Fillable Form Mc 4035 - Medi-Cal Consent Form (Hmong) printable pdf download

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

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State of California – Health and Human Services Agency

Department of Health Care Services

MEDI-CAL NOTICE OF ACTION

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MEDI-CAL

RESTRICTED BENEFITS APPROVAL

DAIM NTAWV TSOCAI

WITH SHARE OF COST:

REFERRED TO THE COUNTY

OR LOCAL-SPONSORED

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HEALTH INSURANCE PROGRAM

Hnub Sau Tsab Ntawv:

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Lej Cim Ntaub Ntawv:

Tus Tuav Ntaub Ntawv Npe:

Tus Tuav Ntaub Ntawv Tus Lej:

Tus Tuav Ntaub Ntawv Xovtooj:

Sijhawm Ua Haujlwm:

Tsab Ntawv Hais Txog:

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Tej zaum koj tus menyuam uas muaj npe teev rau saumtoj no tsimnyog yuav tau txais cov kev fajseeb

khomob dawb lossis tau them mentsis nqi xwb los ntawm _____________________; ib txoj kev

(Insert name of program)

pabcuam kev khomob rau cov menyuam uas tsis tau txais Medi-Cal lossis Healthy Families. Yog koj

muab kev tsocai rau peb, peb yuav xa koj tus menyuam daim ntawv thov mus rau txoj kev pabcuam no.

Yog koj tsocai rau peb xa koj tus menyuam daim ntawv thov Medi-Cal mus rau txoj kev pabcuam uas hais

saumtoj no, lawv yuav los tshuaj daim ntawv thov saib nws puas tsimnyog tau txais kev pabcuam. Yog koj

tsocai, koj yuav tsis tau ua dua ib daim ntawv thov tshiab los thov txoj kev pabcuam uas hais saumtoj no, thiab

ib tus neeg sawvcev hauv txoj kev pabcuam ntawd yuav hu tuaj rau koj yog lawv xav tau lwm yam kev qhia

ntxiv mam muab tau txoj kev pabcuam ntawd rau koj tus menyuam.

TSEEMCEEB Yog koj xav tsocai kom xa koj tus menyuam cov kev qhia mus rau lawv, koj yuavtsum

tau khij lub npov hauv qab no, suam npe thiab rau hnubtim rau daim ntawv no thiab muab xa mus rau

lub county ntawm lub chaw nyob saumtoj no. Koj tseem hu tau rau koj tus neeg tuav ntaub ntawv Medi-Cal

thiab qhia rau nws tias koj xav muab kev tsocai rau nws.

Yog koj tsis xav tsocai, TSIS txhob xa daim ntawv no rovqab. Yog koj tsis xa daim ntawv no rovqab, koj

TSIS tau muab kev tsocai. Koj tus menyuam daim ntawv thov Medi-Cal yuav tsis raug xa mus thiab koj tus

menyuam yuav tsis tau txais lwm txoj kev pabcuam fajseeb khomob uas lub county muaj tshwj tias koj tau

thov mus.

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Kuv tsocai kom xa kuv tus menyuam daim ntawv thov Medi-Cal mus rau _____________________.

(Insert name of program)

Suam npe:____________________________ Hnubtim:_____________ Xovtooj:__________________

(Xa daim ntawv no rovqab lossis hu mus qhia lawv, tsis pub dhau tsib hnub, rau koj tus neeg tuav ntaub ntawv ntawm lub chaw nyob thiab tus xovtooj saumtoj no)

Yog koj muaj lus nug lossis xav tau kev qhia ntxiv, thov hu rau tus neeg tuav ntaub ntawv Medi-Cal uas

muaj npe hauv tsab ntawv saumtoj no. Thov hu rau _______________ yog koj xav tau kev qhia ntxiv

(Insert program phone number)

txog _____________________.

(Insert name of program)

MC 4035 (04/08) – Hmong