DS-2087 (03-24) SOUTHERN CALIFORNIA
Medical Financial Assistance (MFA) Program
If you need help paying for health care services or prescriptions you have had, or are scheduled to
receive, from Kaiser Permanente, our Medical Financial Assistance (MFA) program may be able to
help you. You may apply by completing and submitting an application, including your household income
information.
How the program works
• The program oers temporary “awards” to help qualied applicants pay for care based on their
nancial needs.
• It’s available to all Kaiser Permanente patients, whether you’re a member or not.
• If awarded, the program will cover emergent/urgent or medically necessary care from Kaiser
Permanente providers or at Kaiser Permanente facilities for a specied time.
• The award does not apply to health care services provided and billed outside of Kaiser Permanente
facilities.
How to qualify
To qualify, you must meet ONE of the following
sets of criteria:
1. Your gross household income (income
before taxes and deductions) is 400%
or less of the federal poverty level.
OR
2. Your out-of-pocket health care costs for
emergency or medically necessary care,
dental care, and medication over a 12-month
period are equal to or more than 10% of your
gross household income.
○ Out-of-pocket costs include copays,
coinsurance, and deductible payments.
○ Out-of-pocket costs do not include any
payments for your health plan itself, like
your monthly premium.
2024 Federal Poverty Guidelines (FPG)
If your
household/
family size
is:
100% award for
gross monthly
household
income at or
below 200% of
FPG
50% award for
gross monthly
household
income between
201% and 400%
of FPG
1 Up to $2,510 $2,511 to $5,020
2 Up to $3,407 $3,408 to $6,813
3 Up to $4,303 $4,304 to $8,607
4 Up to $5,200 $5,201 to $10,400
5 Up to $6,097 $6,098 to $12,193
6 Up to $6,993 $6,994 to $13,987
Visit aspe.hhs.gov/poverty to nd the guidelines for
larger households.
Have questions?
For more information about qualifying for the MFA program, or to see which
health care services it pays for, visit kp.org/mfa/scal, call 1-800-390-3507
(TTY 711), or scan this code.
For more information about health care coverage options, call us at
1-800-479-5764 (TTY 711).
DS-2087 (03-24) SOUTHERN CALIFORNIA
How to apply
If you meet the eligibility requirements, you can apply in any of these ways.
Online
• Complete the MFA application online kp.org/mfa/scal
• Be prepared to provide all the information listed on the MFA application
on the next page.
Fax it
• Complete the MFA application on the following page.
• Fax your completed application to 1-866-519-1693.
Mail it
• Complete the MFA application on the following page.
• Mail your completed application to:
Kaiser Permanente MFA Program
PO Box 7086
Pasadena, CA 91109-7086
Drop it o
• Complete the MFA application on the following page.
• Drop o your completed application at your local Kaiser Permanente
Hospital Admitting Department.
Meet with
a nancial
counselor
• Meet with a nancial counselor at one of our designated facilities,
Monday through Friday, 8 a.m. to 5 p.m. PST.
• Be prepared to provide all the information listed on the MFA application
on the next page.
Call us
• Call us at 1-800-390-3507 (TTY 711), Monday through Friday, 8 a.m.
to 5 p.m. PST.
• Be prepared to provide the information listed on the MFA application
on the next page.
Important: When applying online, by mail or fax, or dropping o your application in person, please be
sure to ll out the application as much as you can. Missing information may delay the processing of your
application and could result in a denial for assistance.
DS-2087 (03-24) SOUTHERN CALIFORNIA
Proof-of-income documentation
Income verication is part of determining eligibility for medical nancial assistance. Including proof-of-
income documentation with your completed application will assist in conrming the accuracy of your
income during the review process. The table below lists the optional documents to submit according to
your household income source(s).
Household Income Source(s) Provide Only One of the Following per Income Source
Business/rental income Recent W-2s, 1099 statement(s) or tax return
Employment income/wages
Recent pay stubs
Recent W-2s, 1099 statement(s) or tax return
Received pension/retirement/annuities
income
Recent pay stubs
Pension/retirement disbursement statement
Recent W-2s, 1099 statement(s) or tax return
Self-employed income
Recent pay stubs
Recent W-2s, 1099 statement(s) or tax return
Social Security/supplemental security
income
Benet verication letter from Social Security
Administration
Social Security statement
Unemployment benets/disability income
Unemployment/disability benets verication letter
Recent W-2s, 1099 statement(s) or tax return
Veteran benets income
VA benets verication letter
Recent W-2s, 1099 statement(s) or tax return
Government assistance (e.g., Medicaid,
TANF, SNAP, WIC, or low-income housing)
Approval of eligibility letter
Interest or dividends income Recent tax return
Spousal/child support payments received
A letter showing monthly gross income received for child
support or alimony
No household income Written attestation/explanation
What to expect after you apply
After we review your completed application, we’ll let you know one of the following outcomes within thirty
(30) days of receipt:
• If your application is approved, you’ll receive a letter notifying you of your nancial award.
• If your application is incomplete, you’ll receive a letter explaining the information needed to process
your application. You can either mail or in-person drop o the requested information; this could
include proof of income or copies of your out-of-pocket expenses.
• If your application is denied, you’ll receive a letter notifying you why it was denied, in which case you
can appeal our decision.
DS-2087 (03-24) SOUTHERN CALIFORNIA
Need help?
If you have any questions or need help with your application or need to check the status of your
application, please call 1-800-390-3507 (TTY 711), Monday through Friday, 8 a.m. to 5 p.m., PST. You
can also talk to a nancial counselor at any Kaiser Permanente location.
Hospitals’ shoppable services
A list of pricing information for 300 shoppable services is available at kp.org/price-transparency. These
services can be scheduled in advance by a patient. The prices for some of these services are based on
a typical length of stay at the hospital and not based on the individual care that may be required.
Other benecial programs and extra resources
We’re here to support you however we can. If you need help with essentials like food, housing, paying
for internet or other utilities, and more, the Kaiser Permanente Community Support Hub can help
connect you to resources in your community. Call 1-800-443-6328 (TTY 711), Monday through Friday
between 8 a.m. and 5 p.m. or visit kp.org/socialhealth.
Help paying your bill
There are free consumer advocacy organizations that will help you understand the billing and payment
process. You may call the Health Consumer Alliance at 1-888-804-3536 or go to healthconsumer.org for
more information.
Hospital Bill Complaint Program
The Hospital Bill Complaint Program is a state program, which reviews hospital decisions about whether
you qualify for help paying your hospital bill. If you believe you were wrongly denied nancial assistance,
you may le a complaint with the Hospital Bill Complaint Program. Go to
HospitalBillComplaintProgram.hcai.ca.gov for more information and to le a complaint.
DS-2087 (03-24) SOUTHERN CALIFORNIA
Medical Financial Assistance (MFA) Program Application
Section 1: Patient Information
NAME MEDICAL RECORD NUMBER (OPTIONAL)
DATE OF BIRTH SOCIAL SECURITY NUMBER (OPTIONAL)
MAILING ADDRESS (STREET)
CITY
STATE ZIP CODE
o I do not have a Social Security Number
Is patient currently unhoused? o Yes o No
PRIMARY PHONE NUMBER
o Home o Mobile
o Work o Other
Is the patient enrolled in a state-based assistance program such as Supplemental Nutrition Assistance
Program (SNAP), Temporary Assistance for Needy Families (TANF), Women, Infants & Children (WIC),
low-income housing, or Medicaid? o Yes o No
Section 2: Household Information
Household size: Number of household members (including you) who live
in your home. May include a spouse or qualied domestic partner, children,
a non-parent caretaker, relative, etc.
Household income (monthly): Total gross income (income before taxes
and deductions) for all household members over 18 years of age. Check
ALL income types that apply:
$
o
Business/rental income o Social Security/supplemental security
income
o Employment income/wages o Unemployment benets/disability income
o
Veterans benets income o Spousal/child support payments received
o
Interest or dividends income o Received pension/retirement/annuities
income
o Self-employed income o No one in my household is earning or
has received income in the past 2 months
If the annual gross income for all household members is zero, check the
attestation box above and below, provide a written explanation as to how
the adult family members in the household support yourselves without
income, i.e., food, shelter, utilities, and other necessities.
Health care costs: Total out-of-pocket expenses you had over a 12-month
period for emergency or medically necessary services provided by Kaiser
Permanente or any other health care provider. May include copays,
deposits, coinsurance, or deductible payments for eligible medical,
pharmacy, or dental services.
$
DS-2087 (03-24) SOUTHERN CALIFORNIA
Please list all members of your household applying for Medical Financial Assistance.
Name Date of birth Relationship Medical record #
Uninsured? Kaiser Permanente can help. If you do not have health care coverage, we can help you
understand your options. Check this box if you would like Kaiser Permanente to contact you to discuss
your options or you can call us at 1-800-479-5764 (TTY 711) to obtain a quote.
o Yes, contact me
I hereby declare that all information set forth above in this application is true, accurate, and complete
in all respects. I also acknowledge and agree that I am liable to Kaiser Foundation Health Plan and
Hospitals (KFH/HP) for all amounts owing to Kaiser Foundation Health Plan and Hospitals for medical
goods and services that are not eligible under the program (the “Remaining Amounts”).
Note: When proof-of-income is not provided, Kaiser Foundation Health Plan and Hospitals will use
information from consumer credit reporting agencies and other third-party information sources to
determine eligibility for federal, state, and private medical programs, including the MFA Program.
By submitting this application, I provide KFH/HP permission to request information from consumer credit
reporting agencies and other third-party information sources to verify any information provided in this
application that is deemed necessary.
SIGNATURE DATE
Every reasonable eort will be made to process your application promptly and once your application has
been reviewed you will receive a letter conrming the outcome.
DS-2087 (03-24) SOUTHERN CALIFORNIA
NOTICE OF LANGUAGE ASSISTANCE SERVICES
English: If you need help in your language, language assistance is available at no cost to you,
24 hours a day, 7 days a week (closed holidays). Call our Member Service Contact Center at
1-800-464-4000 (TTY 711) for help or visit any registration desk for more information at any
Kaiser Permanente hospital, Monday through Friday, 8 a.m. to 5 p.m. Aids and services for
people with disabilities, like documents in braille, large print, audio, and other accessible
electronical formats are also available.
:Arabicإذا اﺣﺗﺟت إﻟﻰ ﻣﺳﺎﻋدة ﺑﻠﻐﺗك، ﻓﺗﺗوﻓر ﺧدﻣﺎت اﻟﻣﺳﺎﻋدة اﻟﻠﻐوﯾﺔ ﺑﺻورة ﻣﺟﺎﻧﯾﺔ ﻋﻠﻰ ﻣدار 24 ﺳﺎ ﻋﺔ ﻓﻲ ا ﻟ ﯾ وم و7 أ ﯾ ﺎ م ﻓﻲ
اﻷﺳﺑوع )ﻣﻐﻠق أﯾﺎم اﻟﻌطل(. اﺗﺻل ﺑﻣرﻛز اﺗﺻﺎل ﺧدﻣﺔ اﻷﻋﺿﺎء ﻟدﯾﻧﺎ ﻋﻠﻰ اﻟرﻗم 1-800-464-4000 )TTY 711( ﻟ ﻠ ﺣﺻو ل
ﻋﻠﻰ ﻣﺳﺎﻋدة أو ﯾﻣﻛﻧك زﯾﺎرة أي ﻣﻛﺗب ﺗﺳﺟﯾل ﻟﻣزﯾد ﻣن اﻟﻣﻌﻠوﻣﺎت ﻓﻲ أي ﻣﺳﺗﺷﻔﻰ ﺗﺎﺑﻊ ﻟـKaiser Permanente ، ﻣن اﻹﺛ ﻧ ﯾن
إﻟﻰ اﻟﺟﻣﻌﺔ، ﻣن اﻟﺳﺎﻋﺔ 8 ﺻﺑﺎﺣ
ً
ﺎ ﺣﺗﻰ 5 ﺑﻌد اﻟظﮭر. وﺗﺗوﻓر أﯾﺿ
ً
ﺎ اﻟﻣﺳﺎﻋدات واﻟﺧدﻣﺎت ﻟﻸﺷﺧﺎص ذوي اﻹﻋﺎﻗﺎت ﻣﺛل ﺗوﻓﯾر
اﻟﻣﺳﺗﻧدات ﺑطرﯾﻘﺔ ﺑراﯾل وﻣطﺑوﻋﺔ ﺑﺣروف ﻛﺑﯾرة أو ﺑﺷﻛل ﺗﺳﺟﯾل ﺻوﺗﻲ أو ﺑﺗﻧﺳﯾﻘﺎت إﻟﻛﺗرو ﻧ ﯾ ﺔ آ ﺧرى ﯾ ﺳ ﮭ ل ا ﻟ وﺻو ل إ ﻟ ﯾ ﮭ ﺎ .
Armenian: ºÃ» É»½íÇ Ñ³ñóáõÙ û·ÝáõÃÛ³Ý Ï³ñÇù áõÝ»ù, É»½í³Ï³Ý ³ç³ÏóáõÃÛáõÝÝ ³Ýí׳ñ
Ù³ïã»ÉÇ
¿ Ó»½ ѳٳñ ûñÁ 24 ųÙ, ß³µ³ÃÁ 7 ûñ (÷³Ï ¿ ïáÝ ûñ»ñÇÝ): ú·ÝáõÃÛ³Ý Ñ³Ù³ñ
½³Ý·³Ñ³ñ»ù Ù»ñ ²Ý¹³ÙÝ»ñÇ ëå³ë³ñÏÙ³Ý Ï³åÇ Ï»ÝïñáÝ 1-800-464-4000 (TTY 711)
Ñ»é³Ëáë³Ñ³Ù³ñáí ϳ٠Éñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñÇ Ñ³Ù³ñ ³Ûó»É»ù Kaiser Permanente
ó³Ýϳó³Í ÑÇí³Ý¹³ÝáóÇ ·ñ³ÝóÙ³Ý ë»Õ³ÝÁ »ñÏáõß³µÃÇÇó áõñµ³Ã, ųÙÁ 8 a.m.-Çó 5 p.m.-Á:
гë³Ý»ÉÇ »Ý ݳ¨ ûųݹ³Ï ÙÇçáóÝ»ñ ¨ ͳé³ÛáõÃÛáõÝÝ»ñ ѳßٳݹ³ÙáõÃÛáõÝ áõÝ»óáÕ
³ÝÓ³Ýó ѳٳñ, ÇÝãåÇëÇù »Ýª ÷³ëï³ÃÕûñ µñ³ÛÉáí, Ëáßáñ ïå³·ñáí, Ó³Ûݳ·ñáõÃÛ³Ùµ
¨ ³ÛÉ Ù³ïã»ÉÇ ¿É»ÏïñáݳÛÇÝ Ó¨³ã³÷»ñáí£
Chinese
::
如果您需要使⽤您的语⾔获得帮助，我们每周 7 天、每天 24 ⼩时免费提供语⾔
帮助（节假⽇休息）。请致电 1-800-464-4000 (TTY 711) 联络我们的会员服务联络中⼼以寻求
帮助，或前往任何 Kaiser Permanente 医院的登记台了解更多信息，我们的服务时间为周⼀⾄
周五上午 8 点⾄下午 5 点。我们还为残疾⼈提供辅助⼯具和服务，例如盲⽂、⼤字体、⾳频和
其他⽆障碍电⼦格式的⽂档。
:Farsiاﮔر ﻧﯾﺎزﻣﻧد ﭘﺷﺗﯾﺑﺎﻧﯽ ﺑﮫ زﺑﺎن ﺧودﺗﺎن ھﺳﺗﯾد، ﮐﻣﮏ زﺑﺎﻧﯽ ﺑﮫﺻورت را ﯾﮕﺎن در 24 ﺳﺎﻋت ﺷﺑﺎﻧﮫروز و 7 روز ھ ﻔ ﺗ ﮫ
)ﺑﮫﺟز روزھ ﺎی ﺗ ﻌطﯾ ل( در دﺳ ﺗ رس ا ﺳت. ﺑ ر ای در ﯾ ﺎ ﻓت ﮐ ﻣﮏ، روزھ ﺎی د وﺷ ﻧ ﺑ ﮫ ﺗ ﺎ ﺟﻣﻌ ﮫ ا ز ﺳ ﺎ ﻋت 8 ﺻﺑ ﺢ ﺗ ﺎ 5 ﻋﺻر ﺑ ﺎ ﻣرﮐز
ﺗﻣﺎس ﺧدﻣﺎت اﻋﺿﺎی ﻣﺎ ﺑﮫ ﺷﻣﺎره 1-800-464-4000 (TTY 711) ﺗﻣﺎس ﺑﮕﯾرﯾد ﯾﺎ ﺑرای اطﻼﻋﺎت ﺑﯾﺷﺗر ﺑﮫ ﻣﯾز ﺛﺑتﻧﺎم در
ھر ﯾﮏ از ﺑ ﯾ ﻣ ﺎرﺳﺗ ﺎنھ ﺎی Kaiser Permanente ﻣراﺟﻌﮫ ﮐﻧ ﯾد. ﮐﻣﮏھﺎ و ﺧدﻣ ﺎت ﺑرای ا ﻓرا د ﻣﻌ ﻠ ول، از ﺟﻣ ﻠ ﮫ اﺳﻧ ﺎ د ﺑ ﺎ ﺧط
ﺑرﯾل، ﭼﺎپ درﺷت، ﻓرﻣت ﺻوﺗﯽ و ﺳﺎ ﯾر ﻗ ﺎ ﻟبھ ﺎی ا ﻟ ﮑﺗ رو ﻧ ﯾﮑﯽ دﺳﺗ رسﭘ ذ ﯾر ﻧ ﯾز ﻣوﺟود اﺳت.
Hindi: यिद आपको अपनी
भाषा म/ सहायता चािहए, तो भाषा संबंधी सहायता आपके िलए िदन के 24 घंटे,
स<ाह के 7 िदन (
छुि$यो ं के इलावा) िनःशB उपलD ह। सहायता के िलए आप हमार सदG सेवा स ं प कH क/ I
को 1-800-464-4000 (TTY 711) पर कॉल कर सकत ह या अिधक जानकारी के िलए सोमवार से शMवार,
सुबह 8 बजे से शाम 5 बजे तक, िकसी भी Kaiser Permanente अNताल म/ िकसी भी पजीकरण डेQ पर
जाए। िवकलाग लोगो के िलए सहायता और स े व ा एँ भी उपलD ह, जैसे उभर अUरो म/ दVावज़, बड़े िYंट,
ऑिडयो और अ[ सुगम इल\ॉिनक फामट।
ु ै े
े K ु
ं
ं ं ं K े ं े
े ] _
DS-2087 (03-24) SOUTHERN CALIFORNIA
Hmong: Yog tias koj xav tau kev pab ua koj hom lus, ces kuj yeej muaj kev pab txhais lus yam
tsis tau them nqi rau koj, 24 teev hauv ib hnub, 7 hnub hauv ib lub lim piam (kaw nyob rau cov
hnub so). Hu rau peb Lub Chaw Sib Txuas Lus Pab Cuam Tswv Cuab ntawm tus xov tooj
1-800-464-4000 (TTY 711) txhawm rau thov kom pab los sis mus ntsib lub rooj teev npe twg
los tau kom paub ntau ntxiv nyob rau ntawm Kaiser Permanente lub tsev kho mob twg los tau,
Hnub Monday txog Hnub Friday, 8 teev sawv ntxov txog 5 teev tsaus ntuj. Tsis tas li xwb, kuj
tseem yuav muaj cov kev pab dawb thiab cov kev pab cuam rau cov neeg xiam oob qhab tib si
thiab, xws li cov ntaub ntawv ua ntawv xuas, luam ua tus ntawv loj, kaw suab lus, thiab lwm
yam qauv es lev thaus niv uas tuaj yeem nkag mus siv tau.
Japanese: 母国語でのサポートが必要な場合は、24 時間 365 日（祝日は休業）、無料で言語
アシスタントをご利用いただけます。詳細については、メンバーサービスコンタクトセンター
（1-800-464-4000
、TTY 711）にお電話でお問い合わせいただくか、Kaiser Permanente 病院
の受付カウンターお尋ねください（月曜日から金曜日の午前 8 時から午後 5 時）。障がいを
お持ちの方には、点字、大活字、音声などのアクセシビリティに対応した電子文書などの支援
やサービスもご用意しています。
Khmer: 



 



 24  
 7 

(
)
 

 1-800-464-4000
(TTY 711) 


  

Kaiser Permanente 
 
 8 
 5 


   




Korean: 귀하가 사용하는 언어로 도움이 필요한 경우, 연중무휴 24 시간(공휴일 제외) 무료로 언어
지원 서비스를 이용할 수 있습니다. 가입자 서비스 연락 센터에 1-800-464-4000(TTY 711)번으로
전화하여 도움을 요청하거나 Kaiser Permanente 병원에 있는 등록 데스크를 방문하여 월요일부터
금요일 오전 8 시부터 오후 5 시까지 자세한 정보를 얻을 수 있습니다. 점자, 큰 활자, 오디오 및 기타 접근
가능한 전자 형식의 문서와 같은 장애인을 위한 지원 및 서비스도 제공됩니다.
Laotian: ຖ
້
າທ
່
ານຕ
້
ອງການຄວາມຊ
່
ວຍເຫຼ
ື
ອເປ
ັ
ນພາສາຂອງທ
່
ານ, ກ
ໍ
ຈະມ
ີ
ການຊ
່
ວຍເຫຼ
ື
ອດ
້
ານພາສາ
ໃຫ
້
ແກ
່
ທ
່
ານໂດຍບ
ໍ
່
ເສຍຄ
່
າ, 24 ຊ
ົ
່
ວໂມງຕ
ໍ
່
ວ
ັ
ນ, 7 ວ
ັ
ນຕ
ໍ
່
ອາທ
ິ
ດ (ປ
ິ
ດໃນມ
ື
້
ວ
ັ
ນພ
ັ
ກຕ
່
າງໆ). ໂທຫາ
ສ
ູ
ນຕ
ິ
ດຕ
ໍ
່
ບ
ໍ
ລ
ິ
ການສະມາຊ
ິ
ກ ຂອງພວກເຮ
ົ
າທ
ີ
່
ເບ
ີ
1-800-464-4000 (TTY 711) ເພ
ື
່
ອຂ
ໍ
ຄວາມຊ
່
ວຍເຫຼ
ື
ອ
ຫຼ
ື
ເຂ
ົ
້
າໄປຫາໂຕະລ
ົ
ງທະບຽນໃດກ
ໍ
ໄດ
້
ເພ
ື
່
ອສອບຖາມຂ
ໍ
້
ມ
ູ
ນເພ
ີ
່
ມເຕ
ີ
ມ ຢ
ູ
່
ໂຮງໝ
ໍ
ຂອງ Kaiser Permanente
ແຫ
່
ງໃດກ
ໍ
ໄດ
້
, ແຕ
່
ວ
ັ
ນຈ
ັ
ນ ເຖ
ິ
ງ ວ
ັ
ນສຸກ, 8 ໂມງເຊ
ົ
້
າ ຫາ 5 ໂມງແລງ. ນອກຈາກນ
ັ
້
ນ, ກ
ໍ
ຍ
ັ
ງມ
ີ
ການຊ
່
ວຍເຫຼ
ື
ອ ແລະ
ການບ
ໍ
ລ
ິ
ການຕ
່
າງໆ ສ
ໍ
າລ
ັ
ບຄ
ົ
ນພ
ິ
ການອ
ີ
ກດ
້
ວຍ ເຊ
ັ
່
ນ: ເອກະສານທ
ີ
່
ເປ
ັ
ນຕ
ົ
ວອ
ັ
ກສອນນ
ູ
ນ, ພ
ິ
ມເປ
ັ
ນຕ
ົ
ວໃຫຍ
່
, ສຽງບ
ັ
ນທ
ຶ
ກ
ແລະ ຮ
ູ
ບແບບເອເລ
ັ
ກໂຕນ
ິ
ກອ
ື
່
ນໆທ
ີ
່
ສາມາດເຂ
ົ
້
າເຖ
ິ
ງໄດ
້
.
DS-2087 (03-24) SOUTHERN CALIFORNIA
Mien: Beiv hnangv meih qiemx zuqc longc mienh tengx douc benx meih nyei waac bun
muangx nor, ninh mbuo mbenc duqv maaih faan waac mienh tengx wangv henh douc waac
bun meih muangx mv zuqc heuc meih ndortv nyaanh, yietc hnoi tengx goux junh 24 norm
ziangh hoc, yiem norm leiz baaix tengx zuqc 7 hnoi (Cih cuotv gingc nyei hnoi oc). Douc waac
lorx taux yie mbuo nyei ziux goux zuangx mienh nyei dinc zangc domh gorn (Member Service
Contact Center) yiem njiec naaiv 1-800-464-4000 (TTY 711) liouh tengx ziux goux nzie weih
a’fai bieqc lorx taux ninh mbuo faaux mbuoz nyei gorn zangc liouh muangx waac-fienx tipv
yiem njiec haaix norm Kaiser Permanente zorc baengc dorngh yaac duqv, yiem leiz-baaix-
yietv mingh taux leiz-baaix-hmz, yiem 8 diemv ziangh hoc lungh ndorm mingh taux 5 diemv
ziangh hoc lungh hmuangx. Ninh mbuo mbenc duqv maaih jaa-dorngx aengx caux gong-bou
jauv-louc tengx ziux goux wuaaic fangx mienh, dorh nyungc horngh sou zoux benx nzangc-
pokc bun hluo, nqaapv bieqc domh zeiv-fangx, zoux benx waac-qiez bun muangx, aengx caux
da’nyeic nyungc horngh gong yiem ga’nyuoz electronic bun longc oc.
Navajo: Saad Din4 k’ehj8’ bee shik1 a’doowo[ nin7zingo, t’11 j77k’e n1beehaz’3, t’11 1hw77j7 t’11 1hw77t[‘66’,
tsosts’idj9 22’1t’4 (dahodiyin n7dei’aah g0ne’ 47 da’deelkaal). Member Service Contact Centerj8’
hod77lni 1-800-464-4000 (TTY 711) 47 doodago t’11ni Kaiser Permanente bi azee’ 1daal’7n7j8’ d77n11[
d00 baa nid7n7itaa[ dam0o biisk1n7 d00 nil47 nida’iin77shj8’ aa’1daat’4 ab7n7go tseeb99 bik’i dahazk’55zgo
d00 yaa adi’1ago ashdla’ bik’i dahazkeezj8’ n1 22’1t’4. T’11 h17da bits’88’ d00 binis7k55s bee bich’8’
an7dahast’7’7g77 b1 ahoot’i’ n11n1 t’11 h17da doo da’oo’77nii binaaltsoos yee de7y0[ta’7g77 b1 h0l- a[do’
11d00 saad nitsaago bee bik’i da’ashch7n7g7 a[do’ h0l- n11n1 saad bik’i naha’n7[7g77 n1 h0l= n11n1 b44sh
bee t’11 b7 nits7daak55s7g77 a[’22 1daa t’4ego bee nahwidinitingo a[do’ n1 dah0l=.
Punjabi: ਜ
ੇ ਤੁਹਾਨੂੰ ਆਪਣੀ ਭਾ/ਾ ਿਵੱ ਚ ਮਦਦ ਦੀ ਲੋ ੜ ਹੈ, ਤ: ਭਾ/ਾ ਸਹਾਇਤਾ ਤੁਹਾਡੇ ਲਈ ਿਬਨ: ਿਕਸੇ ਕੀਮਤ ਦੇ,
ਿਦਨ ਦੇ 24 ਘੰ ਟੇ, ਹਫਤੇ ਦੇ 7 ਿਦਨ (ਛੁੱਟੀਆਂ ਦੇ ਿਦਨ ਬੰ ਦ ਹੈ) ਉਪਲਬਧ ਹੈ। ਮਦਦ ਲਈ ਸਾਡੇ ਮHਬਰ ਸੇਵਾ ਸੰਪਰਕ ਕJਦਰ ਨ ੂੰ
1-800-464-4000 (TTY 711) 'ਤੇ ਕਾਲ ਕਰੋ ਜ: ਿਕਸੇ ਵੀ Kaiser Permanente ਹਸਪਤਾਲ ਿਵੱ ਚ , ਸੋਮਵਾਰ ਤK
/ੁੱਕਰਵਾਰ, ਸਵੇਰੇ 8 ਵਜੇ ਤK /ਾਮ 5 ਵਜੇ ਤੱ ਕ ਿਕਸੇ ਵੀ ਰਿਜਸਟLੇ/ਨ ਡੈਸਕ 'ਤੇ ਜਾਓ। ਅਪਾਹਜ ਲੋ ਕ: ਲਈ ਸਹਾਇਤਾ ਅਤੇ
ਸੇਵਾਵ:, ਿਜਵJ ਿਕ ਬLੇਲ, ਵੱ ਡੇ ਿਪLੰਟ, ਆਡੀਓ, ਅਤੇ ਹੋਰ ਪਹੁੰਚਯੋਗ ਇਲੈਕਟLਾਿਨਕ ਫਾਰਮੈਟ: ਿਵੱ ਚ ਦਸਤਾਵੇਜ਼ ਵੀ ਉਪਲਬਧ ਹਨ।
Russian: Если вам требуется помощь на вашем языке, бесплатные услуги перевода
доступны круглосуточно в любой день недели (кроме праздничных дней). За помощью
и информацией обращайтесь в контактный центр отдела обслуживания участников
по номеру 1-800-464-4000 (TTY: 711) или на стойку регистрации любой больницы
Kaiser Permanente с понедельника по пятницу с 8:00 до 17:00. Лица с инвалидностью
могут получить документы напечатанными шрифтом Брайля или крупным шрифтом,
в специальном электронном формате, в виде аудиозаписи, а также другие услуги
и помощь.
DS-2087 (03-24) SOUTHERN CALIFORNIA
Spanish: Si necesita ayuda en su idioma, contamos con asistencia de idiomas sin costo
alguno para usted las 24 horas del día, los 7 días de la semana (excepto los días festivos).
Comuníquese con nuestra Central de Llamadas de Servicio a los Miembros al 1-800-464-4000
(TTY 711) para obtener ayuda. O visite el mostrador de recepción en cualquier hospital de
Kaiser Permanente para obtener más información, de lunes a viernes, de 8 a. m. a 5 p. m.
También ofrecemos ayudas y servicios para personas con discapacidades, como documentos
en braille, letra grande, audio y otros formatos electrónicos accesibles.
Tagalog: Kung kailangan mo ng tulong na nasa iyong wika, may available na tulong sa wika
nang wala kang babayaran, 24 na oras sa isang araw, 7 araw sa isang linggo (sarado kapag
may mga holiday). Tumawag sa aming Member Service Contact Center sa 1-800-464-4000
(TTY 711) para sa tulong o bisitahin ang anumang mesa para sa pagrerehistro para sa higit
pang impormasyon sa alinmang ospital ng Kaiser Permanente, Lunes hanggang Biyernes,
8 a.m. hanggang 5 p.m. Mayroon ding mga tulong at serbisyo para sa mga taong may mga
kapansanan, tulad ng mga dokumentong nasa braille, malaking print, audio, at iba pang
maa-access na electronic na format.
Thai
: หากคุณต ้องการความช
่
วยเหลือในภาษาของคุณ
คุณสามารถใช
้
บริการความช
่
วยเหลือด ้านภาษาได ้โดยไม่มีค่าใช
้
จ่ายตลอด 24 ช
ัG
วโมงทุกวัน
(ยกเว ้นวันหยุดนักขัตฤกษ์) โปรดติดต่อศูนย์ติดต่อบริการสมาช
ิ
กทีG 1-800-464-4000 (TTY 711)
หากต ้องการความช
่
วยเหลือ หรือไปทีGโต๊ะลงทะเบียนทีGโรงพยาบาล Kaiser Permanente
ทุกแห่งหากต ้องการข ้อมูลเพิGมเติม ตัTงแต่วันจันทร์ถึงวันศุกร์เวลา 8.00 น. ถึง 17.00 น.
และยังมีความช
่
วยเหลือและบริการส
ํ
าหรับผู ้พิการ เช
่
น เอกสารอักษรเบรลล์ ส
ิG
งพิมพ์ขนาดใหญ่ เส
ี
ยง
และรูปแบบช
่
วยการเข ้าถึงอิเล็กทรอนิกส
์
อืGนๆ ด ้วยเช
่
นกัน
Ukrainian: Якщо вам потрібна допомога вашою мовою, безкоштовні послуги перекладу
доступні цілодобово в будь-який день тижня (за винятком святкових днів). По допомогу
чи докладнішу інформацію звертайтеся до контактного центру відділу обслуговування
учасників за номером 1-800-464-4000 (TTY: 711) або на стійку реєстрації будь-якої лікарні
Kaiser Permanente з понеділка до п’ятниці з 8:00 до 17:00. Особи з інвалідністю можуть
отримати документи надрукованими шрифтом Брайля або великим шрифтом, у вигляді
аудіозапису чи в спеціальному електронному форматі, а також інші послуги та допомогу.
Vietnamese: Chúng tôi cung cấp miễn phí dịch vụ hỗ trợ ngôn ngữ 24/7 (đóng cửa vào những
ngày lễ), nếu quý vị cần được hỗ trợ bằng ngôn ngữ của quý vị. Vui lòng gọi điện đến Trung
Tâm Liên Lạc Ban Dịch Vụ Hội Viên theo số 1-800-464-4000 (TTY 711) để được trợ giúp hoặc
đến quầy đăng ký bất kỳ tại mọi bệnh viện của Kaiser Permanente để hỏi thêm thông tin,
chúng tôi phục vụ từ thứ Hai đến thứ Sáu, từ 8 giờ sáng đến 5 giờ chiều. Ngoài ra, chúng tôi
cũng cung cấp công cụ hỗ trợ và dịch vụ dành cho người khuyết tật, như tài liệu bằng chữ nổi,
bản in khổ chữ lớn, dạng âm thanh và các định dạng điện tử dễ truy cập khác.