t1J · A...

6
mrofi Mt1tn8ffmJJlt11ld8 Bl:1mn:nmnut~: 1riijurlt:nirl S mns: en mnutt1 St3ijltHUljf'itHlm t1J ftJU:f!ut nm f'i~cn mnui~ ltIJ:m ru ism1cn mnut~: [ ~rulMufitnmnJ mmnutl'U'tjlJ:flU: ____ I tpU'19itU3fflf: -- ---------- tflluff M~U1SHfflPltmtU3 n~tlMMITTUl~ (SBC) is:§~~t!JHf'iO~ffiJ\l~ Nf flltufflt5Sffitfl18ffi 0"1 SBC U~O]ijf'inm.fluf ~ruijM ~~ttS 8mn s: §~tunff runmtnrun lll rtmf}utttmilui13tel 81 (IJ8ffi '1 "1 {;run rimri sfrnmtnruntuisttS smn s: ct~ nrnmtn mtm mnrn~ts :) §~1r!1m sg nmtn.ut9Jf'iri8) "1 ts:ltfFflsinttltfllu6M~~llJj Gtm:nii'tflSUt~m~lnHnFrnmmnummw{fn -t1i~t:ffg~rumsQ.flUGJ;!;tlt:1,tuiSrutj8'1JlUlffiirum1snummnum [U'!l rurifi'tf1Sffifi9tl]i c;im: 2tutf2 tu1t,tITT1srucr~rnJ1~tITT ~otti os s §nJPJfit~ rumm-rnrrnn , li'iruu1nnru1r1H1 , n11ci tum mnum , nliGllin tummiditfffi , ffltfflfifitl, Hfitl rutwn 11m111t~itli~lnt~ rum St;jfuU@fiiS: wmarunJffiSjfitfj tlfifflmHrunJ~91fitlm1 www.[insert].com !JiUTI 1-800-[insert] i~t:Ui~rt;QjlUGJ;!;tlt:1,tui . ' I ~~lU I \Ul"ltlffiSctimns:w211h ftUlJlf fl181 S :J - - -- - - -- - - - ---- - - - - - --- ----- -- .. ' .. tnmrmnn~Jl:Jttl!:f ? $ tm:n stlufihm13td rums " ' mmn~b tfSt~ruijng umr mnn~ruruHntne ? - ' ti'itfl smtmnnb tt5J~t9Jtit9 flJU:flffifutlf'i ' ' ijctlf'iCU'lffl.It9? $ tn~nnruims mnum rur.u iin.rmo1 cunnm trn $ mn a:msi;QsQ~s? tnij{druasmrm~mtru rQ~~Ql3, i'iJ!!nnruimsmno w ru wnruntcrf ? -- . ,. 1m.1nsborun wt,mnnu . .. ., . tp fllSttJUmtJJffittS rutfll tns1i'i~urunwJi wm9? tfiunulfmtmrurn s taf;U t91~UHi'itli'it9 flltn9? 1ru2n1tUJnnsnJ oMs 1545-2229, 1210-0141, 2t1 0938-1146 1 ts s mmuQJtlJ1tumi1~§ 6 famnflf{l 2016

Transcript of t1J · A...

Page 1: t1J · A i~~tGOJD~Gij)irJ_rug,2~rutnmmnmtliHlHNG12Utp{!)m1q~ii~n1mntlm:etu~unm1mnn~ruNtifitfjfG12UtrlQJ iU nJ 2mtffin1"itlti WU'jf Gl 2H ~t~ 1 fili'iCTifinJUleiiSUUJ(X-ray ...

mrofi Mt1tn8ffmJJlt11ld8 Bl:1mn:nmnut~: 1riijurlt:nirl S mns: en mnutt1 St3ijltHUljf'itHlm t1J ftJU:f!ut nm f'i~cn mnui~ ltIJ:m ru ism1cn mnut~: [ ~rulMufitnmnJ

mmnutl'U'tjlJ:flU: ____ I tpU'19itU3fflf: --

----------tflluff M~U1SHfflPltmtU3 n~tlMMITTUl~ (SBC) is:§~~t!JHf'iO~ffiJ\l~ Nf flltufflt5Sffitfl18ffi 0"1 SBC U~O]ijf'inm.fluf ~ruijM ~~ttS 8 mns: §~tunff runmtnrun lll rtmf}utttmilui13tel 81 (IJ8ffi '1 "1 {;run ~ rimri sfrnmtnruntuisttS smns: ct~ nrnmtnmtm mnrn~ts :) §~1r!1m sg nmtn.ut9Jf'iri8) "1

ts:ltfFflsinttltfllu6M~~llJj Gtm:nii'tflSUt~m~lnHnFrnmmnummw{fn -t1i~t:ffg~rumsQ.flUGJ;!;tlt:1,tuiSrutj8'1JlUlffiirum1snummnum [U'!l rurifi'tf1Sffifi9tl]i c;im: 2tutf2 tu1t,tITT1srucr~rnJ1~tITT ~ottios s §nJPJfit~ rumm-rnrrnn, li'iruu1nnru1r1H1, n11ci tum mnum, nliGllin tummiditfffi, ffltfflfifitl , Hfitl rutwn 11m111t~itli~lnt~ rum St;jfuU@fiiS: wmarunJffiSjfitfj tlfifflmHrunJ~91fitlm1 www.[insert].com !JiUTI 1-800-[insert] i~t:Ui~rt;QjlUGJ;!;tlt:1,tui

• . ' I ~~lU I \Ul"ltlffiSctimns:w211h ftUlJlf fl181 S :J - - -- - - -- - - - ---- - - - - - --- ----- --.. ' .. tnmrmnn~Jl:Jttl!:f? $

tm:n stlufihm13td rums " ' mmn~b tfSt~ruijng

umrmnn~ruruHntne? - ' ti'itfl smtmnnb tt5J~t9Jtit9 flJU:flffifutlf'i

' ' ijctlf'iCU'lffl.It9? $

tn~nnruimsmnum rur.u iin.rmo1 cunnmtrn $ mna:msi;QsQ~s? tnij{druasmrm~mtru rQ~~Ql3, ~ i'iJ!!nnruimsmno w ru wnruntcrf? - - . ,. 1m.1nsborun wt,mnnu . .. ., . tp fllSttJUmtJJffittS rutfll tns1i'i~urunwJiwm9? tfiunulfmtmrurn staf;U t91~UHi'itli'it9flltn9?

1ru2n1tUJnnsnJ oMs 1545-2229, 1210-0141, 2t1 0938-1146 1 ts s mmuQJtlJ1tumi1~§ 6 famnflf{l 2016

Page 2: t1J · A i~~tGOJD~Gij)irJ_rug,2~rutnmmnmtliHlHNG12Utp{!)m1q~ii~n1mntlm:etu~unm1mnn~ruNtifitfjfG12UtrlQJ iU nJ 2mtffin1"itlti WU'jf Gl 2H ~t~ 1 fili'iCTifinJUleiiSUUJ(X-ray ...

A i~~tGOJD~Gij)irJ_rug,2~rutnmmnmtliHlHNG12Utp{!)m1q~ii~n1mntlm:etu~unm1mnn~ruNtifitfjfG12UtrlQJ iU nJ 2mtffin1"itlti WU'jf Gl 2H ~t~ 1

fili'iCTifinJUleiiSUUJ(X-ray mHnmmtf)) filihl:!Uffln (lt\18 CT / PET, MRls)

l}JtuBM;f"1J]1mJ11P11i g1~rn1 ,atff'}flmrut"Ja 1---. -... - ., --, ---1--------+-------+-----------I

Yflf'BmnruflJW'i glru1un1~ rutmm 2 nnm 2ut~msjnHnm g1tfhunt~ nrumH~m 2 1mmnt'.ntmffl~tfnrnu u6m2 1-----------1-------------+---------------f--------------1 titflummmm mtlnUHu www.[insert].com

1P MsifttmnamJt:m nt"J68SfylMUrfm9J

" ., i!Jfii~~ (8.91. tf~nJlru m1t:ffifi nn~: US18)

.) e I I

mntl91usun11 m:um2

" 212 6

Page 3: t1J · A i~~tGOJD~Gij)irJ_rug,2~rutnmmnmtliHlHNG12Utp{!)m1q~ii~n1mntlm:etu~unm1mnn~ruNtifitfjfG12UtrlQJ iU nJ 2mtffin1"itlti WU'jf Gl 2H ~t~ 1 fili'iCTifinJUleiiSUUJ(X-ray ...

9 8}£ [-[wo:rµesur MMM] l,S1l!)HLYfl.1 U1ffi!LYS f;J}!lf\J !JQfl.1 f}1RrY rtfl.1}!.JQ.11l!J-1!!.Jrt~1_,Jt.n.Hf S ~HJt!!J(B 1RSµ1S lB~~!;lB1fY .]

• • • krt1W~USL0Sf)rugp=!YlSC1J1SlU~61qll311Jlnq~

RSJfiB~Ut;iu=llilJtUJBP!ft.NU~Qn[nfi L!,l.ULYrul.13uufµiu\1Uat\J > q«;il!S6!Jf«:Ynnws PlfWlSN1Q.1t1tUJJ.51i!ui ~ YI B1q1p1q¥;1l!La l!ltJru1q~ ru w~us LOSfJA!JlSN1

!LR!J~ rnlil tu!!J ~ Y !LY uO}fiIDBnfl.uppwtw !LR!J~ ruLY s~ stfluf«:YruatijJls{.lJ rtl

[===========t=======t=====+==!tlB~!J~!V, ~n~!!J~Y1! .. !J~~~Y~!LY~ ru muu lJfYlD-1 ~!LY

u(a1qfp1~lZ~S~~ 18 qruwnntJ1Jt!J utJ1Jus gi I!' fD ,0 • • ~

1m u(a1qfpwIY1 sw=~=w"-"'"u-;;"101-1fu!-:-tl-,-:lf\JC--:-,P-·~~ltl-1=1=y=n=a uuw8lYtwifflusuui

l.£ g}w IB ~ s lB!J.H IDtq(aun flYfl.1 lJ U UJ 6fl.1!1.f\J lJf\JlD-1 f;J!LY WJ1:IYUltUJt;}lfilNm flYfl.1 lJ U UJ 6 ru !lf\J lJfYlfl.1 f;J!LY ~ ~tl!Jst{luff01S{.Y rtl I

: tll,S1lJ UJ3f\J lp g}!LY

sttru UfY !LY/S Yfl.1 UfY tl Sl!JR!J lSfY1 --·-------~ -·-(' -------

:mu:iss LRru r2m "' .. .. Yfl.1 U!:J !LY/S Yfl.1 U!:J !JR!JlSfY1

mru U1ULYDY S!fY 6 ,. .. ..

ru LO Lf u Y LR1ru t.tNiru P!LY I

tlPlJ!V1fl.1 ~!LY IP • I

YLY:JfB U1t!1tf6 uit!1fh I ~

: w1fi1a t.RUHJllS{.lJ rll

SlfilWl!1 llN ru LOlllJRUtJYlfi unwlh!JLHUUJ8N

QgspUUJ8lY .. l.l"JUUJJUlufqµS{Yril

re UU!RJSU:1 upnnu

(YbQsg'l1¥L01~nq~um uw'lmuru9~~u.m I 1

@ufu u D • IDufun w~luiru ., Hrutllfl!JlS!V1 nµlliµ:;mUtSru1Q.1 PYH qf.lµ:;lfiYlJN1Q.1 tluR µua

ru !lJlJ an1.!.l.uwgu1 ---um1~riqsuHfutl}fl I I p

Page 4: t1J · A i~~tGOJD~Gij)irJ_rug,2~rutnmmnmtliHlHNG12Utp{!)m1q~ii~n1mntlm:etu~unm1mnn~ruNtifitfjfG12UtrlQJ iU nJ 2mtffin1"itlti WU'jf Gl 2H ~t~ 1 fili'iCTifinJUleiiSUUJ(X-ray ...

• • •

flJijruruwnat:fiu~m1mmnmtl:ffi8JJlfHm1~ruffiU~llimStUtu8tUijfiG~U~fmmmnuttuUt\JijfiU~urinmsu'J)U1 &-, o to • t o C'll

'1fiffi2981fi92~ftlLffiU.glfitnHntltm:i:i: [insert State, HHS, DOL, and/or other applicable agency contact information]i ciiLHftltSFntmmt1Ui~i~tltsjnffiUffi8~'1Jijfi~tl1m !BU'J)ru9'1tlfflt9Q)Fmmmnumtrnrummru: 9tlj)immnUitlft18f'fl'1i utm:nt'imsu1~mg)nHns11m nJHQrul9ifflS www.HealihCare.gov ynmt9ims 1-800-318-2596i

flf 9trurQltl MJEf O at3 M nna qmnru ftJUfH m 201 fitrn en ttfl 21~ ruH'l uij mm s tu N sttiijnm s m nJU ~tlti rntum~ 2 ~1tl s rm iUt\Jt[fitutmumru~tflJCTffifiJUq'.fltltitlli ffifiJU~tlis:mtmmmm1th ftflfgfi YU(Hl~8~HlJ1i utm:nft'i:f12Ul~Hi9jiiHriftJ§tut\Jt[fi nJHmt~rum1qt1~m~Jru~~1:,ntrntmt121~ruy~2t1~~rum~Ntmu~nJU(Hl~ttgML'1Jtm:i , .,. ., , ~fiful!t~2mnytutrnn~ .. ru .. n_:1m~mmtrumt.~~JmnmnJU'1-fltlct'lu~tl2~m.nynrugntillitutmuttnfj~rut9i2tltl'.32mnututrni mm:nnmsrn~m9JiiH'7tu~ruftlt[fi m1~2~ruit1m: yci~lli njHITTfi9tl~ [insert applicable contact information from instructions]1

ttltcismns:~ru~tm1mmnmtlmmt3HUJUnflY19? [018!:!ffiftJMffl9] tUN2tUtfnH2'i:f12m1m2nummmiiHuJurtf1tutmutiwfa, trnsmgm1~miiu~m1mru1~rutrmgn~u;sJUHn1mrun'.rt§nt9 n,:tmlnijfi'i:f12 rugrui: fuHJ~ti:iULffl 2 tut'i:f1UfflmUfiirutl nnmtmil~ rut§fi'i:f12fflim mnum fl18nl n tut'i:f1Ui8im: j

1rutignntfil,mrumM~ l'tHlujlQ) ('iHNj1Q)): Para obtener asistencia en espafiol, llame al [insert telephone number].]

[Tagalog (Tagalog) : Kung kailangan ninyo ang tu long sa Tagalog tumawag sa [insert telephone number].]

[Chinese ( q:ix ): :!zll :lfd\\!~i:px~ffl!l)J, i~~H~1-%:Pi:! [insert telephone number].]

[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [ insert telephone number].]

---1iJE/ftff msrnmHiilfnmguft1mft1ntrmn:mammilwtJm1dnmwfvlYllf fJ!JBmnilgMf lJl1tWft1mtnfiJ liJY1ff mfgn11!Jifi----

1>

4 ts 6

Page 5: t1J · A i~~tGOJD~Gij)irJ_rug,2~rutnmmnmtliHlHNG12Utp{!)m1q~ii~n1mntlm:etu~unm1mnn~ruNtifitfjfG12UtrlQJ iU nJ 2mtffin1"itlti WU'jf Gl 2H ~t~ 1 fili'iCTifinJUleiiSUUJ(X-ray ...

9 ms .. r.,:sm1ptW)L!LBUHLYSµ~RYlJN!S}Y(smfp1muruf}!UJ!;!LruNSY1ruaru55!LYSlfl~~:SUUJSl3l

(LSf;J!JUJSUJ.R UJC}~ ill ufunt:}Q~.m~ LSn: ~hru !;!Snµrnw)

e,w rurnudit1Yn1Yl!l1w

(fu S lD U UJS Lru t:} ~1n~1t UJ '

mill ufunCiY!B!LS p11wsmlfi5 millmR~Q) , o (" ,1 ,a

aor J;Yru z §BwilaP!fll.S1Y§B!il~~11w

(mHsYru uruf5 mrsH~s 0 "' ~

YYtru msi!ill ufunt:tYl.81LS puw mm 6) f0 0 c-c;. ("

ffifl!.lll6SLR~UY Bad I .. ,

r.,:wu1hY!~US8ffiLmtnnULBltl!UJ!J!ru1Yfl!~(jfll!)tY1:mt'.tLStHnULBltl!LYS!U1HUll58WUD.Rfu 0 (" t O ("fC;> (" P O t H 1-, ,:, 0 0

r.,l.Gt:}f~mwaN=-1w,....,s=p=1HLY111.m~nm.HYHru~!muruQ!WS!YU1.1}QnLbmLn11[.R~1:msLE}:!~01t i.,:suwSP}t'.tYl.81 ruwn.Rislbs.RrumAY1Jrums (mnuLBltltwmrut:}swmmurumwt:}YYuuw) murumwYruuYm!w

s1uuLE1nwrntl111.,1J~m!~m~1iu:iwiJ~~ mru1.1~YH~rn1Jru1r:u£:JYHru~ii=i1Y swruiswf!ru~i~ .. i!wiYy Lli.!muwru1mru1LH t.GruauwsLE~SYHrunmYL01Yumurumw 1.,fu!Lrufh1LSpuwmnuLBLtmLH:m C IO P P t ~ o a C-tH

tw s ~!ru ~1n(mm1m RU_:tHUlLS 8 ltl!J}~ w1~ w Lf}ns wru ~ }ru LO L!iHw l.. Bun uru91wuu t.ruil~ UJtLYUlSll}S6: si

.

; : S1tll.8tUflUl.31!1tlYS1Lrtmfll.68 UH • • •• < .. '°.

Page 6: t1J · A i~~tGOJD~Gij)irJ_rug,2~rutnmmnmtliHlHNG12Utp{!)m1q~ii~n1mntlm:etu~unm1mnn~ruNtifitfjfG12UtrlQJ iU nJ 2mtffin1"itlti WU'jf Gl 2H ~t~ 1 fili'iCTifinJUleiiSUUJ(X-ray ...

• ttlsm1 iam1mnnl3 s • trlsm1 ~ m1mnnl3 $ • trlsmr iam1mnnb $

• ~ unifflfnrn1.inmlIJ] $ • ~ flfnrn1.inmllJ] $ • ijfi~S'l[!)[ffl11Uf'fflrunm1fm.mtll] $

• a;nneJ cm~t3) 1rnnanifmnrn1.inmllJ] %

• 1rlJ~19Jn[ff}Ouffifflff'frn1f;nmlIJ] % • a;nn9J (ffllsb) rrnnr;nifnmrnninmmJ %

• nljtwaJn1rnna!'fif(lffjfl1t.inmllJ] % • ttDooqi (~b) ~nmlIJ] %

tliftmmnamtnmrns :p:rur.vnnC\Jh~c;thf mn 91 ml u.n ru lllijfi Q ms tu rmrf d m ff s mm ft1[J:fl mJ ttutlnHnnJnrunS/filit\Ji10JfiStjjOJtf12il:tlat:

._.. V U W

ttutlnHnts{;l Nn runs1m1 Nn runs """' N II &I

mngm t\,ftn tils g ru (IHfJ stJ mr mr mn FJJ filitITT~UijfiQfilStu (f[,{JyJftf§U)

tfi~mmnamtnuu1ts:Jt:ru'.{!rueitnrut1~rnni mmn~umlu.n OJllllfjtrl SJtt3 ifJUUH

O ,o O di

(JYUIJI {lJ flJ{;J fi7IHUitJtJ) mngfrH\Jtn r:ils g ru rm1mr mn FJ) ffitfl SUt:lU m1 ct ... ...

a~,ni nil~~~ L '1Jtttitm Nm s UJi (iEf[fi/J ftjtj] fj fJ!I)

_ffll:f __ ,.0..._,8_9'l_tn_· f_M_ NJU..._, _____ __._ __ $_ fiilJ8fllUlUUI~

m1ou 8 91t.J1UU11S: Joe §~U~J!Jlri: mrfanif wnmronmllf mrfanifwnmronrnllf

m 1 m An tl $ m 1m ii n ~ -------------m m 6 t'rn .m t1JI H Bl $ mmtu1runt11f.HB1 ----- --------tu tn mm nu m $ tutnmmnum -----.---------1 ff lff tJ llf Y S ntmsfJ&tJ 1ffllftJwfjs ntmsnu1tJ krnfulfliiumnruntru{;l $ t~ s frn11ii umnruntru{;l -------------G rulUlJ MU Peg §b 6 $ {m.mwruru Joe §13 6 ___ ..i,__ _ _ ....._ _____ ._______,;~

• trlJl310JnfrnnaflifnmrnmnmlJJ] %

t~nha~ruiu3~nmit3tM'l;umf mnt3:FiJ1U~~ rui~ :u~ s (JYflJtJ m1f! nf!tJif/ nilf1 M[ fJI) filfigint\,ftntiiSQtll (X-Ray)

aum~u~ M~ttitm Nm s UJi r1nUzaliJ filiwruttutl~rnntuHJSl rm1f/f7mm1m llfullf S?J

$ ffllf89ltflfrulfll1U

1s1QU89'lt.J1frul1S: Mia §UUl3J!Jlti: n11funff wnmronrnllf

$ fill fil fl fi{;l $ fillUt!Uru11t111,H81 $ tutn m mnu1{:l

1fflfftJWYS tmsfJu1tJ $ t~ sfmnii umnruntru{;l $ {mmwruru Mia §b 6

$

$

$

$

$

$

,, 618 6