Commonwealth of Virginia
Spotsylvania County (177) Department of Social Services
FL 2 Questions? Call: (540) 507-7898
9019 OLD BATTLEFIELD BLVD
SPOTSYLVANIA, VA 22553
Letter Date: June 03, 2024
Case Number: 127972529
Karli A Brandom
6111 Sunlight Mountain RD
Spotsylvania, VA 22553
Why Karli A Brandom is getting this letter
We must re-evaluate eligibility for the following individual: Karli A Brandom.
You cannot remain in your current health care coverage due to one or more of the following reasons:
• You are about to turn 65.
• You are about to or have gained Medicare eligibility.
Please give us the information requested by: June 18, 2024
• The Re-Evaluation Questionnaire (found on the back of your return cover sheet).
• The Appendix D (found after the return cover sheet).
Ways you can return your information: Your CommonHelp Account
CommonHelp.Virginia.gov keeps all important
1. Online. Go to CommonHelp.Virginia.gov information about your family's application. You
and follow the website directions to can choose to get letters like this online. Your
complete this re-evaluation. CommonHelp account is secure. Your
2. By phone: Call (540) 507-7898 and reference information is used only to determine eligibility
this letter to complete the questionnaire and for Medicaid or other benefits.
Appendix D information over the phone.
3. By fax. Fax a copy to us at (540) 507-7810. To create an account, go to
4. By mail. Send a copy to us at P O BOX 249 CommonHelp.Virginia.gov and click “Check My
SPOTSYLVANIA, VA 22553 or use the Benefits.” To link your case to your CommonHelp
enclosed cover sheet and reply envelope to account using the information below, log in and
return your information. select “Manage My Account.”
5. In person. Bring us a copy to 9019 OLD
BATTLEFIELD BLVD OFC STE 200 Case Number: 127972529
SPOTSYLVANIA, VA 22553. Client ID: 2007017080
Case #: 127972529 Page 1 of 2 Correspondence #: 784003985
Worker Name: Telephone Number: For Free Legal Advice Call:
L. MOTZ (540) 755-1279 1-866-534-5243
For health coverage from Virginia Medicaid: It is important we treat you fairly. We will keep your
information secure and private. This agency complies with applicable Federal civil rights laws and
does not discriminate on the basis of race, color, national origin, age, disability, or sex. This agency
does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex.
This agency provides free aids and services to people with disabilities to communicate effectively
with us, such as, qualified sign language interpreters and written information in other formats (large
print, audio, accessible electronic formats, other formats). If you need these services, call us at (804)
786-7933 (TTY: 1-800-343-0634). This agency also provides free language services to people whose
primary language is not English, such as qualified interpreters and information written in other
languages. If you need these services, call us at 1-855-242-8282 (TTY: 1-888-221-1590). If you believe
that this agency has failed to provide these services or discriminated in another way on the basis of
race, color, national origin, age, disability, or sex, you can file a grievance in person, by mail, or by
phone at: Civil Rights Coordinator, DMAS, 600 E. Broad St., Richmond, VA 23219, Telephone: (804)
786‐7933 (TTY: 1‐800‐343‐0634).
You may also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or
phone at U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room
509F, HHH Building, Washington, D.C. 20201; 1-800‐368‐1019 (TTY 800‐537‐7697). Complaint forms
are available at https://hhs.gov/ocr/office/file/index.html.
This institution is an equal opportunity provider.
Case #: 127972529 Page 2 of 2 Correspondence #: 784003985
Re-Evaluation Return Cover Page
Karli A Brandom Commonwealth of Virginia
6111 Sunlight Mountain RD Department of Social Services
Spotsylvania, VA 22553 Questions? Call (540) 507-7898
Spotsylvania County (177)
FL 2
9019 OLD BATTLEFIELD BLVD
SPOTSYLVANIA, VA 22553
Make sure both addresses above show in the return envelope.
FOLD 2
Fold the paper at FOLD 1, and then FOLD 2 so that the top portion
of the page shows in the windows of the return envelope.
The return envelope is postage paid, so there is no reason to use your own stamps!
If you would like to return your verifications in person, online, or by fax,
please see the steps on the previous page for instructions.
FOLD 1
Letter Date: June 03, 2024
Case Number: 127972529
Worker Name: L. MOTZ
Case #: 127972529 Page 1 of 12 Correspondence #: 784003985
Re-Evaluation Questionnaire
Name: Karli A Brandom
1) Plan First: Plan First is Virginia’s FREE family planning program for men and women. Plan First
offers FREE yearly family planning exams, contraceptives, lab testing, family planning education, and
more. Individuals between 19 and 64 are automatically evaluated for this coverage unless they opt
out. However, individuals 65 and older must choose to be evaluated for this coverage.
Would you like to be evaluated for Plan First? Yes No
2) Medicare: Medicare is the federal health insurance program for people who are 65 or older,
certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant, sometimes called ESRD). While we may obtain your Medicare
information using our data sources, please tell us more about your coverage.
Are you eligible for Medicare? Yes No Not sure
Are you enrolled in Medicare? Yes No Not sure
If yes: What coverage do you have? (Check all that apply): Part A Part B Part D
What is your monthly premium? (Complete all that apply):
Part A: $____________ Part B: $___________ Part D: $___________
What is your Medicare Beneficiary Identifier (11 Digit ID): _________________________
Complete this questionnaire to the best of your ability along with the enclosed Appendix D. Turn in all
paperwork or use one of the methods mentioned on the first page of this letter for other ways to
submit this information.
Case #: 127972529 Page 2 of 12 Correspondence #: 784003985
Name: Karli A Brandom
Application for Health Coverage and Help Paying Costs
APPENDIX D
Complete Appendix D if you are applying for Health Care Coverage for:
• someone who has disabilities
• someone age 65 years or over
• all people, including children, in need of Long-term Care Services (nursing facility or
community based care)
• someone who is medically needy (has income greater than Medicaid limit and would like
to be evaluated based on their income, resources and medical expenses) - Spenddown
What is Appendix D Used For?
Appendix D gathers additional information needed to determine your eligibility for
Health Care Coverage.
Appendix D is not a stand-alone application. You must also complete the Application for
Health Coverage and Help Paying Costs and submit Appendix D with the application.
If completing Appendix D for someone else, please answer the questions for that person.
SECTION 1 Household Information
1. Are You? Married Never married Divorced Widowed Separated
2. Has anyone in your household ever applied for or received any Health Care Coverage from a
social service agency in another state or Virginia city or county?
Yes No
— If yes, please indicate which state or Virginia city or county below:
State or Virginia city or county
3. Is anyone in your household temporarily away from home? Yes No
— If yes, please provide the following information:
Name Date Left
Reason for Leaving
Where is the person currently staying? Expected Return Date
Case #: 127972529 Page 3 of 12 Correspondence #: 784003985
Answer questions 4-11 if any applicants are under age 65 years.
4. Are you or is anyone for whom you are applying disabled? Yes No
— If yes, please provide the name of the persons:
Name of Person Name of Person
5. Have you or anyone for whom you are applying ever applied for Social Security, Supplemental
Security Income (SSI) or Railroad Retirement benefits as a disabled person?
Yes No
— If yes, please provide the name of the persons and date of application:
Name of Person and Date of Application Name of Person and Date of Application
6. Have you or anyone in your household for whom you are applying been approved for disability
for Social Security, SSI, Railroad Retirement or Medicaid purposes? Yes No
— If yes, please provide the name of the individual:
Name Name
7. If the application for Social Security, SSI or Railroad Retirement benefits was denied, did you
file an appeal of the denial? Yes No
— If yes, please tell us the outcome of the appeal:
Outcome
8. Has it been less than 12 months since the most recent application for Social Security, SSI or
Railroad Retirement benefits was denied?
Yes No
9. Has the condition changed or worsened since the most recent application for disability was
denied? Yes No
10. Do you or anyone for whom you are applying have a new medical condition since the most
recent application for disability was denied? Yes No
Case #: 127972529 Page 4 of 12 Correspondence #: 784003985
11. Have you or anyone for whom you are applying ever received SSI, disability benefits from the
Social Security Administration or Auxiliary Grant payments?
Yes No
Has the payment stopped? Yes No
— If yes, explain whose payment stopped, when it stopped, and why it stopped.
Explain
SECTION 2 Long-term Care
Answer questions 12-14 if you are applying for anyone who is in a nursing facility or
assisted living facility, or who requires nursing home care or assistance to remain in the
home
12. Do you or anyone for whom you are applying need nursing facility care or help such as
bathing, dressing, toileting, etc., so that you can remain in your own home? Yes No
— If yes, and there is a spouse who lives somewhere else, what is the name and address of the
spouse? (Note: Under Virginia law persons are considered married and legally responsible for each
other until they divorce)
Name
Address
13. Do you or anyone for whom you are applying live in one of the following?
Assisted Living Facility (ALF) Nursing Facility Group Home Hospital or other Medical
Facility
— If you checked one of the above, please provide the following information:
Name Date of Entry In what County was the prior address?
Person’s address prior to entering the facility
Facility Name Facility Address
Was Placement made by a State agency? Yes No
14. Does the individual in the nursing facility or requiring assistance in the home have long-term
care insurance? Yes No — If yes, please provide the following information:
Name of Insurance Company Address City, State, ZIP
Policy Number Person(s) Insured Is this a Partnership Policy?
Yes No
Case #: 127972529 Page 5 of 12 Correspondence #: 784003985
15. Have you or your spouse sold, transferred, placed in a trust/annuity, or given away any
resources, such as your home or other real property, cash, bank accounts, or cars in the last
sixty (60) months (5 years)? Yes No — If yes, please provide the following information:
Type of Property Transferred Value at Transfer Amount Received Date of Transfer
$ $
From Whom To Whom
Explain the Reason for Transfer
Note: If more than one transfer has occured, please attach documentation of each transfer.
SECTION 3 Resources and Assets
16. Do you or your spouse have any money/cash on hand that is not in the bank? Yes No
— If yes, please provide the following information:
Name Amount
$
Name Amount
$
17. Do you or your spouse have any of the following resources? Yes No
— If yes, please check the boxes that apply and provide the information requested below:
Checking, Savings Deferred Compensation Plan Christmas Club
Credit Union Certificate of Deposit (CD) Money Market Funds
1. Owner Name Co-Owner Name
Name of Bank Account Type Account Number Balance/Value
$
2. Owner Name Co-Owner Name
Name of Bank Account Type Account Number Balance/Value
$
3. Owner Name Co-Owner Name
Name of Bank Account Type Account Number Balance/Value
$
Is your income (Social Security or SSI benefits, retirement pension, wages, etc.) deposited directly into
any of the accounts? Yes No If yes, which account?
Case #: 127972529 Page 6 of 12 Correspondence #: 784003985
18. You must report ownership of all annuities you and your spouse have. You and your spouse
may have to name the Commonwealth of Virginia as the beneficiary of any annuity you or
your spouse own.
Do you or your spouse have any stocks or bonds, trust funds, pension plans, retirement
accounts, trusts, annuities, promissory notes, or deeds of trust? Yes No
— If yes, please provide the following information:
1. Owner Name Co-Owner Name
Where is the Account Held? Account Type Account Number Balance/Value
$
2. Owner Name Co-Owner Name
Where is the Account Held? Account Type Account Number Balance/Value
$
3. Owner Name Co-Owner Name
Where is the Account Held? Account Type Account Number Balance/Value
$
19. Do you or your spouse have any life insurance? Yes No
— If yes, please provide the following information:
1. Owner Name Person Insured Type of Insurance (whole life or term)
Company Name Policy Number Face Value Cash Value
$ $
2. Owner Name Person Insured Type of Insurance (whole life or term)
Company Name Policy Number Face Value Cash Value
$ $
3. Owner Name Person Insured Type of Insurance (whole life or term)
Company Name Policy Number Face Value Cash Value
$ $
Case #: 127972529 Page 7 of 12 Correspondence #: 784003985
20. Do you or your spouse have burial plots, burial arrangements, or trust funds for burial
Yes No
— If yes, please provide the following information:
Owner(s) Item/Type Value/Amount Owned
$
Owner(s) Item/Type Value/Amount Owned
$
Owner(s) Item/Type Value/Amount Owned
$
21. Do you or your spouse have real property, including home property, life rights/estates, shares
in undivided heir property, land, buildings, or mobile homes? Yes No
— If yes, please provide the following information:
Owner(s) Type of Property/Number of Acres Value/Amount Owned
$
Do you live on this property? Is this property currently for sale?
Yes No Yes No
Is this property rented? Do you received money from this property?
Yes No
Yes No
22. Do you or your spouse have any licensed or unlicensed cars, trucks, vans, boats, motors
homes, recreational vehicles, utility trailers, motorcycles, or mopeds? Yes No
— If yes, please provide the following information:
Owner(s) Year-Make-Model Value/Amount Owned
$
Owner(s) Year-Make-Model Value/Amount Owned
$
Owner(s) Year-Make-Model Value/Amount Owned
$
23. Do you or your spouse have any property that is used in the operation of a business, such as
farm equipment, tools, or livestock? Yes No
— If yes, please provide the following information:
Owner(s) Type Value Amount Owned
$ $
Owner(s) Type Value Amount Owned
$ $
Case #: 127972529 Page 8 of 12 Correspondence #: 784003985
24. Do you or your spouse expect a change in resources this month or next month?
Yes No
— If yes, please explain below and give the date the change is expected:
Explain
Date Change Expected
SECTION 4 Other Income
25. Do you receive child support? Yes No
— If yes, please provide the following information:
Amount How Often? Is the payment for past-due child support payments?
$
Yes No
26. Do you receive Veteran’s Administration benefits? Yes No
— If yes, please provide the following information:
Amount How Often? Type
27. Does anyone help you pay, or lend you money to pay rent, utilities, medical bills, or any other
bills? Yes No
— If yes, please provide the following information:
Person Receiving Money Person Providing Help
Type of Help Received Amount
$
Does the money come directly to you?
Yes No
Is this a loan?
Yes No
Is repayment expected?
Yes No
Case #: 127972529 Page 9 of 12 Correspondence #: 784003985
Person Receiving Money Person Providing Help
Type of Help Received Amount
$
Does the money come directly to you?
Yes No
Is this a loan?
Yes No
Is repayment expected?
Yes No
Sign the application
I am signing this application under penalty of perjury which means I’ve provided true answers
to all the questions on this application to the best of my knowledge. I know that I may be
subject to penalties under federal law if I provide false or untrue information.
Signature Relationship to Applicant Date
Case #: 127972529 Page 10 of 12 Correspondence #: 784003985
English: Get help in your language
This Notice has important information about your benefits or application for health coverage from Virginia
Medicaid. Look for important dates. You might need to take action by certain dates to keep your benefits.
You have the right to get this letter for free in your language, in large print, or in another way that is best for you.
Call us at 1‐855‐242‐8282 (TTY: 1‐888‐221‐1590).
Spanish: Obtenga ayuda en su idioma ﺍﺣﺻﻝ ﻋﻠﻰ ﺍﻟﻣﺳﺎﻋﺩﺓ ﺑﻠﻐﺗﻙ:Arabic
Este aviso tiene información importante de Virginia ﻳﺗﺿﻣﻥ ﻫﺫﺍ ﺍﻹﺧﻁﺎﺭ ﻣﻌﻠﻭﻣﺎﺕ ﻣﻬﻣﺔ ﻋﻥ ﺍﻟﻣﺯﺍﻳﺎ ﺍﻟﺗﻲ ﺳﻭﻑ ﺗﺣﺻﻝ
ﻣﻥ ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ ﺍﻟﻣﻘﺩﻡ ﻣﻥ-ﺃﻭ ﻋﻧﺩ ﺍﻟﺗﻘﺩﻡ ﻟﻠﺣﺻﻭﻝ ﻋﻠﻳﻬﺎ- ﻋﻠﻳﻬﺎ
Medicaid sobre sus beneficios o solicitud de
ﻗﺩ. ﺍﺑﺣﺙ ﻋﻥ ﺍﻟﺗﻭﺍﺭﻳﺦ ﺍﻟﻣﻬﻣﺔ.Virginia Medicaid ﻓﻳﺭﺟﻳﻧﻳﺎ ﻣﻳﺩﻛﻳﺩ
cobertura de salud. Busque fechas importantes.
.ﻳﺗﻌﻳﻥ ﻋﻠﻳﻙ ﺍﻟﻘﻳﺎﻡ ﺑﺈﺟﺭﺍءﺍﺕ ﺑﺣﻠﻭﻝ ﺗﻭﺍﺭﻳﺦ ﻣﺣﺩﺩﺓ ﻟﻼﺣﺗﻔﺎﻅ ﺑﻣﺯﺍﻳﺎﻙ
Puede que necesite hacer algo antes de ciertas
، ﻣﻁﺑﻭﻋًﺎ ﻁﺑﺎﻋﺔ ﻛﺑﻳﺭﺓ،ﻳﺣﻖ ﻟﻙ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﻫﺫﺍ ﺍﻟﺧﻁﺎﺏ ﻣﺟﺎﻧًﺎ ﺑﻠﻐﺗﻙ
fechas para conservar sus beneficios. Tiene derecho ﺍﺗﺻﻝ ﺑﻧﺎ ﻋﻠﻰ ﺭﻗﻡ.ﺃﻭ ﺑﺄﻓﺿﻝ ﻁﺭﻳﻘﺔ ﺗﺭﺍﻫﺎ
a obtener esta carta en su idioma, con letra grande, .(TTY: 1‐888‐221‐1590) 1‐855‐242‐8282
o de cualquier otra manera que sea mejor para
usted, de manera gratuita. Llámenos al ﺍﭘﻧﯽ ﺯﺑﺎﻥ ﻣﻳں ﻣﺩﺩ ﺣﺎﺻﻝ ﮐﺭﻳں:Urdu
1‐855‐242‐8282 (telefonía de texto [TTY]: ﺳﮯ ﺻﺣﺕVirginia Medicaid ﺍﺱ ﻧﻭﭨﺱ ﻣﻳں ﺁپ ﮐﮯ ﺑﻳﻧﻳﻔﭨﺱ ﻳﺎ
1‐888‐221‐1590). ﮐﮯ ﮐﻭﺭﻳﺞ ﮐﮯ ﻟﻳﮯ ﺩﺭﺧﻭﺍﺳﺕ ﮐﮯ ﺑﺎﺭے ﻣﻳں ﺍﮨﻡ ﻣﻌﻠﻭﻣﺎﺕ ﮨﻳں۔ ﺍﮨﻡ
ﺗﺎﺭﻳﺧﻭں ﭘﺭ ﻧﻅﺭ ﺭﮐﻬﻳں۔ ﺁپ ﮐﻭ ﺍﭘﻧﮯ ﺑﻳﻧﻔﭨﺱ ﺑﺭﻗﺭﺍﺭ ﺭﮐﻬﻧﮯ ﮐﮯ ﻟﻳﮯ
Korean: 본인의 언어로 도움을 받으세요. ﻣﺧﺻﻭﺹ ﺗﺎﺭﻳﺧﻭں ﺗﮏ ﮐﺎﺭﺭﻭﺍﺋﯽ ﮐﺭﻧﮯ ﮐﯽ ﺿﺭﻭﺭﺕ ﮨﻭﺳﮑﺗﯽ ﮨﮯ۔
이 통지서에는 버지니아 메디케이드의 의료 ﻳﺎ ﮐﺳﯽ ﺩﻭﺳﺭے، ﺑڑے ﺣﺭﻭﻑ ﻣﻳں،ﺁپ ﮐﻭ ﻳہ ﺧﻁ ﺍﭘﻧﯽ ﺯﺑﺎﻥ ﻣﻳں
보험 혜택 또는 의료 보험 신청에 대한 중요한 ﻣﻔﺕ ﺣﺎﺻﻝ ﮐﺭﻧﮯ ﮐﺎ ﺣﻖ،ﻁﺭﻳﻘﮯ ﺳﮯ ﺟﻭ ﺁپ ﮐﮯ ﻟﻳﮯ ﺑﮩﺗﺭﻳﻥ ﮨﻭ
정보가 들어 있습니다. 이에 대한 중요한 ( ﭘﺭ1‐888‐221‐1590 : )ﭨﯽ ﭨﯽ ﻭﺍﺋﯽ1‐855‐242‐8282 ﮨﮯ۔ ﮨﻣﻳں
마감일도 공지하고 있습니다. 혜택을 받으려면 ﮐﺎﻝ ﮐﺭﻳں۔
마감일까지 조치를 취하셔야 합니다. 이
Hindi: अपनी भाषा म मदद ल
통지서는 본인이 사용하는 언어로 또는 큰
इस नोिटस म Virginia Medicaid से पर्ा होने वाले आपके लाभ या
글자로 인쇄된 서신으로 또는 본인에게 최선이
हेल्थ कवरे ज हेतु आवेदन के बारे म महत्वपूणर् जानकारी दी गयी है।
될 수 있는 방법으로 무료로 받을 수 있는 권리가
महत्वपूणर् तारीख देख। आपको अपने लाभ को बनाये रखने के िलए
있습니다. 저희에게 문의해 주십시오. 문의처
िनि त तारीख तक कायर्वाही करने की आवश्यकता हो सकती है।
1‐855‐242‐8282 (TTY: 1‐888‐221‐1590)로
आपको इस पतर् को अपनी भाषा म, बड़े िपर्ंट म, या ऐसे िकसी अन्य ढंग
전화하십시오.
म जो आपके िलए सबसे अच्छा हो, िन:शुल्क पर्ा करने का अिधकार है।
Vietnamese: Nhận giúp đỡ bằng ngôn ngữ của quý vị हम 1‐855‐242‐8282 (TTY: 1‐888‐221‐1590) पर फोन कर।
Thông báo này có thông tin quan trọng về cách quý
vị nhận phúc lợi hoặc cách nạp đơn nhận bảo hiểm y ﺩﺭﻳﺎﻓﺕ ﮐﻣﮏ ﺑﻪ ﺯﺑﺎﻥ ﺧﻭﺩ:Farsi
ﺍﻳﻥ ﺍﻁﻼﻋﻳﻪ ﺣﺎﻭی ﺍﻁﻼﻋﺎﺕ ﻭ ﻣﻁﺎﻟﺏ ﻣﻬﻣﯽ ﺩﺭﺑﺎﺭﻩ ﻣﺯﺍﻳﺎ ﻳﺎ ﺩﺭﺧﻭﺍﺳﺕ
tế thuộc chương trình Medicaid của tiểu bang
ﻣﯽVirginia Medicaid ﺷﻣﺎ ﺑﺭﺍی ﭘﻭﺷﺵ ﺑﻬﺩﺍﺷﺗﯽ ﻭ ﺩﺭﻣﺎﻧﯽ ﺍﺯ
Virginia. Hãy chú ý đến những ngày quan trọng. Quý
ﺷﺎﻳﺩ ﻻﺯﻡ ﺑﺎﺷﺩ ﺑﺭﺍی ﺣﻔﻅ. ﺑﻪ ﺗﺎﺭﻳﺧﻬﺎی ﻣﻬﻡ ﺗﻭﺟﻪ ﺩﺍﺷﺗﻪ ﺑﺎﺷﻳﺩ.ﺑﺎﺷﺩ
vị có thể phải hành động trước một số ngày trong ﺷﻣﺎ ﺣﻖ ﺩﺍﺭﻳﺩ ﺍﻳﻥ.ﻣﺯﺍﻳﺎ ﺩﺭ ﺗﺎﺭﻳﺧﻬﺎی ﻣﺷﺧﺻﯽ ﺍﻗﺩﺍﻣﺎﺗﯽ ﺑﻌﻣﻝ ﺁﻭﺭﻳﺩ
Thông báo này để tiếp tục nhận phúc lợi. Quý vị có ﺑﺎ ﺣﺭﻭﻑ ﭼﺎﭘﯽ ﺩﺭﺷﺕ ﻳﺎ ﻫﺭ ﺭﻭﺵ،ﻧﺎﻣﻪ ﺭﺍ ﺑﻪ ﺭﺍﻳﮕﺎﻥ ﺑﻪ ﺯﺑﺎﻥ ﺧﻭﺩ
quyền nhận thư này miễn phí bằng tiếng Việt, bằng ﻟﻁﻔﺎ ً ﺑﺎ ﻣﺎ ﺩﺭ ﺷﻣﺎﺭﻩ.ﺩﻳﮕﺭی ﮐﻪ ﺑﺭﺍﻳﺗﺎﻥ ﻣﻧﺎﺳﺏ ﺍﺳﺕ ﺩﺭﻳﺎﻓﺕ ﮐﻧﻳﺩ
chữ khổ lớn hoặc theo cách nào phù hợp nhất với .( ﺗﻣﺎﺱ ﺑﮕﻳﺭﻳﺩTTY: 1‐888‐221‐1590) 1‐855‐242‐8282
quý vị. Xin gọi cho chúng tôi theo số 1‐855‐242‐8282
(máy TTY: 1‐888‐221‐1590). Bengali: আপনার নিজের ভাষায় সাহায্য পান
Virginia Medicaid এর স্বাস্থ্য বিমা বিষয়ক আপনার সুযোগ‐
Chinese (Traditional): 用您使用的語言獲得幫助 সুবিধা অথবা আবেদন সম্পর্কিত গুরুত্বপূর্ণ তথ্য এই নোটিশে
本通知包含有關您的Virginia Medicaid福利或醫療 আছে। গুরুত্বপূর্ণ তারিখগুলির অনুসন্ধান করুন। আপনার প্রাপ্য
承保申請的重要資訊。請查看重要的日期。您可 সুযোগ‐সুবিধা চালু রাখতে হলে আপনাকে নির্দিষ্ট তারিখের
能需要在某些日期之前採取行動,才能保持您的 মধ্যে পদক্ষেপ গ্রহণ করতে হতে পারে। আপনার অধিকার আছে
福利。您有權免費用您使用的語言、大印刷體或 নিজের ভাষায়, বড় অক্ষরে ছাপা অথবা আপনার পক্ষে
其他最適合您的方式收到本信函。請電洽 সর্বশ্রেষ্ঠ এমন যে কোনও উপায়ে এই চিঠিটি বিনামূল্যে
1‐855‐242‐8282(TTY: 1‐888‐221‐1590)。 পাওয়ার। আমাদের টেলিফোন করুন এই নম্বরে:
1‐855‐242‐8282 (TTY: 1‐888‐221‐1590)।
Case #: 127972529 Page 11 of 12 Correspondence #: 784003985
Tagalog: Tumanggap ng tulong sa inyong wika German: Holen Sie sich Hilfe in Ihrer Sprache
May mahalagang impormasyon ang patalastas na ito Diese Mitteilung enthält wichtige Informationen zu
tungkol sa inyong mga benefit [kapakanan] o Ihren Krankenversicherungsleistungen oder zu Ihrem
paghiling na masakop ng segurong pangkalusugan ng Antrag auf Krankenversicherung von Virginia Medicaid.
Virginia Medicaid. Tignan ang mga mahahalagang Achten Sie auf wichtige Daten. Sie müssen
petsa. Maaaring dapat kumilos kayo sa ilan mga möglicherweise zu bestimmten Terminen Maßnahmen
petsa upang mapanatili ang inyong mga benefit. May ergreifen, um Ihre Leistungen weiterhin zu erhalten. Sie
karapatan kayong matanggap ang sulat na ito sa haben das Recht, diesen Brief kostenlos in Ihrer
iyong wika. malaking mga letra, o sa anumang paraan Sprache, in Großdruck oder auf eine andere Weise zu
na pinakamahusay sa inyo. Tawagan kami sa erhalten, die für Sie am besten ist. Rufen Sie uns bitte
1‐855‐242‐8282 (TTY: 1‐888‐221‐1590). an unter 1‐855‐242‐8282 (TTY: 1‐888‐221‐1590).
Amharic: በቋንቋዎ እርዳታ ያግኙ Bassa: M ɓɛì́ n gbo‐kpá‐kpá dyéɛ ɖé wuɖu m̀ poɛɛ mú
ይህ ማስታወቅያ ከቨርጂንያ ሜዲኬይድ የሚያገኙትን ጥቅሞችዎን Céè‐ɖɛ̀ nìà kɛ ɓéɖé bɔ̃̌ kpa ɖɛ ɓě ɓó wé ɓě kɔ̃̀ ɓaɖa m̀
ወይም የጤና ሽፋን ማመልከቻን አስመልክቶ አስፈላጊ መረጃ ያዘለ ɓɛ́ìn gbo‐kpá‐kpá ɓě dyéɛ ɔ jǔ ké m̀ dyi gbo‐kpá‐kpá zɔ̀
ነው። አስፈላጊ ቀኖችን ይመልከቱ። ጥቅሞችዎ እንዳይቋረጥብዎ፣ ɓó nì kpóɖó‐dyùàɔ̀ dyi káná jè sɔ̀ìn ɖé nyɔ Kũùn jè gbo‐
በተወሰኑ ቀኖች ውስጥ እርምጃዎችን መውሰድ ሊያስፈልግዎ ይችል kpáìn‐naín nìà ɖé Vɔ̀jínìà kɛɛ ní. Dè wé kpa ɖɛ ɓě kɔ̃̀ mú
ይሆናል። ይህን ደብዳቤ፣ በነጻ፣ በቋንቋዎ፣ ተለቅ ባሉ ፊደሎች
m̀ ɓɛ́ìn gbo‐kpá‐kpá ɓě nìà kɛ dyéɛ kɛɛ jè dyéɖé gbo.
ታትሞ፣ ወይም ለእርስዎ በሚያመቹ በሌላ መንገዶች የማግኘት
መብት አልዎት። ወደኛ በ 1‐855‐242‐8282 M kɔ̃̀ ɓɛ́ m̀ ké gbo‐kpá‐kpá nìà kɛ zɔ̀ ɓó wé jɛ́ɛ́ ɓě ɓaɖa,
(TTY: 1‐888‐221‐1590) መደወል ይችላሉ። ɓɛ́ m̀ ké nì gbo‐kpá‐kpá ɓěɔ̀ dyé. M ɓɛ́ìn céè‐ɖɛ̀ nìà kɛ
dyéɛ pídyi ɖé wuɖu m̀ poɛɛ mú ɖé céè‐ɖɛ̀‐dyèɖè boo‐
French: Obtenez de l'aide dans votre langue boo mú, mɔɔ ɖé hwìè kà kò ɖò kɔ̃̀ mú m̀ mɔ́ ɓɛ́ wa ké nì
Cet avis contient des informations importantes sur céè‐ɖɛ̀ɔ̀ céè kɛɛ mú. Ɖá à nììn ɖé nɔ̀ɓà nìà kɛ kɔ̃
vos prestations ou votre demande d’assurance‐ 1‐855‐242‐8282 (TTY: 1‐888‐221‐1590).
maladie auprès de Virginia Medicaid. Recherchez les
dates importantes. Vous devrez peut‐être prendre Ibo: Nweta enyemaka n’asusu gị
des mesures avant certaines dates pour conserver Nkwupụta nke a nwere ozi dị mkpa banyere uru ndị gị
vos prestations. Vous avez le droit d'obtenir cette maọbụ arịrịọ gị maka mkpuchi ahụike site na Virginia
lettre gratuitement dans votre langue, en gros Medicaid. Chọọ maka deeti dị mkpa. Aga‐achọrọ ka ịme
caractères ou de la manière qui vous convient le ufọdu ihe n’ufọdu ubọchị iji dowe uru gị gasị. Ị nwere
mieux. Appelez‐nous au 1‐855‐242‐8282 (ATS: ikike ịnweta akwukwọ ozi nke a n’efu n’asụsụ gị,
1‐888‐221‐1590). ebiputara n’iji nnukwu mkpụrụedemede, maọbu n’uzọ
ọzọ kacha mma maka gị. Kpọọ anyị na 1‐855‐242 8282
Russian: Получите помощь на вашем языке (TTY: 1‐888‐221‐1590).
В этом уведомлении содержится важная
информация о ваших льготах или заявке на Yoruba: Gba iranlowo ni ede rẹ
медицинское страховое покрытие Medicaid штата Akiyesi yi ni iwifun‐ni pataki nipa awon anfaani tabi iwe
Вирджиния. Обратите внимание на важные даты. ìbẹwẹ fun agbegbe ilera lati Virginia Medicaid. Wa
От вас может требоваться выполнение тех или awọn ọjọ pataki. Ó se é se lati gbe igbésẹ ni awọn ọjọ
иных действий в определенные сроки для kan lati fi awọn anfaani rẹ pamọ. Ó ni ẹtọ lati gba lẹtà
сохранения ваших льгот. Вы имеете право на yi ni ọfẹ ni ede rẹ, ni kikọsilẹ gàdàgbà tabi ni ọnà miran
бесплатное получение этого письма на вашем ti ó dara fun ọ. Pè wá ni 1‐855‐242‐8282
языке, крупным шрифтом или в другом удобном (TTY: 1‐888‐221‐1590).
для вас формате. Позвоните нам по номеру
1‐855‐242‐8282 (TTY: 1‐888‐221‐1590).
Case #: 127972529 Page 12 of 12 Correspondence #: 784003985