Form 13614-C (Ar) - Intake/interview & Quality Review Sheet (Arabic Version) Page 3

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3 ‫ﺍﻟﺻﻔﺣﺔ‬
‫ﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ ﺍﻟﻣﻼﺋﻡ ﻟﻛﻝ ﺳﺅﺍﻝ ﻓﻲ ﻛﻝ ﻓﻘﺭﺓ‬
‫ﻏﻳﺭ ﻭﺍﺛﻕ‬
‫ﻻ‬
‫ﻧﻌﻡ‬
(‫ﺍﻟﺟﺯء ﺍﻟﺳﺎﺩﺱ: ﺗﻐﻁﻳﺔ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ – ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ، ﻫﻝ ﻛﻧﺕ ﺃﻧﺕ ﺃﻭ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﺃﻭ ﻣﻌﺎﻟﻙ )ﻣﻌﺎﻟﻳﻙ‬
‫( ﺗﺣﻣﻝ ﺗﻐﻁﻳﺔ ﺭﻋﺎﻳﺔ ﺻﺣﻳﺔ؟‬B) .1
1095C ‫ﺍﻹﺳﺗﻣﺎﺭﺓ‬
1095B ‫ﻹﺳﺗﻣﺎﺭﺓ‬
(‫( ﺗﻠﻘﻳﺕ ﻭﺍﺣﺩﺓ ﺃﻭ ﺃﻛﺛﺭ ﻣﻥ ﻫﺫﻩ ﺍﻹﺳﺗﻣﺎﺭﺍﺕ؟ )ﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ‬B) .2
[1095A ‫[؟ ]ﻗ ﺩ ّﻡ ﺍﻹﺳﺗﻣﺎﺭﺓ‬Marketplace] ‫( ﻟﺩﻳﻙ ﺗﻐﻁﻳﺔ ﻋﺑﺭ ﺳﻭﻕ ﺷﺭﺍء ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ ﺑﻛﻠﻔﺔ ﻣﻳﺳﻭﺭﺓ‬A) .3
‫( ﺇﺫﺍ ﻧﻌﻡ، ﻫﻝ ﺗﻠﻘﻳﺕ ﻣﺩﻓﻭﻋﺎﺕ ﺇﺋﺗﻣﺎﻧﻳﺔ ﻣﺳﺑﻘﺔ ﻟﻠﻣﺳﺎﻋﺩﺓ ﻋﻠﻰ ﺩﻓﻊ ﺍﻷﻗﺳﺎﻁ ﺍﻟﺷﻬﺭﻳﺔ ﻟﺭﻋﺎﻳﺗﻙ ﺍﻟﺻﺣﻳﺔ؟‬A) .‫3ﺃ‬
‫ ﺍﻟﺧﺎﺻﺔ ﺑﻙ ﻣﻌﻠﻥ ﻋﻠﻰ ﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ؟‬A-1095 ‫( ﺇﺫﺍ ﻻ، ﻫﻝ ﻛﻝ ﺷﺧﺹ ﻣﺩﺭﺝ ﻋﻠﻰ ﺍﻹﺳﺗﻣﺎﺭﺓ‬A) .‫3ﺏ‬
‫( ﺗﺣﻣﻝ ﺇﻋﻔﺎ ء ً ﻣﻧﺣﺗﻪ ﺳﻭﻕ ﺷﺭﺍء ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ ﺑﻛﻠﻔﺔ ﻣﻳﺳﻭﺭﺓ؟‬B) .4
‫ﻗﻡ ﺑﺯﻳﺎﺭﺓ‬
.‫ﻟﻠﺣﺻﻭﻝ ﻋﻠﻰ ﻣﺯﻳﺩ ﻣﻥ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﻋﻥ ﺧﻳﺎﺭﺍﺕ ﺗﻐﻁﻳﺔ ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ ﻭﺍﻟﻣﺳﺎﻋﺩﺓ ﻓﻲ ﺷﺄﻧﻬﺎ‬
1-800-318-2596
‫ﺃﻭ ﺍﻻﺗﺻﺎﻝ ﺑﺎﻟﺭﻗﻡ‬
‫ﺇﻥ ﻛﻧﺕ ﺗﺗﻠﻘﻰ ﻣﺩﻓﻭﻋﺎﺕ ﻣﺳﺑﻘﺔ ﻣﻥ ﺍﻟﺧﺻﻡ ﺍﻟﺿﺭﻳﺑﻲ ﻋﻠﻰ ﺃﻗﺳﺎﻁ ﺍﻟﺗﺄﻣﻳﻥ ﻟﻣﺳﺎﻋﺩﺗﻙ ﻋﻠﻰ ﺩﻓﻊ ﺃﻗﺳﺎﻁ ﺗﻐﻁﻳﺔ ﺗﺄﻣﻳﻧﻙ ﺍﻟﺻﺣﻲ، ﻓﻌﻠﻳﻙ ﺇﺑﻼﻍ ﺳﻭﻕ ﺷﺭﺍء ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ ﺑﻛﻠﻔﺔ ﻣﻳﺳﻭﺭﺓ ﻋﻥ ﺃﻱ ﺗﻐﻳﻳﺭﺍﺕ ﺣﻳﺎﺗﻳﺔ، ﻣﺛﻝ ﺍﻟﺗﻐﻳﻳﺭﺍﺕ ﻓﻲ ﺍﻟﺩﺧﻝ ﺃﻭ‬
.‫ﺍﻟﺣﺎﻟﺔ ﺍﻟﺯﻭﺟﻳﺔ ﺃﻭ ﺣﺟﻡ ﺍﻟﻌﺎﺋﻠﺔ. ﻓﺎﻹﺑﻼﻍ ﻋﻥ ﺍﻟﺗﻐﻳﻳﺭﺍﺕ ﺳﻳﺳﺎﻋﺩﻙ ﻋﻠﻰ ﺿﻣﺎﻥ ﺣﺻﻭﻟﻙ ﻋﻠﻰ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﻼﺋﻡ ﻣﻥ ﺍﻟﻣﺩﻓﻭﻋﺎﺕ ﺍﻟﻣﺳﺑﻘﺔ‬
(.‫( ﻟﻛﻝ ﻣﻥ ﻫﻭ ﻣﺩﺭﺝ ﻋﻠﻰ ﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ‬Minimum Essential Coverage] (MEC] "‫ﻳﺳﺗﻛﻣﻠﻪ ﺍﻟﻣﺗﻁﻭﻉ ﺍﻟﻣﻌﺗﻣﺩ ﻹﻋﺩﺍﺩ ﻛﺷﻭﻑ ﺍﻟﺿﺭﺍﺋﺏ )ﺍﺳﺗﺧﺩﻡ ﺍﻟﻣﻧﺷﻭﺭ 2104 ﻭﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ )ﺍﻟﻣﺭﺑﻌﺎﺕ( ﺍﻟﻣﻼﺋﻡ ﻟﻺﺷﺎﺭﺓ ﺇﻟﻰ "ﺍﻟﺗﻐﻁﻳﺔ ﺍﻷﺳﺎﺳﻳﺔ ﺍﻷﺩﻧﻰ‬
‫ﺇﻋﻔﺎء‬
(‫إﻋﻔﺎء )ﺳ ﺠ ّ ﻞ اﻷﺷﻬﺮ اﻟﺘﻲ ﺗﴪي ﻋﻠﻴﻬﺎ إﻋﻔﺎءات‬
‫ﺗﻐﻁﻳﺔ ﺃﺳﺎﺳﻳﺔ ﺃﺩﻧﻰ ﺃﺛﻧﺎء ﺟﺯء ﻣﻥ ﺍﻟﺳﻧﺔ‬
‫ﻻ ﺗﻐﻁﻳﺔ ﺃﺳﺎﺳﻳﺔ‬
‫ﺗﻐﻁﻳﺔ ﺃﺳﺎﺳﻳﺔ ﺃﺩﻧﻰ‬
‫ﺍﻹﺳﻡ‬
‫ﻣﻼﺣﻅﺎﺕ‬
‫ﻁﻭﺍﻝ ﺍﻟﺳﻧﺔ‬
(‫)ﻋﺩﺩ ﺍﻟﻣﻌﺎﻟﻳﻥ ﺑﺗﺭﺗﻳﺏ ﻣﻁﺎﺑﻕ ﻟﻠﺟﺯء ﺍﻟﺛﺎﻧﻲ‬
(‫ﺍﻟﻣﺎﺿﻳﺔ )ﺳﺟّ ﻝ ﺍﻷﺷﻬﺭ ﺫﺍﺕ ﺍﻟﺗﻐﻁﻳﺔ‬
‫ﺃﺩﻧﻰ‬
‫ﺃﺛﻧﺎء ﻛﺎﻣﻝ ﺍﻟﺳﻧﺔ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﺩﺍﻓﻊ ﺍﻟﺿﺭﺍﺋﺏ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﺍﻟﺯﻭﺟﺔ/ﺍﻟﺯﻭﺝ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﺍﻟﻣﻌﺎﻝ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﺍﻟﻣﻌﺎﻝ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﺍﻟﻣﻌﺎﻝ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﻱ ﻑ ﻡ ﺃ ﻡ ﻱ ﻱ ﺃ ﺱ ﺃ ﻥ ﺩ‬
‫ﺍﻟﻣﻌﺎﻝ‬
‫ﺍﻟﺟﺯء ﺍﻟﺳﺎﺑﻊ- ﻣﻌﻠﻭﻣﺎﺕ ﺇﺿﺎﻓﻳﺔ ﻭﺃﺳﺋﻠﺔ ﻣﺗﻌﻠﻘﺔ ﺑﺈﻋﺩﺍﺩ ﻛﺷﻑ ﺿﺭﺍﺋﺑﻙ‬
(‫1. ﺯﻭّ ﺩ ﻋﻧﻭﺍﻥ ﺑﺭﻳﺩ ﺇﻟﻛﺗﺭﻭﻧﻲ )ﺧﻳﺎﺭﻱ( )ﻟﻥ ﻳ ُﺳﺗﺧﺩﻡ ﻋﻧﻭﺍﻥ ﻫﺫﺍ ﺍﻟﺑﺭﻳﺩ ﺍﻹﻟﻛﺗﺭﻭﻧﻲ ﻟﻺﺗﺻﺎﻻﺕ ﻣﻥ ﻣﺻﻠﺣﺔ ﺿﺭﻳﺑﺔ ﺍﻟﺩﺧﻝ‬
(.‫2. ﺻﻧﺩﻭﻕ ﺣﻣﻠﺔ ﺍﻹﻧﺗﺧﺎﺑﺎﺕ ﺍﻟﺭﺋﺎﺳﻳﺔ )ﺇﻥ ﺍﺧﺗﺭﺕ ﻣﺭﺑﻌ ﺎ ً ، ﻟﻥ ﻳﺣﺩﺙ ﺗﻐﻳﻳﺭ ﺍ ً ﻓﻲ ﺿﺭﻳﺑﺗﻙ ﻭﻻ ﻓﻲ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﺳﺗﺭﺟﻊ ﻟﻙ‬
‫ﺍﻟﺯﻭﺟﺔ/ﺍﻟﺯﻭﺝ‬
‫ﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ ﻫﻧﺎ ﺇﻥ ﻛﻧﺕ ﺃﻧﺕ، ﺃﻭ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﻓﻲ ﺣﺎﻝ ﺭﻓﻊ ﻛﺷﻑ ﻣﺷﺗﺭﻙ، ﺗﺭﻳﺩ ﺃﻥ ﻳﺧﺻﺹ ﻣﺑﻠﻎ 3$ ﻟﻬﺫﺍ ﺍﻟﺻﻧﺩﻭﻕ‬
‫ﺃﻧﺕ‬
‫3. ﺇﻥ ﻛﻧﺕ ﺗﺳﺗﺣﻕ ﻣﺑﻠﻐ ﺎ ً ﻣﺳﺗﺭﺟﻌ ﺎ ً ، ﻫﻝ ﺗﻭﺩ‬
ً ‫ﺃ. ﺇﻳﺩﺍﻋ ﺎ ً ﻣﺑﺎﺷﺭ ﺍ‬
‫ﺝ. ﻗﺳﻡ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﺳﺗﺭﺟﻊ ﻟﻙ ﺑﻳﻥ ﺣﺳﺎﺑﺎﺕ ﻣﺧﺗﻠﻔﺔ‬
‫ﺏ. ﺷﺭﺍء ﺳﻧﺩﺍﺕ ﺗﻭﻓﻳﺭ ﺃﻣﺭﻳﻛﻳﺔ‬
‫ﻻ‬
‫ﻧﻌﻡ‬
‫ﻻ‬
‫ﻧﻌﻡ‬
‫ﻻ‬
‫ﻧﻌﻡ‬
‫4. ﺇﻥ ﻛﺎﻥ ﻟﺩﻳﻙ ﺭﺻﻳﺩ ﻣﺳﺗﺣﻕ، ﻫﻝ ﺗﻭﺩ ﺩﻓﻊ ﻣﺑﻠﻎ ﻣﻥ ﺣﺳﺎﺑﻙ ﺍﻟﻣﺻﺭﻓﻲ؟‬
‫ﻻ‬
‫ﻧﻌﻡ‬
‫ﻻ‬
‫ﻧﻌﻡ‬
‫5. ﻫﻝ ﺗﻠﻘﻳﺕ ﺃﻧﺕ ﺃﻭ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﺃﻱ ﺭﺳﺎﺋﻝ ﻣﻥ ﻣﺻﻠﺣﺔ ﺿﺭﻳﺑﺔ ﺍﻟﺩﺧﻝ؟‬
.‫ﺗﻌﻣﻝ ﻣﻭﺍﻗﻊ ﻋﺩﻳﺩﺓ ﻹﻋﺩﺍﺩ ﻛﺷﻭﻑ ﺍﻟﺿﺭﺍﺋﺏ ﻋﺑﺭ ﺇﺳﺗﻼﻡ ﺃﻣﻭﺍﻝ ﻣﻧﺢ. ﻭﻗﺩ ﻳﺳﺗﺧﺩﻡ ﻫﺫﺍ ﺍﻟﻣﻭﻗﻊ ﺍﻟﺑﻳﺎﻧﺎﺕ ﻣﻥ ﺍﻷﺳﺋﻠﺔ ﺍﻟﺗﺎﻟﻳﺔ ﻟﺗﻘﺩﻳﻡ ﻁﻠﺑﺎﺕ ﻟﻠﺣﺻﻭﻝ ﻋﻠﻰ ﻫﺫﻩ ﺍﻟﻣﻧﺢ. ﻭﺳﺗـ ُ ﺳﺗﺧﺩﻡ ﺃﺟﻭﺑﺗﻙ ﻷﻏﺭﺍﺽ ﺇﺣﺻﺎﺋﻳﺔ ﻓﻘﻁ‬
‫6. ﻏﻳﺭ ﺍﻟﻠﻐﺔ ﺍﻹﻧﺟﻠﻳﺯﻳﺔ، ﻣﺎ ﻫﻲ ﺍﻟﻠﻐﺔ ﺍﻟﻣﺣﻛﻳﺔ ﻓﻲ ﻣﻧﺯﻟﻙ؟‬
‫ﺃﻓﺿﻝ ﺍﻻﻣﺗﻧﺎﻉ ﻋﻥ ﺍﻹﺟﺎﺑﺔ‬
‫ﺃﻓﺿﻝ ﺍﻻﻣﺗﻧﺎﻉ ﻋﻥ ﺍﻹﺟﺎﺑﺔ‬
‫ﻻ‬
‫ﻧﻌﻡ‬
‫7. ﻫﻝ ﻟﺩﻳﻙ ﺃﻧﺕ ﺃﻭ ﺃﺣﺩ ﺃﻓﺭﺍﺩ ﺃﺳﺭﺗﻙ ﺍﻟﻣﻌﻳﺷﻳﺔ ﺇﻋﺎﻗﺔ؟‬
‫ﻻ‬
‫ﻧﻌﻡ‬
‫ﺃﻓﺿﻝ ﺍﻻﻣﺗﻧﺎﻉ ﻋﻥ ﺍﻹﺟﺎﺑﺔ‬
‫8. ﻫﻝ ﺃﻧﺕ ﺃﻭ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﻓﺭﺩ ﺳﺎﺑﻕ ﻓﻲ ﺍﻟﻘﻭﺍﺕ ﺍﻟﻣﺳﻠﺣﺔ ﺍﻷﻣﺭﻳﻛﻳﺔ‬
‫ﺗﻌﻠﻳﻘﺎﺕ ﺇﺿﺎﻓﻳﺔ‬
13614-C (AR)
58970P ‫ﺍﻟﻛﺗﺎﻟﻭﺝ ﺭﻗﻡ‬
(2017-10 ‫)ﺗﻌﺩﻳﻝ‬
‫ﺍﻹﺳﺗﻣﺎﺭﺓ‬

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