covered None
scans, MRIs)

$5 / prescription (retail), Up to a 30-day supply retail and a 100-day supply

Generic drugs (Tier 1) $10 / prescription (mail Not covered mail order. Female contraceptives are no charge.
order). Subject to formulary guidelines.
If you need drugs to
treat your illness or $20 prescription (retail), Up to a 30-day supply retail and a 100-day supply
condition Preferred brand drugs
$40 / prescription (mail Not covered mail order. Female contraceptives are no charge.
More information (Tier 2)
order). Subject to formulary guidelines.
about prescription
drug coverage is The cost-sharing for non-preferred brand drugs
$20 prescription (retail),
available at Non-preferred brand under this plan aligns with the cost-sharing for
$40 / prescription (mail Not covered
www.kp.org/formulary drugs (Tier 2) preferred brand drugs (Tier 2), when approved
order). through the formulary exception process.
10% coinsurance up to Up to a 30-day supply (retail). Subject to formulary
Specialty drugs (Tier 4) Not covered
$250 / prescription guidelines.
Facility fee (e.g.,
ambulatory surgery $125 / procedure Not covered None
If you have
center)
outpatient surgery
Physician/Surgeon Fee is included in the Facility
Physician/surgeon fees Not Applicable Not covered
Fee.

2 of 6
 What You Will Pay
Common Medical Services You May Limitations, Exceptions, & Other Important
Event Need Plan Provider Non-Plan Provider Information
(You will pay the least) (You will pay the most)
Copayment is waived if admitted to hospital as
Emergency room care $150 / visit $150 / visit
inpatient.
If you need
Emergency medical
immediate medical $150 / trip $150 / trip None
transportation
attention
Non-Plan providers covered when temporarily
Urgent care $20 / visit $20 / visit
outside the service area.
Facility fee (e.g., $250 / day up to 5 days
Not covered None
If you have a hospital room) then no charge
hospital stay Physician/Surgeon Fee is included in the Facility
Physician/surgeon fees Not Applicable Not covered
Fee.
If you need mental $20 / individual visit;
Mental / Behavioral health: $10 / group visit;
health, behavioral Outpatient services $20 / day for other Not covered
Substance Abuse: $5 / group visit
health, or outpatient services
substance abuse
Inpatient services $250 / day up to 5 days Not covered None
services
Depending on the type of services, a copayment,
coinsurance, or deductible may apply. Maternity care
Office visits No charge Not covered
may include tests and services described elsewhere
in the SBC (i.e., ultrasound).
If you are pregnant Childbirth/delivery
Not Applicable Not covered Professional services are included in the Facility Fee.
professional services
Childbirth/delivery
$250 / day up to 5 days Not covered None
facility services
Up to 2 hours / visit, up to 3 visits / day, up to 100
Home health care $20 / visit Not covered
visits / year.
If you need help Inpatient: $250 / day up to 5
recovering or have Rehabilitation services days Not covered None
other special health Outpatient: $20 / visit
needs Inpatient: $250 / day up to 5
Habilitation services days. Not covered None
Outpatient: $20 / visit
Skilled nursing care $150 / day up to 5 days Not covered Up to 100 days limit / benefit period.

3 of 6
 What You Will Pay
Common Medical Services You May Limitations, Exceptions, & Other Important
Event Need Plan Provider Non-Plan Provider Information
(You will pay the least) (You will pay the most)
Durable medical Up to $2,000 supplemental benefit limit / year for
10% coinsurance Not covered
equipment certain items. Requires prior authorization.
Hospice services No charge Not covered None

Children’s eye exam No charge Not covered None

If your child needs Limited to one pair of glasses/year from select
Children’s glasses No charge Not covered
dental or eye care frames and lenses
Children’s dental
No charge Not covered Limited to two check-ups / year.
check-up
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Chiropractic care • Infertility treatment • Private-duty nursing
• Cosmetic surgery • Long-term care • Routine foot care
• Dental care (Adult) • Non-emergency care when traveling outside the U.S • Weight loss programs
• Hearing aids

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Abortion • Bariatric surgery • Routine eye care (Adult)
• Acupuncture (plan provider referred)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is shown in the chart below. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health
Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318- 2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is
called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan
documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your
rights, this notice, or assistance, contact the agencies in the chart below.

4 of 6
Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights:
Kaiser Permanente Member Services 1-800-278-3296 (TTY: 711) or www.kp.org/memberservices
Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
Department of Health & Human Services, Center for Consumer Information & Insurance Oversight 1-877-267-2323 x61565 or www.cciio.cms.gov
California Department of Insurance 1-800-927-HELP (4357) or www.insurance.ca.gov
California Department of Managed Healthcare 1-888-466-2219 or www.healthhelp.ca.gov/

Does this plan provide Minimum Essential Coverage? Yes

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

[Spanish (Español): Para obtener asistencia en Español, llame al 1-800-788-0616 (TTY: 711)
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-278-3296 (TTY: 711).
[Chinese (中文): 如果需要中文的帮助, 请拨打这个号码1-800-757-7585 (TTY: 711)
[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-278-3296 (TTY: 711)

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

5 of 6
About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts
(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might
pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)

 The plan’s overall deductible $0  The plan’s overall deductible $0  The plan’s overall deductible $0
 Specialist copayment $30  Specialist copayment $30  Specialist copayment $30
 Hospital (facility) copayment $250  Hospital (facility) copayment $250  Hospital (facility) copayment $250
 Other copayment $20  Other copayment $20  Other copayment $30

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $500 Copayments $700 Copayments $500
Coinsurance $0 Coinsurance $50 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $50 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $550 The total Joe would pay is $750 The total Mia would pay is $500

The plan would be responsible for the other costs of these EXAMPLE covered services.

6 of 6
 Nondiscrimination Notice
Kaiser Permanente does not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, religion, sex,
gender identity, gender expression, sexual orientation, marital status, physical or mental disability, source of payment, genetic information,
citizenship, primary language, or immigration status.
Language assistance services are available from our Member Service Contact Center 24 hours a day, 7 days a week (except closed holidays).
Interpreter services, including sign language, are available at no cost to you during all hours of operation. Auxiliary aids and services for individuals
with disabilities are available at no cost to you during all hours of operation. We can also provide you, your family, and friends with any special
assistance needed to access our facilities and services. You may request materials translated in your language at no cost to you. You may also request
these materials in large text or in other formats to accommodate your needs at no cost to you. For more information, call 1-800-464-4000 (TTY 711).
A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. For example, if
you believe that we have discriminated against you, you can file a grievance. Please refer to your Evidence of Coverage or Certificate of Insurance
or speak with a Member Services representative for the dispute-resolution options that apply to you.
You may submit a grievance in the following ways:
• By phone: Call member services at 1-800-464-4000 (TTY 711) 24 hours a day, 7 days a week (except closed holidays).
• By mail: Call us at 1-800-464-4000 (TTY 711) and ask to have a form sent to you.
• In person: Fill out a Complaint or Benefit Claim/Request form at a member services office located at a Plan Facility (go to your provider
directory at kp.org/facilities for addresses)
• Online: Use the online form on our website at kp.org
Please call our Member Service Contact Center if you need help submitting a grievance.
The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race, color, national origin,
sex, age, or disability. You may also contact the Kaiser Permanente Civil Rights Coordinator directly at:
Northern California Southern California
Civil Rights/ADA Coordinator Civil Rights/ADA Coordinator
1800 Harrison St. SCAL Compliance and Privacy
16th Floor 393 East Walnut St.,
Oakland, CA 94612 Pasadena, CA 91188
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 ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and
Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TTY).
Complaint forms are available at hhs.gov/ocr/office/file/index.html.
 Aviso de no discriminación
Kaiser Permanente no discrimina a ninguna persona por su edad, raza, etnia, color, país de origen, antecedentes culturales, ascendencia, religión,
sexo, identidad de género, expresión de género, orientación sexual, estado civil, discapacidad física o mental, fuente de pago, información genética,
ciudadanía, lengua materna o estado migratorio.
La Central de Llamadas de Servicio a los Miembros brinda servicios de asistencia con el idioma las 24 horas del día, los 7 días de la semana
(excepto los días festivos). Se ofrecen servicios de interpretación sin costo alguno para usted durante el horario de atención, incluido el lenguaje de
señas. Se ofrecen aparatos y servicios auxiliares para personas con discapacidades sin costo alguno durante el horario de atención. También
podemos ofrecerle a usted, a sus familiares y amigos cualquier ayuda especial que necesiten para acceder a nuestros centros de atención y servicios.
Puede solicitar los materiales traducidos a su idioma sin costo para usted. También los puede solicitar con letra grande o en otros formatos que se
adapten a sus necesidades sin costo para usted. Para obtener más información, llame al 1-800-788-0616 (TTY 711).
Una queja es una expresión de inconformidad que manifiesta usted o su representante autorizado a través del proceso de quejas. Por ejemplo, si usted
cree que ha sufrido discriminación de nuestra parte, puede presentar una queja. Consulte su Evidencia de Cobertura (Evidence of Coverage) o
Certificado de Seguro (Certificate of Insurance), o comuníquese con un representante de Servicio a los Miembros para conocer las opciones de resolución
de disputas que le corresponden.
Puede presentar una queja de las siguientes maneras:
• Por teléfono: Llame a servicio a los miembros al 1-800-788-0616 (TTY 711) las 24 horas del día, los 7 días de la semana (excepto los
días festivos).
• Por correo postal: Llámenos al 1-800-788-0616 (TTY 711) y pida que se le envíe un formulario.
• En persona: Llene un formulario de Queja Formal o Reclamo/Solicitud de Beneficios en una oficina de servicio a los miembros ubicada
en un Centro de Atención del Plan (consulte su directorio de proveedores en kp.org/facilities [haga clic en “Español”] para obtener
las direcciones).
• En línea: Use el formulario en línea en nuestro sitio web en kp.org/espanol.
Llame a nuestra Central de Llamadas de Servicio a los Miembros si necesita ayuda para presentar una queja.
Se le informará al Coordinador de Derechos Civiles de Kaiser Permanente (Civil Rights Coordinator) de todas las quejas relacionadas con la
discriminación por motivos de raza, color, país de origen, género, edad o discapacidad. También puede comunicarse directamente con el
coordinador de derechos civiles de Kaiser Permanente en:
Northern California Southern California
Civil Rights/ADA Coordinator Civil Rights/ADA Coordinator
1800 Harrison St. SCAL Compliance and Privacy
16th Floor 393 East Walnut St.,
Oakland, CA 94612 Pasadena, CA 91188
También puede presentar una queja formal de derechos civiles de forma electrónica ante la Oficina de Derechos Civiles (Office for Civil Rights) en el
Departamento de Salud y Servicios Humanos de los Estados Unidos (U.S. Department of Health and Human Services) mediante el Portal de Quejas
Formales de la Oficina de Derechos Civiles (Office for Civil Rights Complaint Portal), en ocrportal.hhs.gov/ocr/portal/lobby.jsf (en inglés) o por
correo postal o por teléfono a: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington,
D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TTY). Los formularios de queja formal están disponibles en hhs.gov/ocr/office/file/index.html
(en inglés).
 無歧視公告

Kaiser Permanente禁止以年齡、人種、族裔、膚色、原國籍、文化背景、血統、宗教、性別、性別認同、性別表達、性取向、婚姻狀況、
生理或心理殘障、付款來源、遺傳資訊、公民身份、主要語言或移民身份為由而歧視任何人。

會員服務聯絡中心每週7天每天24小時提供語言協助服務（節假日除外）。本機構在全部營業時間內免費為您提供口譯服務，包括手語服
務，以及殘障人士輔助器材和服務。我們還可為您和您的親友提供使用本機構設施與服務所需要的任何特別協助。您可免費索取翻譯成
您的語言的資料。您還可免費索取符合您需求的大號字體或其他格式的版本。若需更多資訊，請致電1-800-757-7585（TTY 711）。

申訴指任何您或您的授權代表透過申訴程序來表達不滿的做法。例如，如果您認為自己受到歧視，即可提出申訴。若需瞭解適用於自己的
爭議解決選項，請參閱《承保範圍說明書》(Evidence of Coverage) 或《保險證明書》(Certificate of Insurance)，或諮詢會員服務代表。

您可透過以下方式提出申訴：
• 透過電話：請致電1-800-757-7585（TTY 711）與會員服務部聯絡，服務時間為每週7天，每天24小時（節假日除外）。
• 透過郵件：請致電1-800-757-7585（TTY 711）與我們聯絡並請我們將表格寄給您。
• 親自遞交：在計劃設施的會員服務辦事處填寫投訴或福利理索賠／申請表（請參閱kp.org/facilities上的保健業者名錄以查看地址）
• 線上：使用我們網站上的線上表格，網址為kp.org
如果您在提交申訴時需要協助，請致電我們的會員服務聯絡中心。

涉及人種、膚色、原國籍、性別、年齡或殘障歧視的一切申訴都將通知Kaiser Permanente的民權事務協調員 (Civil Rights Coordinator)。

您也可與Kaiser Permanente的民權事務協調員直接聯絡，地址：

Northern California Southern California

Civil Rights/ADA Coordinator Civil Rights/ADA Coordinator
1800 Harrison St. SCAL Compliance and Privacy
16th Floor 393 East Walnut St.,
Oakland, CA 94612 Pasadena, CA 91188

您還可以電子方式透過民權辦公室的投訴入口網站 (Office for Civil Rights Complaint Portal) 向美國衛生與民眾服務部 (U.S. Department of
Health and Human Services) 民權辦公室 (Office for Civil Rights) 提出民權投訴，網址是ocrportal.hhs.gov/ocr/portal/lobby.jsf或者按照如下資
訊採用郵寄或電話方式聯絡：U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building,
Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TTY)。投訴表可從網站hhs.gov/ocr/office/file/index.html下載。
 Thông Báo Không Kỳ Thị
Kaiser Permanente không phân biệt đối xử dựa trên tuổi tác, chủng tộc, sắc tộc, màu da, nguyên quán, hoàn cảnh văn hóa, tổ tiên, tôn giáo, giới tính,
nhận dạng giới tính, cách thể hiện giới tính, khuynh hướng tình dục, gia cảnh, khuyết tật về thể chất hoặc tinh thần, nguồn tiền thanh toán, thông tin
di truyền, quốc tịch, ngôn ngữ chính, hay tình trạng di trú.
Các dịch vụ trợ giúp ngôn ngữ hiện có từ Trung Tâm Liên Lạc ban Dịch Vụ Hội Viên của chúng tôi 24 giờ trong ngày, 7 ngày trong tuần (ngoại trừ
ngày lễ). Dịch vụ thông dịch, kể cả ngôn ngữ ký hiệu, được cung cấp miễn phí cho quý vị trong giờ làm việc. Các phương tiện trợ giúp và dịch vụ bổ
sung cho những người khuyết tật được cung cấp miễn phí cho quý vị trong giờ làm việc. Chúng tôi cũng có thể cung cấp cho quý vị, gia đình và bạn
bè quý vị mọi hỗ trợ đặc biệt cần thiết để sử dụng cơ sở và dịch vụ của chúng tôi. Quý vị có thể yêu cầu miễn phí tài liệu được dịch ra ngôn ngữ của
quý vị. Quý vị cũng có thể yêu cầu miễn phí các tài liệu này dưới dạng chữ lớn hoặc dưới các dạng khác để đáp ứng nhu cầu của quý vị. Để biết thêm
thông tin, gọi 1-800-464-4000 (TTY 711).
Một phàn nàn là bất cứ thể hiện bất mãn nào được quý vị hay vị đại diện được ủy quyền của quý vị trình bày qua thủ tục phàn nàn. Ví dụ, nếu quý vị
tin rằng chúng tôi đã kỳ phân biệt đối xử với vị, quý vị có thể đệ đơn phàn nàn. Vui lòng tham khảo Chứng Từ Bảo Hiểm (Evidence of Insurance)
hay Chứng Nhận Bảo Hiểm (Certificate of Insurance), hoặc nói chuyện với một nhân viên ban Dịch Vụ Hội Viên để biết các lựa chọn giải quyết
tranh chấp có thể áp dụng cho quý vị.
Quý vị có thể nộp đơn phàn nàn bằng các hình thức sau đây:
• Qua điện thoại: Gọi cho ban dịch vụ hội viên theo số 1-800-464-4000 (TTY 711) 24 giờ trong ngày, 7 ngày trong tuần (ngoại trừ đóng
cửa ngày lễ).
• Qua bưu điện: Gọi cho chúng tôi theo số 1-800-464-4000 (TTY 711) và yêu cầu được gửi một mẫu đơn.
• Trực tiếp: Điền một mẫu đơn Than Phiền hay Yêu Cầu Quyền Lợi/Yêu Cầu tại một văn phòng ban dịch vụ hội viên tại một Cơ Sở Thuộc
Chương Trình (xem danh mục nhà cung cấp của quý vị tại kp.org/facilities để biết địa chỉ)
• Trực tuyến: Sử dụng mẫu đơn trực tuyến trên trang mạng của chúng tôi tại kp.org
Xin gọi Trung Tâm Liên Lạc ban Dịch Vụ Hội Viên của chúng tôi nếu quý vị cần trợ giúp nộp đơn phàn nàn.
Điều Phối Viên Dân Quyền (Civil Rights Coordinator) Kaiser Permanente sẽ được thông báo về tất cả phàn nàn liên quan tới việc kỳ thị trên cơ sở
chủng tộc, màu da, nguyên quán, giới tính, tuổi tác, hay tình trạng khuyết tật. Quý vị cũng có thể liên lạc trực tiếp với Điều Phối Viên Dân Quyền
Kaiser Permanente tại:
Northern California Southern California
Civil Rights/ADA Coordinator Civil Rights/ADA Coordinator
1800 Harrison St. SCAL Compliance and Privacy
16th Floor 393 East Walnut St.,
Oakland, CA 94612 Pasadena, CA 91188
Quý vị cũng có thể đệ đơn than phiền về dân quyền với Bộ Y Tế và Nhân Sinh Hoa Kỳ (U.S. Department of Health and Human Services), Phòng
Dân Quyền (Office of Civil Rights) bằng đường điện tử thông qua Cổng Thông Tin Phòng Phụ Trách Khiếu Nại về Dân Quyền (Office for Civil
Rights Complaint Portal), hiện có tại ocrportal.hhs.gov/ocr/portal/lobby.jsf, hay bằng đường bưu điện hoặc điện thoại tại: U.S. Department of Health
and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TTY).
Mẫu đơn than phiền hiện có tại hhs.gov/ocr/office/file/index.html.
 NOTICE OF LANGUAGE ASSISTANCE

English: This is important information from Kaiser Permanente. If you need help
understanding this information, please call 1-800-464-4000 and ask for language
assistance. Help is available 24 hours a day, 7 days a week, excluding holidays.
‫ المساعدة‬.‫ وطلب مساعدة لغوية‬1-800-464-4000 ‫ يرجى الاتصال على الرقم‬،‫ إذا كنت بحاجة للمساعدة في فهم هذه المعلومات‬.Kaiser Permanente ‫ تحتوي هذه الوثيقة على معلومات مهمة من‬:Arabic
.‫ باستثناء أيام العطلات الرسمية‬،‫متوفرة على مدار الساعة طيلة أيام الأسبوع‬

Armenian: Սա կարևոր տեղեկություն է «Kaiser Permanente»-ից: Եթե այս տեղեկությունը հասկանալու համար Ձեզ օգնություն է հարկավոր, խնդրում
ենք զանգահարել 1-800-464-4000 հեռախոսահամարով և օժանդակություն ստանալ լեզվի հարցում: Զանգահարեք օրը 24 ժամ, շաբաթը 7 օր` բացի տոն
օրերից:

Chinese: 這是來自 Kaiser Permanente 的重要資訊。如果您需要協助瞭解此資訊，請致電 1-800-757-7585 尋求語言協助。我們每週 7 天，每天 24 小時皆提供

協助（節假日休息）。

‫ کمک‬.‫ تماس گرفته و برای امداد زبانی درخواست کنيد‬1-800-464-4000 ‫ لطفا ً با شماره‬،‫ اگر در فهميدن اين اطلاعات به کمک نياز داريد‬.‫ می باشد‬Kaiser Permanente ‫ اين اطلاعات مهمی از سوی‬:Farsi
.‫ شامل روزهای تعطيل موجود است‬،‫ روز هفته‬7 ‫ ساعت شبانروز و‬24 ‫و راهنمايی در‬

Hindi: यह Kaiser Permanente की ओर से महत्वपर ू ्ण सच

ू ना है । यदि आपको इस सच ू ना को समझने के लिए मिि की जरूरत है , तो कृपया 1-800-464-4000 पर फोन
करें और भाषा सहायता के लिए पछ
ू ें । सहायता छुद्टियों को छोड़कर, सप्ताह के सातों दिन, दिन के 24 घंटे, उपिब्ध है ।

Hmong: Qhov xov xwm no tseem ceeb los ntawm Kaiser Permanente. Yog koj xav tau kev pab kom nkag siab cov xov xwm no, thov hu rau 1-800-464-4000
thiab thov kev pab txhais lus. Muaj kev pab 24 teev ib hnub twg, 7 hnub ib lim tiam twg, tsis xam cov hnub caiv.

Japanese: Kaiser Permanente から重要なお知らせがあります。この情報を理解するためにヘルプが必要な場合は、 1-800-464-4000 に電話して、言語サー

ビスを依頼してください。このサービスは年中無休（祝祭日を除く）でご利用いただけます。

Khmer:នេះគឺជាព័ត៌មាេសំខាេ់ មកពី Kaiser Permanente។ នបសសនេ្នកករតវការជំំេយយ ឲ្យបាេយល់ដឹងព័ត៌មាេនេះ សូមទូជស័ព្ទនៅនលខ 1-800-464-4000 េនងនសកសសំំំេយយខាង

ភាសា។ ំំេយយគឺមាេ 24 នមា្ងមយយ្ងៃងៃ 7 ្ងៃងៃមយយអាទនត្យ ជយមទាំង្ងៃងៃបំណ្យផង។

Korean: 본 정보는 Kaiser Permanente 에서 전하는 중요한 메시지입니다. 본 정보를 이해하는 데 도움이 필요하시면, 1-800-464-4000 번으로 전화해 언어
지원 서비스를 요청하십시오. 요일 및 시간에 관계없이 언제든지 도움을 제공해 드립니다(공휴일 제외).

Laotian: ນີແ ້ ມນຂໍ

່ ມ ້ ນ
ູ ສ ໍຳຄ ັນຈຳກ Kaiser Permanente. ຖຳ້ ວຳ່ ທຳ່ ນຕອ ້ ງກຳນຄວຳມຊວ ່ ຍເຫຼືອໃນກຳນຊວ່ ຍໃຫເ້ ຂົ້ຳໃຈຂໍມ
້ ນ
ູ ນີ,້ ກະຣຸນຳໂທຣ 1-800-464-4000 ແລະຂໍເອົ ຳກຳນ
ຊວ
່ ຍເຫຼືອດຳ້ ນພຳສຳ. ກຳນຊວ ້ ະຫຼ ອດ 24 ຊ່ວົ ໂມງ, 7 ວ ັນຕໍ່ອຳທິດ, ບໍ່ ລວມວ ັນພ ັກຕຳ່ ງໆ.
່ ຍເຫຼືອມີໃຫຕ

Navajo: D77 47 hane’ b7h0ln7ihii 1t’4ego Kaiser Permanente yee nihalne’. D77 hane’7g77 doo hazh0’0 bik’i’diit88hg00 t’11 sh--d7 koji’ hod77lnih 1-800-464-4000 1ko saad
bee 1k1 i’iilyeed y7d77ki[. Kwe’4 1k1 an1’1lwo’ t’11 1[ahj8’ naadiind99’ ah44’7lkidg00 d00 tsosts’id j9 22’1t’4. Dahod7lzing0ne’ 47 d1’deelkaal.

Punjabi: ਇਹ Kaiser Permanente ਵਲੋਂ ਜ਼ਰੂਰੀ ਜਾਣਕਾਰੀ ਹੈ। ਜੇ ਤੁਹਾਨੂੰ ਇਸ ਜਾਣਕਾਰੀ ਨੂੰ ਸਮਝਣ ਲਈ ਮਦਦ ਦੀ ਲੋ ੜ ਹੈ, ਤਾਂ ਕਕਰਪਾ ਕਰਕੇ 1-800-464-4000 'ਤੇ ਫ਼ੋਨ ਕਰੋ ਅਤੇ ਭਾਸ਼ਾ
ਸਹਾਇਤਾ ਲਈ ਪੁੱ ਛੋ। ਮਦਦ, ਛੁੱ ਟੀਆਂ ਨੂੰ ਛੱ ਡ ਕੇ, ਹਫ਼ਤੇ ਦੇ 7 ਕਦਨ, ਅਤੇ ਕਦਨ ਦੇ 24 ਘੰ ਟੇ ਮੌਜੂਦ ਹੈ।

Russian: Это важная информация от Kaiser Permanente. Если Вам требуется помощь, чтобы понять эту информацию, позвоните по номеру
1-800-464-4000 и попросите предоставить Вам услуги переводчика. Помощь доступна 24 часа в сутки, 7 дней в неделю, кроме праздничных дней.
Spanish: La presente incluye información importante de Kaiser Permanente. Si necesita ayuda para entender esta información, llame al 1-800-788-0616 y
pida ayuda linguística. Hay ayuda disponible 24 horas al día, siete días a la semana, excluidos los días festivos.

Tagalog: Ito ay importanteng impormasyon mula sa Kaiser Permanente. Kung kailangan ninyo ng tulong para maunawan ang impormasyong ito, mangyaring
tumawag sa 1-800-464-4000 at humingi ng tulong kaugnay sa lengguwahe. May makukuhang tulong 24 na oras bawat araw, 7 araw bawat linggo, maliban
sa mga araw na pista opisyal.

Thai: นีเ่ ป็ นข ้อมูลสําคัญจาก Kaiser Permanente หากคุณต ้องการความช่วยเหลือในการทําความเข ้าใจข ้อมูลนี้ กรุณาโทรไปยังหมายเลข 1-800-464-4000 เพือ
่ ขอความช่วย
เหลือด ้านภาษา สามารถโทรติดต่อได ้ตลอด 24 ชัว่ โมงทุกวัน ยกเว ้นวันหยุดเทศกาล.

Vietnamese: Đây là thông tin quan trọng từ Kaiser Permanente. Nếu quý vị cần được giúp đỡ để hiểu rõ thông tin này, vui lòng gọi số 1-800-464-4000 và
yêu cầu được cấp dịch vụ về ngôn ngữ. Quý vị sẽ được giúp đỡ 24 giờ trong ngày, 7 ngày trong tuần, trừ ngày lễ.