Enrollment Form – Hmong – Bridging Brighter Smiles

School District*

School Name*

Qhia txog tus menyuas - Thov siv lub npe raug cai

Dependent*

First Middle Last

Date of Birth*

Lom deev*

Qhia Txog niam txiv - Thov siv lub npe raug cai

Parent/Guardian*

First Middle Last

Primary Phone*

Email*

Address*

Street Address City State ZIP Code

Qhia txog koj li ntawv kho mob

Xaiv saib koj li ntawv kho mob yog qhov twg

BadgerCare / Forward Health
(Peb txais yuav BadgerCare/Forward Health Care)
No Dental Insurance
(Kev sau nqi kho Nhiav). Cov nyiaj tau los ntawm koj tus account FSA/HSA yuav raug siv los ua ib daim ntawv them nyiaj, thov nrog koj tus neeg nqa khoom saib xyuas cov ntsiab lus tshwj xeeb.
Other Private Dental Insurance
(Ped tsi txais ntawv kho nhiav tom haujlwm). Cov nyiaj tau los ntawm koj tus account FSA/HSA yuav raug siv los ua ib daim ntawv them nyiaj, thov nrog koj tus neeg nqa khoom saib xyuas cov ntsiab lus tshwj xeeb.

Nhias ntawm no mus nyeem txog Bridging Brighter Smile li txoj kev pab thiab nqi.

Kuv twb nyeem thiab/losis Bridging Brighter Smiles’ dlaim ntawv qhia tias thiab cov nqi lawm.*

Yes

Menyuas kawm ntawv li keeb kwm txog kev noj qab nyob zoo

koj tus menyuas puas muaj tej yam uas nwg noj/siv tsi haum?*

Yes
No

If Yes, Please Explain

Kws kho mob puas tau hais tias koj tus menyuas muaj mob rau nws lub cev losis mob hlwb?*

Yes
No

If Yes, Please Explain

kws kho mob puas muab tshuaj rau koj tug menyuas noj?*

Yes
No

If Yes, Please Explain

koj tus menyuas puas siv tshuaj tua kab mob uantej yuav kho nhiav?*

Yes
No

If Yes, Please Explain

Kev Tso cai

Nia ntawm nov mus nyeem Bridging Brighter Smiles Inc’s dlaim ntawv qhia txog tias qhov uas peb xyaus tsi pub lwm tug paub zoo li cas. Kuv nyeem thiab tobtaub hais tais kuv yuav tau txais ib dlaim ntawv no ntawm Bridging Brighter Smiles Inc.’s website ntawm http://bridgingbrightersmiles.org/forms/, lossis hu mus nrog tug neeg ua haujlwm ntawm lub tsev kawm uas Bridging Brighter Smiles muab kev pab.

Yes

Kuv yog tug neeg saib xyuas tug menyuas uas kuv muab sau npe saum no thiab kuv totaub hais tais thaum kuv sau kuv lub npe rau dlaim ntawv no, kuv tug menyuas yuav tau txais kev pab tam sim no thiab lwm nub thiab. Dlaim ntawv sau npe no kav ob xyoos. Yog kuv tsi xav kom kuv tus menyuas txais kev pab, kuv yuav tau sau ib dlaim ntawv rhov npe.*

Yes

Sau npe hauv no mus

Kuv totaub hais tias thaum kuv khij “I Agree” hauv qab no, kuv txaus siab rau BadgerCare/Medicaid Insurance them cov nqi uas Bridging Brighter Smiles, Inc tau pab kuv tug menyuas. Kuv txaus siab yuav them tug nqi uas yog kuv ntiag tug. Yog kuv tus menyuas tsi muaj ntawv kho mob los ntawm BadgerCare/Medicaid Insurance, kuv tso siab yuav them tug nqi raws li Bridging Brighter Smiles, Inc hais kom kuv them.*

I Agree

First Name*

Last Name*

Date*

Phone

This field is for validation purposes and should be left unchanged.

Bridging Brighter Smiles Inc. Enrollment Form

Qhia txog tus menyuas - Thov siv lub npe raug cai

Qhia Txog niam txiv - Thov siv lub npe raug cai

Qhia txog koj li ntawv kho mob

Menyuas kawm ntawv li keeb kwm txog kev noj qab nyob zoo

Kev Tso cai

Sau npe hauv no mus