Enrollment Form NEW HMONG

Tsev kawm ntawv District*

Tsev Kawm Ntawv lub npe*

Qhia txog tus menyuas - Thov siv lub npe raug cai

Nyob*

Npe Nruab nrab pib Xeem

Nu Yug*

Lom Deev*

Qhia Txog niam txiv - Thov siv lub npe raug cai

Niam Txiv/Tus Saib Xyuas*

Npe Nruab nrab pib Xeem

Xov tooj*

Email*

Shaw nyob*

chaw nyob Lub Nroog State Cheeb tsham

Qhia txog koj li ntawv kho mob

Xaiv saib koj li ntawv kho mob yog qhov twg:*

BadgerCare/ForwardHealth
Tsis muaj kev pov hwm
Lwm yam

*(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.

Txhua tus menyuam kawm ntawv uas tsis muaj tsev neeg kws kho hniav raug txais tos tuaj rau npe. Yog tias koj tsis muaj BadgerCare/ForwardHealth, cov kev pabcuam tiv thaiv yuav raug pub dawb rau koj tus menyuam kawm ntawv. Yog xav paub ntxiv thov hu rau Bridging Brighter Smiles.

Xaiv saib koj li ntawv kho mob yog qhov twg:*

BadgerCare/ForwardHealth
Tsis muaj kev pov hwm
Lwm yam

Xaiv saib koj li ntawv kho mob yog qhov twg:*

BadgerCare/ForwardHealth
Blue Cross Blue Shield
ICare
Molina
Children's Community Health Plan
United Healthcare of Wisconsin
MHS Health WI
No Insurance
Other

*(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.

Xaiv saib koj li ntawv kho mob yog qhov twg:*

BadgerCare/ForwardHealth
Blue Cross Blue Shield
ICare
Molina
Children's Community Health Plan
United Healthcare of Wisconsin
MHS Health WI
No Insurance
Other

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. Kuv pom zoo them tus nqi qauv rau cov kev pabcuam uas tau muab (saib Cov Ntaub Ntawv Kev Pabcuam) ncaj qha rau Bridging Brighter Smiles, Inc.*

Yog

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?*

Yog
Tsis muaj

Yog Yog, Thov Piav Qhia

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

Yog
Tsis muaj

Yog Yog, Thov Piav Qhia

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

Yog
Tsis muaj

Yog tias muaj, thov qhia yog dlabtsi

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

Yog
Tsis muaj

Yog Yog, Thov Piav Qhia

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.

Yog

Kuv tso cai rau BRIDGING BRIGHTER SMILES, INC. TAM SIM NO THIAB nthuav tawm cov ntaub ntawv kho mob nrog lwm tus neeg laus:

Lub npe ntawm tus neeg tso cai

Lub Xeem

Sau npe hauv no mus

Kuv lees paub tias kuv yog tus saib xyuas raws cai ntawm tus menyuam kawm ntawv saum toj no thiab nkag siab tias qhov pib thiab kev tiv thaiv kev kho hniav tsis tu ncua yuav raug muab rau kuv tus neeg nyob. Kuv tso cai rau BadgerCare/Medicaid cov nyiaj pov hwm them nqi kho mob rau cov kev pab cuam xa mus rau Bridging Brighter Smiles, Inc. Yog tias yav tom ntej Medicaid xav tau kev them nqi, kuv pom zoo them. Kuv muaj peev xwm rho npe tau txhua lub sijhawm los ntawm kev sau ntawv tshem tawm ntawm kev tso cai.*

Kuv pom zoo

Npe*

Xeem*

Hnub*