All-in-one In Service 2024A Jade 1Name(必填) First Name 名 Last Name 姓 Date of Birth 出生日期(必填)Aide Code 護理編號(必填)SSN 工卡號碼HiddenFirst Day of Work 第一天工作日期Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Medical Benefit Coverage Waiver Request 免除醫療福利申请Waiving Health Coverage 放棄醫療保險(Please select one of the following 請選擇以下一項)(必填) 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）I understand that it is my sole responsibility to maintain the minimum coverage required by applicable federal regulations. By signing this Medical Benefit Coverage Waiver form, I certify that I and/or my current health insurance plans are legally responsible for my own medical expenses and that Golden Touch Home Health, LLC. is not responsible for such expenses. 本人了解，維持聯邦法規要求的最低醫保是我的個人責任。通過簽署此免除醫療福利申請表，本人聲明 我或/和我當前的醫療保險計劃承擔我個人醫療費用上的法律責任。Golden Touch Home Health LLC 萬有 護理公司不承擔此項費用的責任。HiddenHEPATITIS B VACCINATION ACCPETANCE/DECLINATION 乙型肝炎疫苗接種Hidden乙型肝炎疫苗接種（請選擇以下一項）(必填) Yes, I accept vaccination. 是，我接受接種疫苗。 No, I decline vaccination. 否，我拒絕接種疫苗。I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me. 我了解由於我的職業接觸血液或其他潛在的傳染性 根據材料，我可能有感染乙型肝炎 (HBV) 的風險。 此時我有機會接種B型肝炎疫苗。 我了解，如果拒絕接種該疫苗，我將繼續面臨感染B型肝炎的風險，這是一種 嚴重的疾病。 如果將來我想接種B型肝炎疫苗，我可以 我可以免費接受系列疫苗接種。Initial(必填)Date 日期(必填)Signature 簽名(必填)