In Service 2024 B MaggieFull Name 全名(Required) First Name 名 Last Name 姓 Date of Birth 出生日期(Required) MM slash DD slash YYYY Aide Code 護理員號碼(Required)SSN 工卡號嗎Initial 縮寫(必填)(Required)Address 地址 Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Waiving Health Coverage 放棄醫療保險(Required) I am covered under another group plan as a spouse or dependent 本人作為配偶或受撫養人得到其他團體醫療計劃保障 I am covered by Medicaid, Medicare, or Veterans Program 我現有醫療補助，聯邦醫療保險或退伍軍人計劃的保障 I am covered under a health insurance plan sponsored by second employer 我現有第二雇主所提供的醫療保險計劃的保護 I am covered through a non-group, individual or private health care plan not offered through my employer 我現有非團體, 個人或私人醫療保健計劃 I don't wish to participate in health care benefits at this time (I am declining health insurance entirely) 我目前不希望參加任何醫療保健福利（我完全拒絕了醫療保險）Signature 簽名(Required)Date 日期 MM slash DD slash YYYY This field is hidden when viewing the formRN InitialThis field is hidden when viewing the formHEPATITIS B VACCINATION Yes, I accept vaccination. No, I decline vaccination.EmailThis field is for validation purposes and should be left unchanged.
