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1 Survey Code: Survey 1 February 6, 2008 Dear Delta Dental Enrollee: Recent changes in California law will require that all health care plans provide language assistance to their plan enrollees beginning January 1, If you or a member of your family covered by Delta Dental cannot speak, read or write English well enough to understand information received from Delta Dental, or to communicate with your dentist, dental office staff, or Delta Dental about your dental coverage and treatment, then you may request language assistance beginning in To prepare for our language assistance program we are surveying our enrollees to assess who will require assistance and in what languages we will need to communicate. We are also required by the regulation to collect demographic information from all our enrollees regarding race and ethnicity and we have included those questions on this survey. Responding to this survey is optional and will not affect your dental coverage. When you complete the survey, please return it by March 31 st, 2008 to: Delta Dental of California Attn: LAP P.O. Box San Francisco, CA or complete the survey online at: Sincerely, DELTA DENTAL OF CALIFORNIA
2 Survey Code: Survey 1 DELTA DENTAL LANGUAGE ASSISTANCE AND DEMOGRAPHIC PROFILE SURVEY PLEASE COMPLETE THE TABLE BELOW First Name Last Name Date of Birth Primary Enrollee or person under whose name and ID Delta Dental provides coverage (Required) Dependent Enrollee #1 Dependent Enrollee #2 Dependent Enrollee #3 (Attach additional paper if necessary.) Relationship to Primary Enrollee Enrollee ID* Language Preferred Ethnicity ** (Optional) y Hispanic or y Not Hispanic or y Hispanic or y Not Hispanic or y Hispanic or y Not Hispanic or y Hispanic or y Not Hispanic or Race ** (Optional) * The Primary Enrollee ID is your Social Security Number, assigned ID, or alternate ID. ** We are required to ask these questions, but you may choose not to answer them. Privacy Assurance: Delta Dental employs industry-standard security measures to control access to the personal enrollee information under our control and to safeguard the confidentiality of your information. The personal information you supply in this questionnaire will be cross-referenced with your Delta Dental records and will not be used for any other purposes. Delta 3044 #45562 (rev. 2/08)
3 Código de la encuesta: Survey 1 February 7, 2008 Estimado afiliado de Delta Dental: Los cambios recientes en las leyes de California dispone que todos los planes de seguro médico proporcionen asistencia lingüística a sus afiliados a partir del 1º de enero del Si usted o un miembro de su familia con cobertura de Delta Dental no puede hablar, leer ni escribir en inglés con suficiente aptitud para entender la información recibida de Delta Dental o para comunicarse con su dentista, el personal del consultorio dental o Delta Dental sobre su cobertura y tratamiento dental, entonces puede solicitar asistencia lingüística a partir del Con el fin de preparar nuestro programa de asistencia lingüística tenemos que saber quién requerirá asistencia y en qué idioma será necesario comunicarnos. El reglamento también exige que obtengamos información demográfica de todos nuestros afiliados con respecto a raza y origen étnico y hemos incluido esas preguntas en esta encuesta. Responder a la encuesta es opcional y no afectará su cobertura dental. Una vez que haya completado la encuesta, sírvase enviarla antes del 31 de marzo del 2008 a: o puede completar la encuesta en línea en: Atentamente, Delta Dental of California Attn: LAP P.O. Box San Francisco, CA DELTA DENTAL OF CALIFORNIA
4 Código de la encuesta: Survey 1 DELTA DENTAL ASISTENCIA LINGÜÍSTICA Y PERFIL DEMOGRÁFICO ENCUESTA COMPLETE LA SIGUIENTE TABLA. Afiliado primario o persona bajo cuyo nombre e identificación proporciona Delta Dental la cobertura (obligatorio completar) Primer miembro de la familia inscrito Segundo miembro de la familia inscrito Tercer miembro de la familia inscrito (si es necesario puede usar otra hoja de papel) Nombre Apellido(s) Fecha de nacimiento Relación con el afiliado primario ID del afiliado* Idioma preferido Origen étnico (la información es optativa)** Hispano o Hispano o Hispano o Hispano o Raza (la información es optativa)** Indio o Indio o Indio o Indio o * El ID del afiliado primario es su Número de Seguro Social (NSS), ID asignado o ID alternativo. ** Tenemos la obligación de hacer estas preguntas, pero si usted lo desea, no las tiene que contestar. Garantía de la privacidad: Delta Dental utiliza medidas de seguridad típicas del sector para controlar el acceso a la información privada de nuestros afiliados de la que nosotros tenemos control y para salvaguardar la confidencialidad de su información. La información personal que usted nos suministra en este cuestionario se ligará a sus expedientes de Delta Dental y no utilizará para ningún otro fin. Delta 3044 #45562 (rev. 1/08)
5 問 卷 調 查 代 碼 : Survey 1 February 7, 2008 親 愛 的 Delta Dental 參 加 者 : 最 近 加 州 法 律 有 所 變 更, 要 求 所 有 保 健 計 畫 從 2009 年 1 月 1 日 起 向 該 計 畫 成 員 提 供 語 言 幫 助 如 果 您 或 參 加 Delta Dental 的 任 何 家 人 的 英 語 說 讀 寫 程 度 不 足 以 理 解 Delta Dental 的 資 料, 或 不 能 與 您 的 牙 科 醫 生 牙 醫 辦 公 室 工 作 人 員 或 Delta Dental 交 流 您 的 牙 科 保 險 和 治 療 事 項, 那 麼 從 2009 年 起 您 可 以 尋 求 語 言 幫 助 為 了 準 備 我 們 的 語 言 幫 助 專 案, 我 們 需 要 瞭 解 哪 些 人 需 要 幫 助, 以 及 我 們 需 要 交 流 哪 些 語 種 照 規 定, 我 們 須 向 所 有 投 保 人 收 集 有 關 與 族 裔 的 人 口 統 計 資 訊, 我 們 已 將 這 些 問 題 附 在 這 份 問 卷 內 您 不 一 定 要 回 答 這 份 問 卷, 這 不 會 影 響 您 的 牙 科 保 險 福 利 填 完 問 卷 後 請 在 2008 年 3 月 31 日 之 前 寄 至 : 或 是 上 網 填 寫 問 卷 : 謹 此, DELTA DENTAL OF CALIFORNIA Delta Dental of California Attn: LAP P.O. Box San Francisco, CA
6 問 卷 調 查 代 碼 : Survey 1 DELTA DENTAL 語 言 協 助 與 人 口 資 料 問 卷 請 填 寫 下 表 名 姓 主 要 加 入 者 或 是 以 該 人 姓 名 和 身 分 證 明 獲 得 Delta Dental 保 險 的 人 士 ( 必 填 ) 出 生 日 期 與 主 要 加 入 者 之 間 的 關 係 受 撫 養 加 入 者 #1 受 撫 養 加 入 者 #2 受 撫 養 加 入 者 #3 ( 若 有 必 要, 可 另 外 附 紙 說 明 ) 加 入 者 身 份 證 明 * 首 選 語 種 族 裔 ( 選 填 )** ( 選 填 )** 美 其 他 美 其 他 美 其 他 美 其 他 * 主 要 加 入 者 身 份 證 明 為 您 的 社 會 安 全 號 碼 (SSN) 指 定 或 替 代 身 份 證 明 ** 我 們 照 規 定 詢 問 這 些 問 題, 但 是 您 可 以 選 擇 不 作 答 隱 私 權 保 護 : Delta Dental 使 用 業 界 標 準 的 安 全 措 施 控 制 調 閱 我 們 控 管 的 會 員 個 人 資 料, 並 維 護 您 的 資 訊 隱 私 您 在 本 問 卷 提 供 的 個 人 資 訊 只 會 與 您 的 Delta Dental 紀 錄 交 叉 參 照, 不 會 用 於 其 他 任 何 用 途 Delta 3044 #45562 (rev. 1/08)
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