Form Mc 371 - Additional Family Members Requesting Medi-Cal (Hmong)
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1
2State of California - Health and Human Services Agency
Department of Health Care Services
Lwm Cov Neeg Hauv Tsev Neeg Uas Thov Kev Pab Los Ntawm Medi-Cal
County Use Only
Case name:
Case #
Tus neeg thov kev pab/Tus saib xyuas qhov txheeb rau tus
u
Tus neeg thov kev pab/Tus saib xyuas lub npe (Npe,
(cov) Me Nyuam
Worker #
Npe nrab, Lub xeem)
Date:
Linkage
Lub npe nyob rau ntawm
Poj Niam los sis Txiv Neej
q
q
Cev puas Xeeb Me Nyuam?
Xeeb
Tsis Xeeb
Daim Ntawv Yug
Hnub Yuav Los Yug: _______________
q
q
Txiv Neej
Poj Niam
Yuav Muaj Pes Tsawg Tus Me Nyuam Mos _____
SSN
Zauv Pua Cev
Hnub Yug
q
q
Puas Thov Medi-Cal?
Thov
Tsis thov
(Social Security No.)
Yog Thov, muab tus zauv hauv Daim Yuaj Kho Mob (Benefits Identification
Hli
Hnub
Xyoo
Card) yog tias koj muaj:
PREG
Chaw Yug (Nroog/Xeev/Teb Chaws)
Puas yog neeg Mis Kas los
q
q
Yog
Tsis yog
yog Neeg Teb Chaws no?
Yog tias Tsis yog, hnub tuaj txog __________________________
ID
rau hauv Teb Chaws Mis Kas
Hli
Hnub
Xyoo
Tus neeg no puas muaj kev ua tsis taus ntawm cev, kev xav,
Kev Sib Yuav (kos ib qho):
kev xav hauv siab los yog kev loj hlob?
q
q
Muaj txij nkawm
Tsis tau muaj txij nkawm
Other
q
q
Muaj. Hnub kev ua tsis taus pib: __________
Tsis muaj
q
q
q
Poj ntsuam/yawg ntsuag
Sib nrauj
Sib cais
Linkage
Txheeb Tus Neeg Thov Kev Pab/Tus Saib Xyuas
v
Tus txij nkawm/Lwm Tus Niam Txiv Lub Npe (Npe, Npe
Nrab, Lub xeem)
SSN
Lub npe nyob rau ntawm
Poj Niam los sis Txiv Neej
q
q
Cev puas Xeeb Me Nyuam?
Xeeb
Tsis Xeeb
Daim Ntawv Yug
Hnub Yuav Los Yug: _______________
q
q
Txiv Neej
Poj Niam
Yuav Muaj Pes Tsawg Tus Me Nyuam Mos _____
PREG
Zauv Pua Cev
Hnub Yug
q
q
Puas Thov Medi-Cal?
Thov
Tsis thov
(Social Security No.)
Yog Thov, muab tus zauv hauv Daim Yuaj Kho Mob (Benefits Identification
Hli
Hnub
Xyoo
Card) yog tias koj muaj:
ID
Chaw Yug (Nroog/Xeev/Teb Chaws)
Puas yog neeg Mis Kas los
q
q
Yog
Tsis yog
yog Neeg Teb Chaws no?
Yog tias Tsis yog, hnub tuaj txog __________________________
rau hauv Teb Chaws Mis Kas
Hli
Hnub
Xyoo
Other
Tus neeg no puas muaj kev ua tsis taus ntawm cev, kev
Kev Sib Yuav (kos ib qho):
xav, kev xav hauv siab los yog kev loj hlob?
q
Muaj txij nkawm
q
Tsis tau muaj txij nkawm
q
q
Muaj. Hnub kev ua tsis taus pib: __________
Tsis muaj
q
q
q
Poj ntsuam/yawg ntsuag
Sib nrauj
Sib cais
w
Tus Me Nyuam Lub Npe: (Npe, Npe Nrab, Xeem) los
Txheeb Tus Neeg Thov Kev Pab/Tus Saib Xyuas
Linkage
yog “Tsis Tau Yug”
q
q
Lub npe nyob rau ntawm
Poj Niam los sis Txiv Neej
Cev puas Xeeb Me Nyuam?
Xeeb
Tsis Xeeb
Daim Ntawv Yug
Hnub Yuav Los Yug: _______________
SSN
q
q
Txiv Neej
Poj Niam
Yuav Muaj Pes Tsawg Tus Me Nyuam Mos _____
Zauv Pua Cev
Hnub Yug
q
q
Puas Thov Medi-Cal?
Thov
Tsis thov
(Social Security No.)
Yog Thov, muab tus zauv hauv Daim Yuaj Kho Mob (Benefits Identification
Hli
Hnub
Xyoo
Card) yog tias koj muaj:
PREG
Chaw Yug (Nroog/Xeev/Teb Chaws)
Puas yog neeg Mis Kas los
q
q
Yog
Tsis yog
yog Neeg Teb Chaws no?
ID
Yog tias Tsis yog, hnub tuaj txog __________________________
rau hauv Teb Chaws Mis Kas
Hli
Hnub
Xyoo
q
q
q
q
Tus me nyuam puas nyob hauv tsev?
Nyob
Tsis nyob
Tus me nyuam puas mus kawm ntawv?
Mus
Tsis mus
Medical Support?
Leej niam lub npe:
Leej txiv lub npe:
Yes
No
q
q
CW 2.1 Q
q
Tus me nyuam no puas muaj kev ua tsis taus ntawm cev,
Leej niam los yog leej txiv:
CW 2.1
q
kev xav, kev xav hauv siab los yog kev loj hlob?
q
q
Not in home, 18-21
Tuag lawm
Tsis nyob hauv tsev lawm
q
q
q
tax dependent
Muaj. Hnub kev ua tsis taus pib: __________
Tsis muaj
q
q
Ua tsis taus lawm
Tsis ua hauj lwm lawm
MC 371_HMO_06/09 (Replaces MC 321 HFP-AP and MC 210S-C)
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