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Disability Applicaon
™
®
™
County use only:
County Date of application
This Health First Colorado (Colorado’s Medicaid program)
Disability Determination Application
must be submitted to your county oce.
Only completed and signed applications will be processed.
IF YOU NEED HELP
If you need help with this application, contact your county department of human services. Please
complete as much as you can before contacting your county technician. Find your county’s contact
info at CO.gov/cdhs/contact-your-county.
HOW TO COMPLETE THIS APPLICATION
The information you give on this application will be used to decide if you meet the disability criteria
for Health First Colorado (Colorado’s Medicaid program) benets. Colorado also allows people to qualify
for limited disability if they are employed. Your nancial eligibility will be determined separately from
this application. Please remember that having a disability does not guarantee you will qualify for
Health First Colorado enrollment.
• If you ever applied to the Social Security Administration (SSA) for Disability Benets, include
copies of all letters and notices from SSA about your disability application.
• DO NOT LEAVE ANSWERS BLANK. If you do not know the answer, or the answer is “none” or
“does not apply,” please write: “don’t know” or “none” or “does not apply.”
• Each address should include a ZIP code. Each phone number should include an area code. You
must provide complete information for each doctor you identify on this application. Failure to
provide complete information may result in those medical records not being used to make a
decision on your case.
• Do not ask a doctor or hospital to complete this application. You may get help from a friend,
counselor, case manager, county technician or family member.
• Be sure to show complete dates (month/day/year), and provide an explanation if the question
asks for detail or if you want to give additional information.
• If you need more space or want to tell us more about an answer, please use the Section 8
Remarks on page 10. Provide the number of the question being answered.
• You may send copies of any medical records you have with this application. If you don’t have
copies, the person who reviews your application can get them free of charge.
• There are many factors that impact when your disability application review is completed,
including obtaining all needed medical information. When the review is complete, you will be
notied by letter.
Sign up to get helpful information about your Health First Colorado benets by text! Text “JOIN” to
66596. Message and data rates may apply.
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Section 1 – Information About Your Disability
A. Name (First, middle initial, last)
C. Date of birth D. Age E. Gender
B. Social Security number
Check here if not eligible to receive
a SSN or refuse to obtain due to well
established religious objection.
F. Mailing address (Number, Street, Apt. No./Unit [if any], P.O. Box or Rural Route, City, State, ZIP)
G. Email address
H. Can you speak and understand English? Yes No (The reviewer will pay for an interpreter if they
need to ask you a question about your application. Refer to “Help In Your Language” on page 15.)
If “No,” what language do you speak?
I. Can you read English? Yes No Can you write in English? Yes No
J. Daytime telephone number: If you have no phone where you can be reached, please provide a
daytime telephone number where we can leave a message for you.
(___)________ This is My number Message number
K. If you would like a friend or relative who knows about your disabling conditions to help you with
your application, please provide their information here so we can contact them.
Name
Relationship Phone ( )
Address
(Number, Street, Apt. No./Unit [if any], P.O. Box, or Rural Route, City, State, ZIP)
If you are applying for a child, please ll out questions in L. If not, skip to Section 2.
L. Does the child live with you? Yes No If “No,” ll out who the child lives with below.
Name
Relationship to child Phone ( )
Address
(Number, Street, Apt. No./Unit [if any], P.O. Box, or Rural Route, City, State, ZIP)
Does the child have a legal guardian or custodian other than you? Yes No
Name
Relationship to child Phone ( )
Address
(Number, Street, Apt. No./Unit [if any], P.O. Box, or Rural Route, City, State, ZIP)
Is there another adult who helps care for the child and can help us get information about the child if
necessary? Yes No
Name
Relationship to child Phone ( )
Address
(Number, Street, Apt. No./Unit [if any], P.O. Box, or Rural Route, City, State, ZIP)
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Section 2 – Your Physical or Mental Disabling Conditions and Aects
A. What is your height without shoes: Feet Inches
B. What is your weight without shoes:
Pounds
C. What are your disabling conditions? Please list each condition separately. If you have cancer, please
include the stage and type.
D. How do your disabling conditions limit your ability to work?
E. Do your disabling conditions cause you pain or other symptoms, such as seizures, etc.? Yes No
F. When did your disabling conditions rst bother you? MM/ DD/ YYYY
G. When did you become unable to work because of your conditions? MM/ DD/ YYYY
H. Have you ever worked, including self-employment that gave you earned income? Yes No
If “No,” go to Section 4.
I. Did you work at any time after the date your disabling conditions rst bothered you? Yes No
J. If “Yes,” did your disabling conditions cause you to: (Check all that apply)
Work fewer hours? (Explain below) Change your job duties? (Explain below)
Make job-related changes such as attendance, help needed or change of employers? (Explain below)
K. Are you working now? Yes No If “No,” when did you stop working? MM/ DD/ YYYY
Why did you stop working?
L. Have you ever applied for Social Security Disability Income (SSDI) or Supplemental
Security Income (SSI)? Yes No
If “Yes,” on what date did you le the most recent application? MM/ DD/ YYYY
Is your Social Security claim: Approved Denied Still pending
What was the date of their most recent decision? MM/ DD/ YYYY
If you appealed, on what date did you le the appeal? MM/ DD/ YYYY
If your Social Security claim was denied, are you experiencing new or worsening conditions? Yes No
If the response to the above question is “Yes,” please provide a brief description of the new or
worsening condition(s) in Section 8 Remarks.
If you have had SSDI or SSI and are no longer receiving it, why did your benet stop?
Please include copies of all letters and notices from Social Security Administration (SSA)
about your disability application.
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Section 3 – Information About Your Work
A. List the jobs (up to ve), including sheltered work*, that you have had in the 15 years before
you became unable to work because of your physical, mental, emotional or learning disabling
conditions. List your most recent job rst.
*Sheltered work is an employer that employs people with disabilities separately from others.
Not applicable if you did not work at all in the 15 years before you became unable to work.
Do not answer Section 3 and go to Section 4.
Job title
(See example)
Type of business Dates
worked
(Month/year)
From To
Hours
per
day
Days
per
week
Rate of pay
(Per hour, day,
week, month or
year)
Example: Cook Restaurant 9/99 10/02 8 5 $7.0 0 Hour
B. Which job did you work the longest?
C. Describe this job. What did you do all day? If you need more space, write in Section 8 Remarks.
D. In this job, did you:
Use machines, tools or equipment? Yes No Use technical knowledge or skills? Yes No
Do any writing, complete reports or other similar duties? Yes No
E. In this job, how many total hours each day did you do each of the following:
Walk
Stand Kneel (bend legs to rest on knees)
Sit Climb Handle, grab or grasp big objects
Reach overhead Crouch (bend legs and back, down and forward)
Crawl (move on hands and knees) Handle small objects, write or type
Stoop (bend down and forward at waist)
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Section 3 (continued) – Information About Your Work
F. Lifting and carrying: Explain what you lifted, how far you carried it and how often you did this.
G. Check the heaviest weight lifted:
Less than 10 pounds 10 pounds 20 pounds 50 pounds 100 pounds or more
H. Check the weight frequently lifted: (Frequently means from 1/3 to 2/3 of the workday.)
Less than 10 pounds 10 pounds 20 pounds 50 pounds 100 pounds or more
I. Did you supervise other people in this job? Yes No
If “No,” go to Section 4; If “Yes,” complete the following.
How many people did you supervise?
Did you hire and re employees? Yes No
What part of your time was spent supervising people?
Hours
J Please check if limitations exist in any of the areas below, otherwise check: No Limitations
Breathing Seeing Hearing Speaking Concentrating
Sleeping Eating Communicating Understanding Care for oneself
Dealing with changes in routine work setting Performing manual tasks
Responding appropriately to supervision Co-workers Work situations
Other major bodily functions
Section 4 – Information About Your Medical Records
A. Have you been seen by a doctor, hospital, clinic or anyone else for the physical, emotional, mental
or learning disabling conditions that limit your ability to work? Yes No
If you answered “No” to this question, go to Section 5.
B. List other names you have used on your medical records including your maiden, married names or
nicknames.
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Section 4 (continued) – Information About Your Medical Records
Tell us who may have medical records or other information about your disabling conditions.
C. List each doctor, clinic, therapist and medical professional you have used. Use an extra sheet if
needed. Include the date the provider was last seen and date of your next appointment, if any.
1. Name Patient ID (if known)
Street address Date rst seen
City State ZIP Date last seen
Phone Next appointment (if any)
Reason(s) for visits. What disabling conditions were treated or evaluated?
What treatment was received?
2. Name Patient ID (if known)
Street address Date rst seen
City State ZIP Date last seen
Phone Next appointment (if any)
Reason(s) for visits. What disabling conditions were treated or evaluated?
What treatment was received?
3. Name Patient ID (if known)
Street address Date rst seen
City State ZIP Date last seen
Phone Next appointment (if any)
Reason(s) for visits. What disabling conditions were treated or evaluated?
What treatment was received?
If you need more space, use Section 8 Remarks.
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Section 4 (continued) – Information About Your Medical Records
D. List each hospital and other health care facilities you have used (including emergency room visits, if
occurred), unless listed in Section 4, Question C. List the most recent date rst and include type of visit.
1. Facility name Phone
Street address
City State ZIP
Type of visit
Inpatient stay (Stayed at least overnight) Date in Date out
Outpatient visit (Sent home same day) Date of rst visit Date of last visit
Emergency room visits (If occurred) Date(s)
2. Facility name Phone
Street address
City State ZIP
Type of visit
Inpatient stay (Stayed at least overnight) Date in Date out
Outpatient visit (Sent home same day) Date of rst visit Date of last visit
Emergency room visits (If occurred) Date(s)
If you need more space for this information or telling us about other sources of medical
information about you from workers’ compensation, vocational rehabilitation, insurance companies
who have paid you disability benets, prisons, attorneys, social service agencies and welfare, use
Section 8 Remarks. Be sure to include organization, phone, address, city, state, ZIP code, name of
contact person, claim or ID number (if any), date of rst contact, date of last contact, date of next
contact (if any), reasons for contacts.
If a child, does anyone else have medical records or information about the child’s illnesses, injuries
or disabling conditions (foster parents, social workers, counselors, tutors, school nurses, detention
centers, attorneys, insurance companies, and/or workers’ compensation), or is the child scheduled
to visit anyone else? If so, please include in Section 8 Remarks with organization, phone, address,
city, state, ZIP code, name of contact person, claim or ID number (if any), date of rst contact, date
of last contact, date of next contact (if any), reasons for contacts.
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Section 5 – Information About Your Medical Tests
Have you had any medical tests for your disabling conditions?
Yes (If “Yes,” complete the information below.) No (If “No,” go to Section 6.)
Kind of test Date of test?
(Month/day/year)
Where was test done?
(Name of facility)
Who requested the test?
EKG (Heart test)
Cardiac catheterization
Treadmill (Exercise test)
Biopsy: Name of body part
Hearing test
Vision test
IQ test
Speech/Language test
EEG (Brain wave test)
HIV test
Blood test (Not HIV)
Breathing test
X-Ray: Name of body part
MRI/CT Scan: Name of body part
Other: Name of test and on
what body part
If you have had other tests, list them in Section 8 Remarks.
Section 6 - Information About Your Medications
Do you currently take medications for your disabling conditions? Include non-prescribed or “over the counter”
medications. Yes No If “Yes,” provide the information below, available on your medication bottle:
Name of medicine Doctor name & phone
(If prescribed)
Reason for medicine Side eects experienced
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Section 7 – Information About Your Education and Training
A. Check the highest grade of school completed and approximate date completed. Too young
Grade School: College: Date completed:
Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12 GED 1 2 3 4 Advanced degrees
B. Did you attend any special education classes or complete any type of specialized job training, trade
or vocational school? Yes No If “Yes,” complete the following information:
School name
Address
(Number, Street, Apt. No./Unit [if any], P.O. Box, or Rural Route, City, State, ZIP)
Date attended to Type of program
If you have additional schools, list them in Section 8 Remarks.
If you are applying for a child, please ll out questions C-G. If not, skip to Section 8. If the child has an
Individualized Education Program and/or an Individualized Family Service Plan, include those documents.
C. Is the child attending daycare/preschool? Yes No If “yes” complete the following:
Daycare/preschool/caregiver name
Phone ( )
Address
(Number, Street, Apt. No./Unit [if any], P.O. Box, or Rural Route, City, State, ZIP)
Dates attended to Teacher’s/caregiver’s name
D List the name of the school the child is currently attending and dates attended. If the child is no
longer in school, list the name of the last school attended and dates attended.
School name
Phone ( )
Address
(Number, Street, Apt. No./Unit [if any], P.O. Box, or Rural Route, City, State, ZIP)
Dates attended to Teacher’s name
E If child is not enrolled in school, state reason why
F. List the names of all other schools attended in the last 12 months and dates.
School name
Phone ( )
Address
(Number, Street, Apt. No./Unit [if any], P.O. Box, or Rural Route, City, State, ZIP)
Dates attended to Teacher’s name
If you have additional schools, list them in Section 8 Remarks.
G. Has the child been tested for behavioral or learning problems? Yes No
Type of test
Test date
Type of test Test date
Is the child in special education? Yes No If “yes” and dierent from above, name of special
education teacher
Is the child in speech/language therapy? Yes No If “yes” and dierent from above, name of
speech/language therapist
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Section 8 – Remarks
Use this section for additional information you did not share in earlier parts of this form or did not
have room for. Include any additional information for which there was not enough room in previous
sections, or if you have additional information you want to include that may help making a disability
determination. After completing this section (or if you don’t have anything to add), sign below and go
to the next page. You must sign this application before it can be considered a completed Disability
Application ready for review.
THIS APPLICATION MUST BE SIGNED
By signing this application, I arm that everything is true to the best of my knowledge. I understand
that I am giving the Colorado Department of Health Care Policy & Financing and its designees the
authority to make the necessary contacts to verify any statements made on this application and to
request all records/information necessary to determine medical disability eligibility. I understand that
this application does not guarantee any program benets on my behalf.
Signature of applicant or person ling on applicant’s behalf (parent/guardian) Date (Month, day, year)
If you are unable to sign the application and have a representative (i.e., Medical Power of Attorney
(POA)/medical proxy/legal guardian, Guardian, Conservator or General POA if the General POA
has powers for insurance) sign on your behalf, you must also enclose copies of documentation that
establishes them as your Medical Power of Attorney/medical proxy/legal guardianship with this application.
Witnesses are required ONLY if this statement has been signed by an (X) mark above. If signed by an
(X) mark, two people who know the person making the statement must witness their signing and sign
below themselves, including their addresses.
1. Signature of Witness 2. Signature of Witness
Address (Number, Street, Apt. No./Unit [if any],
P.O. Box or Rural Route, City, State, ZIP)
Address (Number, Street, Apt. No./Unit [if any],
P.O. Box or Rural Route, City, State, ZIP)
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If you want or need someone to help with your
Disability Determination Application, please complete this form.
You have the right to be assisted in the application process by the person of your choice.
I,
, (print your name) name the following
person to help me complete the Disability Determination Application which includes sharing my
protected health information that will help establish health care coverage eligibility. This form does
not designate a person as my Personal Representative.
Name of person helping with application Relationship to applicant named above
Telephone number of person helping with application
PURPOSE OR NEED FOR REQUESTED INFORMATION: This authorization is only to help the applicant
complete the Disability Determination Application and does not apply to any other medical information
disclosure purpose. The information provided on the Disability Determination Application will be shared
with the Disability Determination vendor for the purpose of determining disability eligibility for health
care coverage. The nal determination will be shared with the applicant or their legal representative
at the address provided on the Disability Determination Application.
EXPIRATION OF AUTHORIZATION: This authorization will expire one year from the date signed below or
you may designate a shorter period of authorization here
. You may also revoke
this authorization at any time by contacting your county eligibility worker in writing.
I understand by signing this form that the person who helped me with this application may be contacted
by the Disability Determination vendor or the Colorado Department of Health Care Policy & Financing.
I certify that this request has been made voluntarily and that the information given is accurate to the
best of my knowledge.
Date:
Applicant signature:
Parent, Legal Guardian, Power of Attorney or equivalent signature:
Parent or Legal Guardian may sign on behalf of minor child. Legal Guardian, Power of Attorney, or
equivalent may sign on behalf of adult – documentation is required.
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Medical Records Release Form
™
®
™
WHOSE Records to be disclosed
NAME (First, Middle, Last, Sux) Birthday (MM/DD/YYYY)
Social Security number
Check here if not eligible to receive a SSN or refuse
to obtain due to well established religious objection.
Authorization To Disclose Information To Arbor E & T, LLC, dba Action Review Group (ARG)
** Please Read The Entire Form, Both Pages, Before Signing **
I voluntarily authorize and request disclosure (including paper, oral and electronic interchange):
OF WHAT All my medical records; also education records and other information related to my
ability to perform tasks. This includes specic permission to release:
1. All records and other information regarding my treatment, hospitalization, and outpatient care
for my impairment(s) including, and not limited to:
• Psychological, psychiatric or other mental
impairment(s) (excludes “psychotherapy notes”
as dened in 45 CFR 164.501)
• Drug abuse, alcoholism, or other substance abuse
• Sickle cell anemia
• Records which may indicate the presence of a
communicable or noncommunicable disease;
and tests for or records of HIV/AIDS
• Gene-related impairments (including genetic
test results)
2. Information about how my impairment(s) aects my ability to complete tasks and activities of
daily living, and aects my ability to work.
3. Copies of educational tests or evaluations, including Individualized Educational Programs,
triennial assessments, psychological and speech evaluations, and any other records that can
help evaluate function; also teachers’ observations and evaluations.
4. Information created within 12 months after the date this authorization is signed, as well as
past information.
FROM WHOM
• All medical sources (hospitals, clinics, labs,
physicians, psychologists, etc.) including mental
health, correctional, addiction treatment, and
VA health care facilities
• All educational sources (schools, teachers,
records administrators, counselors, etc.)
• Social workers/rehabilitation counselors
• Consulting examiners used by ARG
• Employers, insurance companies, workers’
compensation programs
• Others who may know about my condition
(family, neighbors, friends, public ocials)
THIS BOX TO BE COMPLETED BY ARG (as needed) Additional information to identify the subject
(e.g., other names used), the specic source, or the material to be disclosed:
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TO WHOM The state contractor authorized to process my case, including contract copy services,
and doctors or other professionals consulted during the process. (Also, for international claims, to the
U.S. Department of State Foreign Service Post.)
PURPOSE Determining my eligibility for benets, including looking at the combined eect of any
impairments that by themselves would not meet SSA’s denition of disability; and whether I can
manage such benets. I understand that I don’t have to sign this authorization. If I don’t sign it, the
benets, treatment, and provider payments I am eligible for will not be aected.
Determining whether I am capable of managing benets ONLY (check only if this applies)
EXPIRES WHEN This authorization is good for 12 months from the date signed (below my signature).
• I authorize the use of a copy (including electronic copy) of this form for the disclosure of the
information described above.
• I understand that there are some circumstances in which this information may be redisclosed to
other parties and no longer protected.
• I may write to ARG and my sources to revoke this authorization at any time (see page 3 for details).
• ARG will give me a copy of this form if I ask; I may ask the source to allow me to inspect or get a
copy of material to be disclosed.
• I have read both pages of this form and agree to the disclosures above from the types of
sources listed.
Date signed Street address
Phone number
(w/ area code)
City State ZIP
I know the person signing this form or am satised of this person’s identity.
WITNESS SIGN
Phone number (or address)
IF needed, second witness sign here (e.g., if signed with “X” above)
SIGN
Phone number (or address)
This general and special authorization to disclose was developed to comply with the provisions regarding
disclosure of medical, educational, and other information under P.L. 104-191 (“HIPAA”); 45 CFR parts 160 and 164;
42 U.S. Code section 290dd-2; 42 CFR part 2; 38 U.S. Code section 7332; 38 CFR 1.475; 20 U.S. Code section 1232g
(“FERPA”); 34 CFR parts 99 and 300; and State law.
PLEASE SIGN
USING BLUE OR BLACK INK ONLY
INDIVIDUAL authorizing disclosure
IF not signed by subject of disclosure, specify basis for authority
to sign
Parent of minor Guardian
Other personal representative (explain below)
Parent/guardian/personal representative SIGN here if two signatures
required by State law.
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Explanation of this form
“Authorization to Disclose Information to ARBOR E & T, LLC dba ACTION REVIEW GROUP (ARG)”
We need your written authorization to help get the information required to process your claim, and to determine
your capability of managing benets. Laws and regulations require that sources of personal information have a signed
authorization before releasing it to us. Also, laws require specic authorization for the release of information about
certain conditions and from educational sources.
You can provide this authorization by signing this form. Federal law permits sources with information about you
to release that information if you sign a single authorization to release all your information from all your possible
sources. We will make copies of it for each source. A covered entity (that is, a source of medical information
about you) may not condition treatment, payment, enrollment, or eligibility for benets on whether you sign
this authorization form. A few States, and some individual sources of information, require that the authorization
specically name the source that you authorize to release personal information. In those cases, we may ask you to
sign one authorization for each source and we may contact you again if we need you to sign more authorizations.
You have the right to revoke this authorization at any time, except to the extent a source of information has already
relied on it to take an action. To revoke, send a written statement to Arbor E & T, LLC dba Action Review Group (ARG).
If you do, also send a copy directly to any of your sources that you no longer wish to disclose information about you;
Arbor E & T, LLC dba Action Review Group (ARG).can tell you if we identied any sources you didn’t tell us about. Arbor
E & T, LLC dba Action Review Group (ARG).may use information disclosed prior to revocation to decide your claim.
It is Arbor E & T, LLC dba Action Review Group (ARG)’s policy to provide service to people with limited English
prociency in their native language or preferred mode of communication consistent with Executive Order 13166
(August 11, 2000) and the Individuals with Disabilities Education Act. Arbor E & T, LLC dba Action Review Group (ARG)
makes every reasonable eort to ensure that the information in the Arbor E & T, LLC dba Action Review Group (ARG)
is provided to you in your native or preferred language.
Privacy Act Statement – Collection and Use of Personal Information - Sections 205(a), 233(d)(5)(A), 1614(a)
(3)(H)(i), 1631(d)(l) and 1631(e)(l)(A) of the Social Security Act as amended, [42 U.S.C. 405(a), 433(d) (5)(A), 1382c(a)
(3)(H)(i), 1383(d)(l) and 1383(e)(l)(A)] authorize us to collect this information. We will use the information you provide
to help us determine your eligibility, or continuing eligibility for benets, and your ability to manage any benets
received. The information you provide is voluntary. However, failure to provide the requested information may
prevent us from making an accurate and timely decision on your claim, and could result in denial or loss of benets.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above.
However, we may use it for the administration and integrity of Social Security programs. We may also disclose
information to another person or to another agency in accordance with approved routine uses, including but not
limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security benets and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., Social Security
Audits / Reviews, Appeals)
3. To make medical determinations of disability based upon available medical records.
We may also use the information you provide in computer matching programs. Matching programs compare our
records with records kept by other Federal, State, or local government agencies. We use the information from these
programs to establish or verify a person’s current disability status with those agencies. A complete list of routine uses
of the information you give us is available by request by contacting Arbor E & T, LLC dba Action Review Group (ARG).
Arbor E & T, LLC dba Action Review Group (ARG) is a partner with and contracted by the State of Colorado’s
Department of Health Care Policy and Financing (HCPF) to perform medical records review services to determine the
level and severity of disability according to the criteria and rules established by the Social Security Administration.
Your records are available to HCPF for review and audit. The laws, rules, and regulations stated in the document also
apply to HCPF. Arbor E & T, LLC dba Action Review Group (ARG) does NOT provide nor establish eligibility for any
Health First Colorado (Colorado’s Medicaid program) or Medicare benets or programs.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. We estimate that it will take about 10 minutes to read
the instructions, gather the facts, and answer the questions.
SEND OR BRING THE COMPLETED FORM TO ARBOR E & T, LLC dba ACTION REVIEW GROUP (ARG), P.O.
BOX 340, OLYPHANT, PA 18447 or FAX THIS FORM TO ARG AT 1.877.672.2077. You may call ARG at
1.877.265.1864 and email ARG at
actionreviewgroupmrt@arboret.com
Help in your Language
Health Care Policy and Financing: 1-800-221-3943 (State Relay: 711)
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주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수
있습니다.
Русский ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны
бесплатные услуги перевода.
አማርኛ
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል
ﺔﯾﺑرﻌﻟا
ﻮﻐﻠﻟا ةﺪﻋﺎﺴﻤﻟا تﺎﻣﺪﺧ نﺈﻓ ،ﺔﻐﻠﻟا ﺮﻛذا ثﺪﺤﺘﺗ ﺖﻨﻛ اذإ :ﺔظﻮﺤﻠﻣ .نﺎﺠﻤﻟﺎﺑ ﻚﻟ ﺮﻓاﻮﺘﺗ ﺔﯾ
Deutsch ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung.
Français ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont
proposés gratuitement.
नेपाल�
:
Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga
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日本語
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。
Oroomiffa XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii,
kanfaltiidhaan ala, ni argama.
ﯽﺳرﺎﻓ
ﮫﺟﻮﺗ.ﺪﺷﺎﺑ ﯽﻣ ﻢھاﺮﻓ ﺎﻤﺷ یاﺮﺑ نﺎﮕﯾار ترﻮﺼﺑ ﯽﻧﺎﺑز تﻼﯿﮭﺴﺗ ،ﺪﯿﻨﮐ ﯽﻣ ﻮﮕﺘﻔﮔ ﯽﺳرﺎﻓ نﺎﺑز ﮫﺑ ﺮﮔا :
Polski UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy
językowej.
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