Form Mc 4035 - Medi-Cal Consent Form (Arabic)

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State of California – Health and Human Services Agency
Department of Health Care Services
MEDI-CAL
‫ﻗﺴﻴﻤﺔ ﻣﻮاﻓﻘﺔ‬
:
‫ﺗﺎرﻳﺦ اﻟﻤﺬآﺮة‬
:
‫رﻗﻢ اﻟﻤﻠﻒ‬
:
‫إﺳﻢ اﻟﻤﻮﻇﻒ‬
:
‫رﻗﻢ اﻟﻤﻮﻇﻒ‬
:
‫رﻗﻢ ﺗﻠﻔﻮن اﻟﻤﻮﻇﻒ‬
:
‫ﺳﺎﻋﺎت اﻟﻌﻤﻞ‬
:
‫ﻣﺬآﺮة ﻟـ‬
‫وهﻮ ﺑﺮﻧﺎﻣﺞ ﻳﻮﻓﺮ رﻋﺎﻳﺔ‬
__________________
‫إﺳﻤﻪ أﻋﻼﻩ ﻗﺪ ﻳﻜﻮن ﻣﺆهﻼ ﻟﺘﻐﻄﻴﺔ ﺻﺤﻴﺔ ﻣﺠﺎﻧﻴﺔ أو ﻣﺨﻔﻀﺔ ﻣﻦ ﺧﻼل‬
‫ﻃﻔﻠﻚ اﻟﻤﺪون‬
(Insert name of program)
،‫إذا ﻗﻤﺖ ﺑﺈﻋﻄﺎء ﻣﻮاﻓﻘﺘﻚ‬
.
‫و ﺑﺮﻧﺎﻣﺞ‬
‫أ‬
‫ﻟﻸﻃﻔﺎل ﻏﻴﺮ اﻟﻤﺆهﻠﻴﻦ ﻟﻠﺤﺼﻮل ﻋﻠﻰ ﺗﻐﻄﻴﺔ آﺎﻣﻠﺔ ﻣﻦ‬
‫ﺻﺤﻴﺔ‬
Healthy Families
Medi-Cal
.
‫ﻓﺴﻨﻘﻮم ﺑﺈرﺳﺎل اﻟﻄﻠﺐ اﻟﺨﺎص ﺑﻄﻔﻠﻚ إﻟﻰ ذﻟﻚ اﻟﺒﺮﻧﺎﻣﺞ‬
‫ﺔ ﺑﻄﻔﻠﻚ إﻟﻰ اﻟﺒﺮﻧﺎﻣﺞ اﻟﻤﺪون أﻋﻼﻩ، ﺳﻴﻘﻮﻣﻮن ﺑﻤﺮاﺟﻌﺔ اﻟﻤﻌﻠﻮﻣﺎت ﻟﻜﻲ ﻳﻘﺮروا‬
‫ﻟﺨﺎﺻ‬
‫ا‬
‫إذا ﻗﻤﺖ ﺑﺈﻋﻄﺎء ﻣﻮاﻓﻘﺘﻚ ﻟﻨﺎ ﺑﺈرﺳﺎل إﺳﺘﻤﺎرة‬
Medi-Cal
‫إذا ﻗﻤﺖ ﺑﺈﻋﻄﺎء اﻟﻤﻮاﻓﻘﺔ، ﻓﻠﻦ ﺗﻀﻄﺮ ﻹآﻤﺎل ﻃﻠﺐ ﺟﺪﻳﺪ ﻟﺘﻘﺪﻳﻢ ﻃﻠﺐ ﻟﻠﺒﺮﻧﺎﻣﺞ اﻟﻤﺪون أﻋﻼﻩ، وﺳﻮف ﻳﻘﻮم أﺣﺪ اﻟﻤﻤﺜﻠﻴﻦ ﻋﻦ اﻟﺒﺮﻧﺎﻣﺞ‬
.
‫أهﻠﻴﺔ ﻃﻔﻠﻚ‬
.
‫ﻞ ﻃﻔﻠﻚ‬
‫ﺑﺎﻹﺗﺼﺎل ﺑﻚ ﻹﺧﺒﺎرك ﺑﺎﻟﻤﻌﻠﻮﻣﺎت اﻹﺿﺎﻓﻴﺔ اﻟﻼزﻣﺔ ﻟﺘﺴﺠﻴ‬
‫هﺎم إذا رﻏﺒﺖ ﻓﻲ إﻋﻄﺎء ﻣﻮاﻓﻘﺘﻚ ﻹرﺳﺎل اﻟﻤﻌﻠﻮﻣﺎت اﻟﺨﺎﺻﺔ ﺑﻄﻔﻠﻚ، ﻋﻠﻴﻚ وﺿﻊ إﺷﺎرة ﻓﻲ اﻟﻤﺮﺑﻊ أدﻧﺎﻩ وﺛﻢ ﺗﻮﻗﻴﻊ وﺗﺄرﻳﺦ هﺬﻩ اﻟﻘﺴﻴﻤﺔ‬
‫ﻋﻨﻚ ﻹﺧﺒﺎرﻩ أو إﺧﺒﺎرهﺎ ﺑﺄﻧﻚ ﺗﺮﻏﺐ ﻓﻲ إﻋﻄﺎء‬
‫اﻟﻤﺴﺆول‬
Medi-Cal
‫ﺑﻤﻮﻇﻒ‬
‫وﻳﻤﻜﻨﻚ أﻳﻀﺎ اﻹﺗﺼﺎل‬
.
‫وإرﺳﺎﻟﻬﺎ إﻟﻰ ﻋﻨﻮان اﻟﻤﻘﺎﻃﻌﺔ أﻋﻼﻩ‬
.
‫ﺘﻚ‬
‫ﻣﻮاﻓﻘ‬
‫ﻟﻦ ﻳﺘﻢ إرﺳﺎل‬
.
‫إذا ﻟﻢ ﺗﻘﻢ ﺑﺈرﺟﺎع هﺬﻩ اﻟﻘﺴﻴﻤﺔ، ﻓﻴﺘﻢ إﻋﺘﺒﺎر ان اﻟﻤﻮاﻓﻘﺔ ﻟﻢ ﺗﻌﻂ‬
.
‫إذا آﻨﺖ ﻻ ﺗﺮﻏﺐ ﻓﻲ إﻋﻄﺎء ﻣﻮاﻓﻘﺘﻚ، ﻓﻼ ﺗﻘﻢ ﺑﺈرﺟﺎع هﺬﻩ اﻟﻘﺴﻴﻤﺔ‬
.
‫اﻟﺨﺎﺻﺔ ﺑﻄﻔﻠﻚ، وﺑﺬﻟﻚ ﻃﻔﻠﻚ ﻟﻦ ﻳﺤﺼﻞ ﻋﻠﻰ ﺗﻐﻄﻴﺔ اﻟﺮﻋﺎﻳﺔ اﻟﺼﺤﻴﺔ ﻣﻦ ﺧﻼل ﺑﺮاﻣﺞ اﻟﻤﻘﺎﻃﻌﺔ إﻻ إذا ﻗﻤﺖ ﺑﺘﻘﺪﻳﻢ ﻃﻠﺐ‬
‫إﺳﺘﻤﺎرة‬
Medi-Cal
.
____________________
‫ﻟﻄﻔﻠﻲ إﻟﻰ‬
‫واﻓﻖ ﻋﻠﻰ إرﺳﺎل ﻗﺴﻴﻤﺔ ﻃﻠﺐ‬
‫أ‬
‫أﻧﺎ‬
Medi-Cal
(Insert name of program)
_________________
:
‫رﻗﻢ اﻟﻬﺎﺗﻒ‬
______________
:
‫اﻟﺘﺎرﻳﺦ‬
________
________________________
:
‫اﻟﺘﻮﻗﻴﻊ‬
(
‫أرﺳﻞ هﺬﻩ اﻟﻘﺴﻴﻤﺔ أو إﺗﺼﻞ هﺎﺗﻔﻴﺎ ﺑﺈﺟﺎﺑﺘﻚ ﺧﻼل ﺧﻤﺴﺔ أﻳﺎم، إﻟﻰ اﻟﻤﻮﻇﻒ اﻟﻤﺴﺆول ﻋﻦ ﻣﻠﻔﻚ، ﻟﻠﻌﻨﻮان أو رﻗﻢ اﻟﻬﺎﺗﻒ اﻟﻤﺪون أﻋﻼﻩ‬
)
‫إذا آﺎﻧﺖ ﻟﺪﻳﻚ أﻳﺔ أﺳﺌﻠﺔ أو آﻨﺖ ﺑﺤﺎﺟﺔ ﻟﻤﻌﻠﻮﻣﺎت إﺿﺎﻓﻴﺔ، أرﺟﻮ اﻹﺗﺼﺎل‬
.
‫اﻟﻤﺴﺠﻞ ﻓﻲ اﻟﺰاوﻳﺔ اﻟﻴﻤﻴﻦ ﻓﻲ أﻋﻠﻰ هﺬﻩ اﻟﻤﺬآﺮة‬
Medi-Cal
‫ﻒ‬
‫ﻇ‬
‫ﺑﻤﻮ‬
.
_____________________
_________________
‫ﻟﻠﺤﺼﻮل ﻋﻠﻰ ﻣﻌﻠﻮﻣﺎت إﺿﺎﻓﻴﺔ ﻋﻦ‬
‫أرﺟﻮ اﻹﺗﺼﺎل ﺑﺎﻟﺮﻗﻢ‬
(Insert name of program)
(Insert program phone number )
MC 4035 (04/08) – Arabic

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