1

Welcome to the TLC Development Centers Family!

We value our educators and want to ensure your success in your new position. Here are some important items to be aware of:

• Prior to your hire date you should have completed Child Growth and Development, anequivalent 3 college credit course or ‘the 45 Hour Class’. If not, this must be completedwithin 6 months of employment – at your own expense. After 9 months (or closestsemester to 9 months) of employment, TLC Development Centers will pay for one collegeclass every semester. It is required that all educators complete a minimum of 3 collegecredit hours per anniversary year - working toward a Bachelor’s Degree in EarlyChildhood Multicultural Education (or a related course of study). You will have oursupport every step of the way!

• On your hire date (or 1 day prior) you must:o Complete New Hire Information Packet – DO NOT complete New Hire Orientation

section until all items have been gone through!o Register for Background Check, complete paperwork and get fingerprintedo Complete W-4, I-9 and Direct Deposit formso Complete CYFD Health and Safety Orientation Training online

• First day of employment (before working with children) you will be given a New HireOrientation. The form should be completed as each item is addressed. Be sure to readyour job description carefully. These – and many other forms are available on ourwebsite: TLCDevelopmentCenters.org

o Be sure you get registered for the time clock. It is your responsibility to clockyourself in and out each shift and for breaks. If you have problems with the timeclock, tell your director or supervisor immediately. Time adjustments will not bemade if not addressed within 24 hours – regardless of the reason.

• Within 3 months of your start date:o CPR and First Aid certificationo 4 hours of Infant/Toddler specific training – must have this every year as well.

• Make a note for your 30- and 90-day reviews. You are responsible for ensuring that yourreviews are done on time.

Questions? – ALWAYS feel free to ask! Many questions that may arise are addressed in our employee handbook. If you cannot find the answer there, please be sure to ask your supervisor or director.

We look forward to a long relationship and will support you every way possible! Welcome!

2

TLC Development Centers Employee Record

For Office use only: FT hours not guaranteed Part Time On Call DOH: _____________

Select only one Position: ________________________________

Driver Current DL on File? YES NO DOT: ______________

Employee Information:

Name: __________________________________________________________________________

Address: _______________________________ _______________ ________ _______________ Street City, State and Zip

Phone: __________________ ______________________ ______________________ Home Cell Other

Emergency Contact:

Name: __________________________________________________________________________

Address: _______________________________ _______________________________________ Street City, State and Zip

Phone: __________________ ______________________ ______________________ Home Cell Other

I have not had an arrest or a substantiated referral to a child protective services agency & I would not be disqualified as a direct provider of care under the most current version of the Background Checks & Employment History Verification provisions pursuant to 8.8.3 NMAC.

I have received and reviewed the Disaster Plan policies and procedures

This declaration must be signed annually. Disposition of any arrests must be documented.

Upon Hire: _________________ _____________________________________________ Date Staff Signature

1st anniversary: _________________ _____________________________________________ Date Staff Signature

2nd anniversary: _________________ _____________________________________________ Date Staff Signature

3rd anniversary: _________________ _____________________________________________ Date Staff Signature

3

Employee File Order: Each list is bottom to top!

1st Clasp: 1. Criminal Record Check Info:

1. Copy of Cogent Registration Receipt2. Copy of Employer Statement3. Copy of Employee Statement4. When letter comes in, it goes on TOP of all this!

2. Any Administrative Action Forms (employee write ups) go BEHIND CRC letter AFTER it isuploaded to Procare.

2nd Clasp: 1. Check ALL pages for signatures and blank lines!!! Nothing should be blank!2. Application for employment –with references verified! This includes employment history3. Job Description4. COMPLETED New Hire Packet5. Current SIGNED Employee Record (Page 2 of NHP). This MUST be signed EACH anniversary

date!

3rd Clasp: 1. Annual Professional Development Plan and Evaluation – Newest on top

1. For a new hire, this section will be empty until their 30 day evaluation.2. Evaluation periods are 30 days, 90 days, 6 months and annually thereafter on the employee’s

anniversary date.

4th Clasp: These must all be uploaded to Procare upon hire 1. High School Diploma (or equivalent)2. Higher educational degree or license3. CPR/1st Aid Certification4. 45 Hour Certificate (or equivalent)

5th Clasp: 1. 6 Hour Inclusion Class2. Full Participation of Each Child3. Powerful Interactions4. Current Training Log

6th Clasp:

1. All training certificates in chronological order. Most recent on TOP.

Note: Be sure to have employee fill out I-9 and W-4. These MUST be scanned and uploaded to Procare ON OR BEFORE FIRST day of employment!

4

TLC Development Centers

Employee Orientation Verification Form

Employee Name:_________________________________________________________

Date of Hire:__________________

Subject of Training Date Rc’d Staff Initials

Program goals, scope of services, activities Facility’s procedures for emergencies or accidents and disaster plan Recognition of childhood illness Indicators of child abuse and reporting requirements Fire prevention measures and emergency evacuation Review of licensing regulations Review of all policies: personnel, parent, health care, Etc. Sanitation procedures Handling of blood borne pathogens and body fluids Personnel handbook Parent handbook Names, ages of children and parents Facility tour and staff introductions Parent introductions

I, __________________________________________, have reviewed all of the above listed materials and understand that I responsible for following all of the above policies and procedures. I also understand that it my responsibility to keep all information concerning children, parents and our program confidential.

Acknowledgement of Personnel Policies / Employee Handbook

I, __________________________________________, acknowledge that I have received and read the Personnel Policies / Employee Handbook and discussed any questions that I may have with my Supervisor.

_______________________________________________ _________________ Employee Signature Date

_______________________________________________ _________________ Supervisor Signature Date

5

Acknowledgement for the Fair Labor Standards Act (FLSA)

The Fair Labor Standards Act (FLSA), also known as the Federal Wage and Hour Law, regulates minimum wage, overtime, equal pay, recordkeeping, and child labor for employees of enterprises engaged in interstate or foreign commerce and employees of state and local governments. The FLSA applies in all states, but states are permitted to develop their own laws and regulations to provide even greater protection for their workers than is provided under federal law. In cases in which the two laws conflict, the law most beneficial to the employee prevails. Therefore, it is essential that employers understand both the state and federal laws. For more information on the Fair Labor Standards Act and how it applies to daycare centers and preschools, read the documents located at the following links listed below:

• 17a Exemption for Executive and Administrative: Fair Labor Standards Acthttp://www.dol.gov/whd/regs/compliance/fairpay/fs17a_overview.pdf

• Daycare Centers and Preschools Under FLSA http://www.dol.gov/whd/regs/compliance/whdfs46.htm• The Fair Labor Standards Act (FLSA)

http://www.dol.gov/compliance/laws/comp-flsa.htm

These links and information can also be found on the New Mexico Kids Website at www.NewMexicoKids.org under Resources for Caregivers and Educators.

I acknowledge that I have read and understand the FLSA (Fair Labor Standards Act) and its implications for

myself and all educators at ___________________________________________________________. (Name of Center)

FOCUS Designee (Director) Printed Name: ____________________________________

FOCUS Designee (Director) Signature: ________________________________________

Date: _________________________

Educator Signature of Acknowledgement:_______________________________________

6

UNIVERSAL PRECAUTIONS ACKNOWLEDGEMENT

TLC Development Centers promotes and requires the use of the Universal Precautions for the protections of our staff and children against the spread of blood borne pathogens.

Universal Precautions is the preventative process of the self-protection by treating all visible blood and body fluids as if they were contaminated. The process for handling visible blood or body fluids is as follows:

1. Hands and arms must always be washed after contact with blood or body fluid (even whengloves are used).

2. Latex or vinyl gloves are to be worn if a person anticipates any possible contact with bloodor body fluids.

3. If needed, safety goggles are to be used to prevent blood from contacting eyes.4. Latex or vinyl gloves will be used when changing diapers.

I understand and am aware that TLC Development Centers requires the use of Universal Precautions for the safety of the employees as well as the children. I agree to use the Universal Precautions when necessary.

___________________________________ __________________ Employee Signature Date

___________________________________ Employee Print

___________________________________ ________________ Director Signature Date

7

SAFETY RULES ACKNOWLEDGMENT FORM

We are very concerned about your safety as well as the safety of the children. You are asked to cooperate in helping to prevent injury to yourself, to other employees, to the children and to visitors by observing the following rules:

1. Keep yourself informed of the current emergency exit plans and disaster plans of yourcenter, where the alarms are located, the drill routine, and what your duties are in case offire or other disaster.

2. Avoid accidents by being aware of and eliminating any potential hazards indoors andoutdoors.

3. Be particularly conscious of safety factors when using electrical equipment, sharp tools,company vehicles or swimming pools.

4. Company vehicles may not be driven by anyone under (21) twenty-one years of age.Proper licensure for vehicle operation in keeping with NM state requirements, drivercertification, and sound knowledge of the vehicle and driving regulations are necessary foranyone who operates a company vehicle.

5. The proper handling of strangers and difficult persons is important in order not to endangeror disturb the children. In all cases make such situations known to the center director and tothe authorities if necessary. Seek immediate aid from any source available in suchsituations. Do not use force to deal with this type of situation except in self-defense. To doso may leave you liable for any damage or injury to another person or property. Allemployees must remain alert to and report any unauthorized person loitering around centergrounds or trying to enter the building. Promptly report the presence of any suspiciouspersons to the center director or local authorities.

6. Everyone entering the center, except parents whom you know, must be asked to identifyhim or herself with a picture ID and to state why they are here. If you have any reason todoubt the sincerity of an individual’s reason for being in the center contact the centerdirector, if necessary, to determine if that person should enter.

7. The safety of the children must remain our priority at all times.

______________________________ _______________________ Employee Signature Date

_____________________________ _______________________ Director Signature Date

8

New Hire Information

Date of Hire:____________________________New Hire:_______

Date of Termination:________________________Re-Hire:_______

Personal Information:

Name:__________________ _____________________________ _______ Last First Middle Initial

Male □ Female □ Email Address:_______________________________________ Social Security Number: ________-______-__________DOB:__________________ Address___________________________________________________________ City______________________________________State_______Zip___________ Phone:________________Cell Phone or Message Phone________________________ Drivers License Number:______________________________State:____________ Expiration Date:_________________ Race:________________

Select One Are you a qualified individual with a disability? □ Y □ NAre you a Veteran? □ Y □ NAre you a special disabled veteran? □ Y □ N

Emergency contact:___________________________________________________ Emergency Contact phone #:____________________________________________ Relationship to employee:_______________________________________________

Employment Information

Job Title:__________________________________________________________ Full Time:_______________ Part Time_______________ On Call:______________ Hourly Wage:_________________ or Salary__________________ per__________

Tax Withholding Information

Federal Filing Status: □ Married □ Single □ Head of Household(Select one)

State Filing Status: □ Married □ Single □ Head of Household(Select one)

9

Additional withholdings: Federal $_________ State $__________ Experience/Education/Credentials

Total relevant experience in child care __________ yrs __________mos Highest level of education completed: HS____ GED____ AS____ AA____ PD_______ CDA______ BA______ BS_______MA________ MS______

Other certificates or training:___________________________________________ ___________________________________________________________________________________________________________________________________________________________________________

Number of clock/credit hours in specific field of study (whether or not degree obtained):

Certified Childcare Teacher ______________________Hrs Child Development Associate______________________Hrs State Certified Teacher_________________________Hrs State Certified Kindergarten_____________________Hrs

Age group of primary responsibility: ______________________________

Employee Signature____________________________________Date___________

Supervisor Signature___________________________________Date___________

10

Employment Contract

I, ____________________________, agree to the following: 1. Participate in any random drug testing. Fees for testing will be taken out of the

employee’s paycheck and reimbursed after 90 days of consecutive employmentupon negative results.

2. To have the cost of fingerprints and background check deducted from theemployee’s final paycheck if, for ANY reason, the employee no longer works forTLC Development Centers, Inc. within 12 month of hire date.

3. To fulfill the responsibilities of the job based upon the employee’s job descriptionfor the position hired – or transferred to.

4. To give a two week notice if change in employment is anticipated.5. To pay for any and all tuition, co-pay or advances incurred by the employee. Total

balance due to TLC Development Centers, Inc. will be deducted from finalpaycheck.

I, ____________________________ have never had an arrest or substantiated referral to a child protective agency

TLC Development Centers agrees to pay the employee $_________ per __________

Employee Signature:_____________________________________Date__________

Supervisor Signature:___________________________________Date:__________

Professional Development

I understand that as an employee of TLC Development Centers, I am an Early Childhood Educator - NOT a babysitter. To help achieve this status, I agree to the professional development plan of continuing education. I will attend classes on an ongoing basis, and successfully complete at least two THREE CREDIT hour college courses through CNM or other accredited educational facility no later than my second anniversary date. I have a high school diploma or GED, and I will abide by all TLC Development Centers policies and procedures. I will learn the language of discipline that meets the standards of TLC Development Centers; no yelling at children, especially from across the room or playground. Never call a child a name other than their given name or nick name. NEVER tell a child that they are bad.

11

Professional Development Plan

Employee Name:_______________________________________ Date:__________________________

Strengths as an Early Child Educator: 1. ________________________________________________________________________________

________________________________________________________________________________2. ________________________________________________________________________________

________________________________________________________________________________Areas in need of growth or improvement:

1. ________________________________________________________________________________________________________________________________________________________________

2. ________________________________________________________________________________________________________________________________________________________________

Professional Goals-MUST BE S.M.A.R.T. (Specific, Measurable, Attainable, Relevant, and have a Time line): 1. ________________________________________________________________________________2. ________________________________________________________________________________3. ________________________________________________________________________________

How will I accomplish these goals? Include a deadline for completion.1.______________________________________________________________________________________________________________________________________Date:___________________2.______________________________________________________________________________________________________________________________________Date:___________________3.______________________________________________________________________________________________________________________________________Date:___________________What assistance will I need from my supervisor or director to accomplish these goals?1.______________________________________________________________________________2.______________________________________________________________________________3.______________________________________________________________________________

You are required to complete 24 hours of training each year. Please explain how you will achieve these training hours in each of the 7 competency areas. Please describe what you are interested in learning, and what classes you will need to take to become more knowledgeable in your field.

1. Child Growth, Development, Learning:___________________________________________________2. Health, Safety, Nutrition, Infection Control:____________________________________________3. Family Community Collaboration:_______________________________________________________4. Developmentally Appropriate Content:___________________________________________________5. Learning Environment & Curriculum Implementation:________________________________________6. Assessment of Children & Programs:____________________________________________________7. Professionalism:____________________________________________________________________

Other comments:________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________

Staff Signature:___________________________ Supervisor Signature:____________________________

Next Review Date: (30 days from date of hire) _____________________ *It is the responsibility of each staff member to ensure their reviews are done on time!

12

Discipline and Termination

The following are examples of conduct that is not permitted and can subject employees to immediate dismissal upon completion of an investigation that confirms the employee engaged in the conduct. Engaging in any of the following types of conduct is considered such a serious breach of responsibility to TLC Development Centers that no prior warning is required for involuntary separation:

1 Leaving a child unattended 2 Negligence or carelessness in caring for children 3 Inappropriate discipline of a child; including isolation, verbal abuse, spanking, pulling hair, or any other

rough or inappropriate handling or inappropriate use of restraints. 4 Possession, sale, or use of alcohol or illegal drugs while on TLC Development Centers property or reporting

to work while under the influence of intoxicating beverages or illegal drugs. 5 Theft, attempted theft, or removal from the premises without proper authorization of TLC Development

Centers property, or property of a customer or another employee. 6 Acting dishonestly or unfairly by violating policies and procedures or compromising yourself or TLC

Development Centers by making decisions that will cause others to question your honesty or integrity. 7 Fighting with or attempting to fight with or to cause bodily harm to another employee or customer. 8 Harassing, name calling, gossiping, or generally creating an unpleasant environment for other employees. 9 Possession of a weapon on TLC Development Centers property. 10 Any act that endangers children 11 Allowing personal visitors in the vicinity of the children entrusted to your care.

A complete Employee Discipline Policy is in your employee handbook.

Guidance & Discipline The program’s goals are to promote independence, autonomy, self-esteem, and caring toward others and the physical environment.

We prefer to use the ‘time-in’ approach to discipline. This is re-directing the child’s inappropriate behavior toward an acceptable form. For example, if the child is throwing blocks, we would show them a ball, and an appropriate manner and place for throwing it.

When ‘time-in’ is ineffective, we use ‘time-out’ – a quiet, relaxed, neutral break; a cooling off period for the child to regain self-control. Time-out is only used when a child is losing control and refuses redirection. For example: acting aggressively, throwing a tantrum, complete defiance.

No one is allowed to spank, hit, bite, shake, yell at, grab, threaten, ridicule, lift or pull by arms/legs or cause any physical or emotional harm to any child while on the Center property. This includes staff, other children, and parents. Children cannot be deprived of any service- transportation, field trips, food, etc.

The following methods should be used on a daily basis:

For Infants and Toddlers:

1. Meet babies’ needs for love and care and build a trusting relationship.

2. Prepare the play space thoughtfully and make child proof.

3. Accept children’s feelings, and provide outlets for them. Example: talking about their feelings, using thequite space for them to relax and breathe - then rejoin the group when ready.

13

4. Refocus toddlers’ attention before inappropriate behavior occurs.

5. State directions clearly and simply.

6. Be clam and consistent.

7. Allow children time to adjust to transitions.

For preschool children:

All of the above PLUS:

1. Arrange classrooms that are comfortable, interesting and encourage children’s self-direction.

2. Help children to express their emotions verbally, and through the art of play.

3. Allow children to resolve their own conflicts when possible.

4. Model and teach children strategies for solving interpersonal conflicts – such as negotiation, compromise,empathy.

5. Help children learn to anticipate logical consequences of their behaviors.

6. Involve children in cooperative projects.

7. Assist children in setting clear, consistent, fair limits for behavior in the classroom.

For School age children:

All of the above PLUS:

1. Involve school age children in planning activities.

2. Involve school age children in setting their own guidelines.

3. Allow school age children to suggest consequences when rules are ‘broken’.

It is not acceptable for adults to administer negative discipline:

1. Inflicting physical pain – suspected child abuse will be reported to the child protection agency;2. Name-calling, shouting, threatening, ridiculing, etc;3. Depriving a child of any service – field trips, food, daily attendance;4. Isolation;5. Sending a child to the office;6. Imposing cumulative or delayed consequences.

Employee Signature____________________________________Date___________

Supervisor Signature___________________________________Date___________

Confidentiality It is our policy not to discuss parents, children or family situations in the presence of children or other parents. If you need to discuss issues with a parent, please bring the parent into the office or break room for a private conversation.

Employee Signature___________________________________Date___________

Supervisor Signature__________________________________Date___________

14

15

Employee Enrollment/Change Form

THNM-O-0002-0318

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

Employer Name: Department/Location: New Enrollee: Effective Date: _____/_____/ _____

Enrollment Changes: Subscriber ID# _______________________ Date of Hire/Reinstated: ____/____/_____ _

COBRA Yes No Variable Hour Employee? Yes No Hours Worked Per Week: _______

Are you waiving your employer’s group coverage? Yes, I hereby waive True Health New Mexico medical coverage. Complete Step 2 below, then sign and date form. Reason for Waiver: Individual exchange plan Individual off-exchange plan Another Employer Group Plan Medicare/Medicaid Other Coverage Not Covered

STEP 1: ENROLLMENT EVENTS/CHANGES

Open Enrollment? No Yes (if Yes, then skip to Step 2) Special Enrollment Event? No Yes , date: ____/____/____

Adding a Dependent? No Yes Marriage Birth, Adoption, Placement for Adoption or Foster Care Court Order Loss of other coverage Other: __________________________

Termination of policy OR Termination of dependent Name: ________________________ Termination Date: ____/____/_____ Reason: Terminated Divorce Death Other: __________________

STEP 2: EMPLOYEE INFORMATION

Last Name: First Name: MI: Social Security Number (SSN): DOB: ____/ _____/ _____

Home Address: Apt./Ste: City: State: ZIP:

Mailing Address (if different then above): Apt./Ste: City: State: ZIP:

Primary Phone: ( ) Other Phone: ( ) Email Address: Gender/Sex: M F Ethnicity/Race (optional): American Indian/Alaskan Native Asian or Pacific Islander Black or African American Hispanic White Multiracial

Do you or any of your dependents prefer a spoken or written language other than English? Yes No If yes, please list here:

Do you or any of your dependents require assistance due to a disability? Yes No If yes, please describe:

STEP 3: PLAN INFORMATION

Your selection will be limited to the benefit plans made available to you by your employer. Any benefit discrepancies will de fault to the benefit plan offering selected by your employer. Please review the information in your enrollment materials or check with your benefits coordinator if you are uncertain about the types of benefit plans available to you. Your coverage election will be the health benefit selection made by your employer.

If your employer offers multiple True Health New Mexico plans, select your coverage: HMO or PPO Plan Name: __________________________________________________________________

Coverage applied for: Employee only 2-Party Employee + Child(ren) Family

STEP 4: DEPENDENT INFORMATION

Last Name First Name M.I. SSN Date of Birth Gender/Sex

Legal Spouse/Domestic Partner M F

Child M F

Child M F

Child M F

Will you or any other family member listed above continue to be covered by any other insurance company? Yes No Insurance Company: List name(s):

Do you or any family member listed above have Medicare? Yes No Part A Part B Member Name: Medicare Number:

STEP 5: SIGN AND DATE

READ PAGE 2 OF THIS APPLICATION. By signing this application, I attest that I have read both sides of this application and warrant my current and continuing authority to act on behalf of and fully bind all of the above Dependents with respect to every provision of the True Health New Mexico Evidence of Coverage. If you have questions, please call our Help Center at 1-855-769-6642, Monday through Friday, from 8 a.m. to 5 p.m.

Employee Signature Date Employer Signature Date

Employee only premium is $546.61 per month- Employee portion is $73.31 per pay periodEmployee + Spouse / Children / Family Plans also available

Coverage is effective on the first day of the month following60 days of employment.

X X

STEP 6: IMPORTANT – PLEASE READ CAREFULLY

RELEASE OF CONFIDENTIAL HEALTH INFORMATION By signing this application, I CONSENT, to the extent permitted by applicable law, to the release of or use of Confidential Health Information (as defined below) by any person or entity including, without limitation, practitioners, pharmacies or pharmacy benefit managers, providers, and insurance companies to True Health New Mexico or its designees for any permitted purpose, including but not limited to insurance eligibility, quality assurance, utilization review, processing of claims, financial audits or other purposes related to the treatment, payment or healthcare operations activities of True Health New Mexico. It is understood that it may be necessary for the parties administering the plan in which I/we are enrolling to obtain and/or provide to others this Confidential Health Information.

I understand that authorizing the disclosure of this Confidential Health Information is voluntary, and signing this authorization can be refused; however, if not signed, the processing of this Application may be delayed or inhibited.

I understand that a full description of True Health New Mexico’s privacy and confidentiality policy related to Confidential (also known as Protected) Health Information is available on our website at truehealthnewmexico.com or by calling True Health New Mexico Customer Care at 1-855-769-6642.

I understand my consent, here, does not permit use of Confidential Health Information when an authorization is required by law.

I understand that this authorization is in effect for twenty-four (24) months from the date of this application or until written notice is sent to True Health New Mexico to revoke it.

I understand that I may revoke this authorization by writing to: True Health New Mexico, HIPAA Privacy Officer, P.O. Box 36719, Albuquerque, NM 87176.

“Confidential Health Information” includes, with respect to me and/or a covered dependent/minor child, any individually identifiable health information, including but not limited to medical, dental, mental health, substance abuse, communicable disease, Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) related information, as well as any disability or employment related information.

AUTHORITY TO ACT I hereby represent my current and continuing authority to act on behalf of myself and/or my legal dependent child(ren) with respect to every provision of the Agreement. All information on this Application is correct and true. I know that my information on this form will only be used to enroll myself and my eligible dependents for health coverage and will be kept private as required by law. I understand that upon completion of my enrollment I will receive an True Health New Mexico Evidence of Coverage and Summary of Benefits and Coverage, which contains the benefits, limitations, and exclusions applicable to my healthcare plan.

ACCURACY OF INFORMATION PROVIDED ON THIS APPLICATION I agree that I have read and understood all questions included on this application. By signing below, I certify that the answers provided are correct, complete and wholly true to the best of my knowledge and belief.

NOTIFICATION OF CHANGES I know that I must tell True Health New Mexico or my Employer if anything changes (and is different than) what I wrote on this application. I can visit truehealthnewmexico.com or call 1-855-769-6642 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household.

COVERED BENEFITS I understand that covered benefits, utilization management procedures, and plan exclusions and limitations are subject to the plan’s Evidence of Coverage (EOC) and/or Summary of Benefits and Coverage (SBC). These documents are available at truehealthnewmexico.com/small-group-plan-documents.aspx and truehealthnewmexico.com/large-group-plan-documents.aspx. I also may contact True Health New Mexico at 1-855-769-6642, Monday through Friday, 8:00 a.m. to 5:00 p.m., to request a printed copy of these documents.

COPY OF APPLICATION I understand that I am entitled to a copy of this signed Application and may contact True Health New Mexico to obtain a copy. Premium, price or charge differentials because of location or age based on objective, valid, and up-to-date statistical and actuarial data are not prohibited. I know that under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability.

Language Assistance Services Servicios de acceso al idioma

THNM-ID0049-1017

English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-769-6642 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-769-6642 (TTY: 711).

Navajo é

1-855-769-6642 (TTY: 711.)

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-769-6642 (TTY: 711).

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-769-6642 (TTY: 711).

Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-769-6642（TTY：711）。

Arabic :(.711)رقم هاتف الصم والبكم: 6642-769-855-1اتصل برقم إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. ملحوظة

Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-769-6642 (TTY: 711) 번으로

전화해 주십시오.

Tagalog-Filipino

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-769-6642 (TTY: 711).

Japanese 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。1-855-769-6642（TTY: 711）まで、お

電話にてご連絡ください。

French ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-855-769-6642 (ATS : 711).

Italian ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-769-6642 (TTY: 711).

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-769-6642 (телетайп: 711).

Hindi ध्यान दें: यदद आप ह िंदी बोलते हैं तो आपके ललए मफु्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-855-769-6642 (TTY: 711) पर कॉल करें।

Farsi 6642-769-855-1 با. باشدی م فراهم شمای برا گانیرا بصورتی زبان لاتیتسه د،یکنی م گفتگو فارسی زبان به اگر: توجه (TTY: 711) دیریبگ تماس.

Thai เรียน: ถา้คุณพดูภาษาไทยคุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-855-769-6642 (TTY: 711).

Notice of Non-Discrimination and Accessibility Aviso de no discriminación y accesibilidad

THNM-ID0050-1017

The following is a statement describing nondiscrimination for True Health New Mexico and the services it provides to its clients and members.

• We do not discriminate on the basis of race, color, national origin, age, disability, or gender in our health programs or activities.

• We provide help free of charge to people with disabilities or whose primary language is not English. To ask for a document in another format such as large print, or to get language help such as a qualified interpreter, please call True Health New Mexico Customer Service at 1-855-769-6642, Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY: 1-800-659-8331.

• If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or gender, you can send a complaint to: True Health New Mexico Compliance Hotline, 2440 Louisiana Blvd. NE, Suite 601, Albuquerque, NM 87110. Phone: 1-855-882-3904. Fax: 1-866-231-1344.

You also have the right to file a complaint directly with the U.S. Dept. of Health and Human Services online, by phone, or by mail:

• Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

• Phone: Toll-free: 1-800-368-1019, TDD: 1-800-537-7697

• Mail: U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC 20201

Aviso de no discriminación y accesibilidad A continuación presentamos una declaración que resume la norma de no discriminación de True Health New Mexico y los servicios que prestamos a nuestros clientes y asegurados.

• No discriminamos por la raza, el color, el origen nacional, la edad, las discapacidades o el sexo en nuestras actividades o programas de salud.

• Ayudamos gratuitamente a las personas que tienen discapacidades o cuyo idioma nativo no es el inglés. Para pedir un documento en otro formato, como en letra grande, o para recibir la ayuda de un intérprete calificado, favor de llamar al Centro de Atención al Cliente de True Health New Mexico al 1-855-769-6642, para los servicios TTY llame al 1-800-659-8331, de lunes a viernes, de las 8:00 de la mañana a las 5:00 de la tarde.

• Si usted cree que no hemos prestado estos servicios o que le hemos discriminado de alguna otra manera por su raza, color, origen nacional, edad, discapacidad o sexo, puede enviar una queja a: True Health New Mexico Compliance Hotline, 2440 Louisiana Blvd. NE, Suite 601, Albuquerque, NM 87110. Teléfono: 1-855-882-3904. Fax: 1-866-231-1344.

Además tiene derecho a presentar una queja directamente al Departamento de Salud y Servicios Humanos de los EE. UU. [U.S. Dept. of Health and Human Services] ya sea en línea, por teléfono o por correo:

• En línea: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Los formularios de queja están a su disposición en: http://www.hhs.gov/ocr/office/file/index.html.

• Por teléfono: Línea telefónica gratis: 1-800-368-1019, TDD: 1-800-537-7697

• Por correo: U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC 20201