San Juan

www.allinforhealth.org

Unied School District

AFFORDABLE CARE ACT INFORMATION AND ENROLLMENT EVENT

Saturday, January 11, 9 am3 pm Rio Americano High School Library
4540 American River Drive Sacramento, CA 95864

What To Bring:
E Social Security numbers for applicants who are U.S. citizens, or document information for immigrants with satisfactory status who need insurance. Proof of citizenship or immigration status is required only for applicants. E Employer and income information for everyone in your family. E Your federal tax information. For example, the person who files taxes as head of household and the dependents claimed on your taxes. E Information about health insurance that you or any family member gets through a job.

FREE Childcare

RETURN BY DECEMBER 17th. You can confirm your attendance and schedule an enrollment appointment at this event, by filling out the form below. Return this section to your students teacher. Our event coordinators will contact you. Name: School Child Attends: Phone: best time to call: morning afternoon evening Email: Home Address:

If you would like to make an appointment with an enrollment specialist certified by Covered California about enrolling in no-cost or low-cost health care, please mark your preferred appointment time for January 11th: 9 10 a.m. 10 11 a.m. 11 a.m. Noon Noon 1 p.m. 1 2 p.m. 2 3 p.m. Please mark the health plan you would be interested in enrolling in: Anthem Blue Shield Health Net Kaiser Permanente Molina Western Health Advantage I have no preference.

Yes, I will need childcare at this event for _______ children. Yes, someone can contact me to confirm my appointment or to help me enroll over the phone.

signature date

For more information, e-mail SanJuan@TeachersforHealthyKids.org or call (916) 440-8811

San Juan
www.allinforhealth.org

Unied School District

AFFORDABLE CARE ACT EVENTO DE INFORMACIN Y INSCRIPCIN

Sbado, 11 de Enero, 9 am3 pm Biblioteca de la Escuela Secundaria Ro Americano
4540 American River Drive Sacramento, CA 95864

Qu Llevar:
E E E E E W2 o Declaracin de impuestos del ao pasado Certicado de Nacimiento o Tarjeta de Residente Legal Comprobante de domicilio: por ejemplo, una factura de servicios Certicado de Naturalizacin Ciudadana + Residencia Estado Nmero de Seguro Social para cada miembro de la familia de la inscripcin

Cuidado de Nios Gratis

VOLVER ANTES DE 17 DE DICIEMBRE. Puede confirmar su asistencia y el horario de la cita de inscripcin en este evento, rellenando los datos del formulario y devolver esta seccin con el maestro de su estudiante. Nuestros coordinadores de este evento estaran en contacto con unsted. Nombre: Escuela de Hio(a): Telfono: Mejor hora para llamar: Maana Tarde Nochebest Email: Domicilio: S, voy a necesitar el cuidado de nios en este evento para _______ nios. S, alguien me puede contactar para confirmar mi cita o que me ayude a inscribirse por telfono.

Si usted desea hacer una cita con un especialista acerca de la inscripcin en ningn costo o cuidado de salud a bajo costo, por favor, marca la hora de la cita preferida para el 11 de enero: 9 10 a.m. 10 11 a.m. 11 a.m. medioda medioda 1 p.m. 1 2 p.m. 2 3 p.m. Estara muy interesado en inscribirse en el siguiente plan de salud: (marque uno): Anthem Health Net Blue Shield Kaiser Permanente

Molina Western Health Advantage No tengo ninguna preferencia

firma fecha

Para obtener ms informacin, correo electrnico SanJuan@TeachersforHealthyKids.org o llame al (916) 440-8811