Form Mc 371 - Additional Family Members Requesting Medi-Cal (Cambodian) Page 2

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etI man Gñ k Na kM B u g man kar Fana r: a b; rg su x PaB
eFµ j b¤
b¤ eT?
man
mi n man eT
q DHCS 6155
x
q
q
/
Medicare
ebI man etI Gñ k Na?
OHC Code:
etI man Gñ k Na dak; Bakü bþ w g eK eday sar rg eRKaH fñ a k; ​ b¤ kar rbY s Edr b¤ eT?
man
mi n man eT
DHCS 6268
y
q
q
q
etI elak Gñ k ​b¤ smaCi k RKY s ar Na mñ a k; cg; [ kmµ v i F I
Fana r: a b; rg éfø su x PaB enA kñ ú g ry³ eBl bI Ex knø g mk enH ehI y
MC 210 A
z
Medi-Cal
q
cg; dak; Bakü su M
Edr b¤ eT?
cg
mi n cg; eT
q
q
Retroactive Coverage
Medi-Cal
mi n cg; eT
ray eQµ a H¬TaM g enaH¦ ³
Month
Month
Month
1
2
3
etI elak Gñ k ​b¤ smaCi k RKY s ar Na mñ a k; Fø a b; beRmI enA kñ ú g kg eyaFa sh rdæ Gaemri k Edr b¤ eT?
Fø a b;
mi n Fø a b; eT
CW 5
q
q
q
ebI Fø a b; etI Gñ k Na xø H ? eQµ a H¬TaM g enaH¦³
RtU v Ca GV I nw g elak Gñ k ³
kmµ v i F I
Gac Eck B½ t ’ m an rbs; elak Gñ k )an elI k Elg Et elak Gñ k KU s RbGb; xag eRkam enH³
Medi-Cal
eyI g nw g Eck Baküsu M rbs; kU n elak Gñ k CamY y nw g kmµ v i F I
Rbsi n ebI kU n rbs; elak Gñ k Elg man si T § i cU l rY m kñ ú g kmµ v i F I
Healthy Families
Medi-Cal
enA eBl GnaKt. ebI elak Gñ k mi n cg; [ eyI g Eck Bakü su M eT sU m KU s enA Rtg; enH
q
eyI g nw g Eck Bakü su M rbs; kU n elak Gñ k CamY y nw g kmµ v i F I
b¤ k¾ kmµ v i F I Ebb Rsedog Kñ a rbs; Rsu k Rbsi n ebI kU n elak Gñ k mi n man lkç N ³
Healthy Kids
sm nw g cU l rY m kñ ú g kmµ v i F I
d¾ eBj elj enaH eT. ebI elak Gñ k mi n cg; [ eyI g Eck Bakü su M eT sU m KU s enA Rtg; enH
q
Medi-Cal
R)ak; cM N U l RbcaM RKY s ar³ sU m ray R)ak; cM N U l én bu K Á l RKb; rU b Edl maneQµ a H enA kñ ú g Bakü su M enH. dak; TaM g R)ak; ]btß m Ö kU n ni g R)ak; ]btß m Ö bþ I
RbBn§
/
Edl RtU v )an TTY l . ¬sU m eRbI bnÞ a t; epSg sRmab; RbPB R)ak; cM N U l nI m Y y ².¦
eQµ a H Gñ k man R)ak; cM N U l
RbPB én R)ak; cM N U l
etI R)ak; cM N U l )an TTY l jw k jab;
etI R)ak; cM N U l man
elx snþ i s u x sgÁ m
¬kargar eFV I snþ i s u x sgÁ m
b: u N Ñ a ?
cM n Y n b: u n µ a n?
¬mi n caM ) ac; d ak; k ¾ ) an¦
¬kU n Edl enA eron mi n caM ) ac; dak; R)ak; cM N U l )an mk
R)ak; esaFn .l.¦
¬ral; GaTi t ü ral; BI r GaTi t ü ral; Ex¦
¬cM N U l sru b ¦
BI kargar eFV I rbs; eK eT.¦
$
$
$
$
$
cM N ay³ raycM N ay RbcaM Ex sRmab; bu K Á l RKb; rU b Edl man eQµ a H xag elI enH.
karEf TaM kU n eBl éf¶ ​ b¤ k ar Ef TaM mnu s S enA kñ ú g bnÞ ú k
sRmab; ¬eQµ a H kU n b¤ mnu s S enA kñ ú g bnÞ ú k ¦³
Gayu ³
cM n Y n Edl bg; ³
________________________________________
_____
______________
etI bg; jw k jab; b: u N Ñ a ?
_________
sRmab; ¬eQµ a H kU n b¤ mnu s S enA kñ ú g bnÞ ú k ¦³
Gayu ³
cM n Y n Edl bg; ³
________________________________________
_____
______________
etI bg; jw k jab; b: u N Ñ a ?
_________
R)ak; ]btß m Ö kU n bgÁ a b; eday tu l akar
bg; [³
bg; eday³
cM n Y n Edl bg; ³
__________________________________
_________________________________
______________
R)ak; ]btß m Ö bþ I
RbBn§ bgÁ a b; eday tu l akar
/
bg; [³
bg; eday³
cM n Y n Edl bg; ³
__________________________________
_________________________________
______________
sU m kt; sM K al; fa elak Gñ k Gac RtU v )an tRmU v [ pþ l ; B½ t ’ m an bEnß m sþ I BI RTBü sm,tþ i R)ak; cM N U l ni g
b¤ FnFan rbs; elak Gñ k ebI si n Ca Tak; Tg.
/
´GHGag bBa¢ a k; fa ´ )an Gan ehI y k¾ yl; nU v B½ t ’ m an xag elI enH. ´ k¾ s U m bBa¢ a k; fa B½ t ’ m an Edl ´ )an pþ l ; enA kñ ú g TRmg; EbbbT enH KW Bi t ehI y Rtw m RtU v .
htß e lxa
ci t ³
______________________________________________________________________
_________________
Page 2 of 2
MC 371_CAM_06/09 (Replaces MC 321 HFP-AP and MC 210S-C)

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