Form Mc 371 - Additional Family Members Requesting Medi-Cal (Hmong) Page 2
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1
2q DHCS 6155
x
Tam sim no puas muaj leej twg tau kev pab them nqi kho mob/kho hniav los yog Medicare?
q
q
Muaj
Tsis muaj
Yog muaj, leej twg?
OHC Code:
DHCS 6268
y
q
q
q
Puas tau muaj leej twg teev ntawv foob vim muaj kev huam yuaj los yog raug mob?
Muaj
Tsis muaj
MC 210 A
z
q
Koj los yog ib tug neeg hauv tsev neeg puas xav kom Medi-Cal them rau cov nqi kho mob rau peb lub hlis tas
Retroactive Coverage
q
q
los thiab xav thov kev pab los ntawm Medi-Cal?
Xav
Tsis xav
Teev lub (cov) npe:
Them lub (cov) hli:
Month
Month
Month
1
2
3
CW 5
q
q
q
Koj los sis ib tug neeg hauv tsev neeg puas tau mus ua tub rog Mis Kas?
Muaj
Tsis muaj
:
Yog Muaj, leej twg? Lub (Cov) Npe
Sib txheeb li cas:
Kev pab cuam Medi-Cal tej zaum yuav muab cov lus qhia txog koj qhia nrog rau lwm tus tshwj tsis yog tias koj ho tau kos lub thawv hauv qab:
•
Peb yuav muab koj tus me nyuam daim ntawv thov kev pab qhia nrog rau Healthy Families yog hais tias koj tus me nyuam tsis tsim nyog
q
tau kev pab dawb los ntawm Medi-Cal ntxiv lawm yav tom ntej no. Yog hais tias koj tsis xav kom peb qhia cov no tawm, kos ntawm no
•
Peb yuav muab koj tus me nyuam daim ntawv thov kev pab qhia nrog rau Healthy Kids los yog lwm cov kev pab hauv lub nras uas muaj ntsis
zoo li no yog hais tias koj tus me nyuam tsis tsim nyog rau kev pab tag nrho los ntawm Medi-Cal. Yog hais tias koj tsis xav kom peb qhia cov
q
no tawm, kos ntawm no
Tsev Neeg Cov Nyiaj Tau: Sau cov nyiaj tau ntawm txhua tus neeg muaj npe nyob hauv daim ntawv thov kev pab no. Suav cov nyiaj pab
them yug me nyuam thiab cov nyiaj yug tus txij nkawm uas tau txais. (Siv ib txoj kab txawv rau txhua qhov nyiaj tau.)
Lub npe ntawm tus neeg tau qhov Nyiaj
Hom Nyiaj Tau
Tau nyiaj heev npaum li
Tau nyiaj pes
Zauv Pua Cev
cas?
tsawg?
(Social Security No.)
(Tsis tas sau cov me nyuam uas tseem
(Hauj lwm, nyiaj laus,
kawm ntawv cov nyiaj tau los ntawm kev
nyiaj so hauj lwm,
(Txhua as thiv, txhua ob as
(Nyiaj tau tag
(Tsis teb los tau)
ua hauj lwm.)
lwm yam txuas mus)
thiv twg, txhua hli)
nrho ua ntej rho
se tawm)
$
$
$
$
$
Cov Nqi: Sau cov nqi txhua hli rau tag nrho cov neeg muaj npe saud.
Zov Me Nyuam los yog Zov Ib Tug Uas Tsis Taus
Rau (me nyuam los yog tus neeg tsis taus lub npe):
Hnub Nyoog:
Them pes tsawg:
Them heev npaum cas? _________
Rau (me nyuam los yog tus neeg tsis taus lub npe):
Hnub Nyoog:
Them pes tsawg:
Them heev npaum cas? __________
Nyiaj them yug me nyuam uas tsev hais plaub kom them
______________________________
___________________________
______________
Them rau:
Them los ntawm:
Them pes tsawg:
Nyiaj them yug txij nkawm uas tsev hais plaub kom them
______________________________
___________________________
______________
Them rau:
Them los ntawm:
Them pes tsawg:
Thov cim tias tej zaum yuav kom muab cov lus qhia ntxiv txog koj tej vaj tse, nyiaj tau thiab/los yog lwm cov kev pab yog hais tias siv.
Kuv pom zoo tias kuv tau nyeem thiab nkag siab cov lus qhia saud. Kuv tseem pom zoo tias cov lus qhia uas kuv muab hauv daim ntawv no nws yeej
muaj tseeb thiab yog.
______________________________________________________________________
: _____________
Kos npe
Hnub tim
Page 2 of 2
MC 371_HMO_06/09 (Replaces MC 321 HFP-AP and MC 210S-C)
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