Form Mc 239 Dra-6 - Information Notice (Hmong)
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1State of California—Health and Human Services Agency
Department of Health Care Services
NTAWV QHIA THIAB PAB KOM
MUAJ KEV KOOM TAU SAI
(COUNTY STAMP)
Hnub qhia:_____________________________________
Tus cim ntaubntawv: _____________________________
Tus ceev ntaubntawv: ____________________________
Tuav ntaub ntawv tus cim: ________________________
Tus ceev ntaubntawv xovtooj:______________________
Caij ua haujlwm: ________________________________
Qhia txog: _____________________________________
Qhov chaw pab ntawv khomob nyob cheebtsam nroog ntawm koj uas yog county Medi-Cal office tau txais ib daim ntawv saunpe noj
mov hauv tsev kawmntawv rau ________________. Nyob hauv daim ntawv ntawd, koj xav kom peb tsomxam saib koj tus menyuam
puas tsimnyog tau txais ntawv khomob uas yog Medi-Cal. Lawvli tej lus koj teb mas:
❒ Koj tus menyuam muaj cai tau txais ntawv khomob uas yog Medi-Cal tamsim no. Yog koj tus menyuam tsi tau muaj dua daim
ntawv khomob uas yog California Benefits Identification Card (BIC), yuav xav ib daim BIC tuaj rau koj tsi ntev no. Siv daim BIC no
coj koj tus menyuam mus ntsib kws khomob tamsim. Txoj kev pab khomob no tsuas yog ib nyuag ntu txog thaum leg koj cov
ntaubntawv khomob uas yog Medi-Cal tiav rau koj. Yuav kom peb paub xam saib koj tus menyuam puas tsimnyog tau kev pab
ntawv khomob ntxiv mus, peb xav kom koj teb suamnpe, thiab xaa daim ntawv no rov tuaj.
❒ Koj tus menyuam tsi muaj cai tau txais ntawv khomob uas yog Medi-Cal tamsim no. Tej zaum nws yuav tau txais ntawv
khomob rau thaum leg tej ntaubntawv tiav tas lawm. Yuav kom peb paub xam saib koj tus menyuam puas tsimnyog tau txais
ntawv khomob, peb xav kom koj teb, suamnpe, thiab xaa daim ntawv no rov tuaj.
LUS TSEEMCEEB: Thov teb cov lus nug hauv qab no thiab xa tej ntaubntawv uas peb xav tau rov tuaj. Thov muab ntim rau
hauv lub hnab xa tuaj nrog no tsi pub dhau lub ______________ yog tsi ua li hais no koj tus menyuam yuav tsi tau txais kev
pab ntawv khomob lossis peb yuav tsi leg nws cov ntaubntawv mus ntxiv lawm.
1. Yog menyuam muaj daim Social Security, thov sau rau nov. __________–__________–__________.
(LUS TSEEMCEEB: Yog menyuam tsi muaj daim Social Security, koj mus thov ib daim rau tamsim no thiab xa tuaj rau peb tsi pub
dhau 60 hnub. Tej zaum tus menyuam yuav mus ntsib tau kws khomob thaum muaj mobnkees nyhav tites titaw yog tias nws ua tsi
tau daim Social Security.)
2. Tus menyuam puas yog lossis puas tau ua neeg Asmeskas? ........................................................................... ❒ Yog
❒ Tsiyog
Yog nws tsi yog, thov teb rau no saib nws puas muaj ntaubntawv nkag tebchaw _____ thiab sau hnub uas
nws nkag tuaj rau tebchaw Asmeskas __________________________.
(Xa nws tej ntaubntawv nkag tebchaw lossis ntaubntawv ntawm INS uas qhia tias nws rov uas dua tshiab
yog tias nws tej ntaubntawv poob lawm. Yog tsi muaj tamsim no, los koj mam xa tuaj tsi pub dhau 30 hnub.)
3. Koj puas xav tau ntawv khomob los them tej nqi khomob uas koj muaj 3 hlis dhau los lwm? ............................. ❒ Xav
❒ Tsixav
4. Tus menyuam puas muaj lwm yam kev pab khomob, khomhniav, lossis kho qhovmuag? .................................. ❒ Muaj ❒ Tsimuaj
Yog muaj, thov teb daim ntawv tuaj nrog no “daim ntawv nug txog kev pab khomob” (DHCS 6155).
(LUS TSEEMCEEB: Koj tus menyuam tseem muaj cai tau txais ntawv khomob txawm nws twb muaj dua
lwm yam kev pab khomob los xij.)
5. Puas muaj lwm tus hauv koj tsevneeg xav thov ntawv khomob Medi-Cal thiab?................................................. ❒ Muaj ❒ Tsimuaj
❒ Yog koj raug them nqi zov menyuam, nqis yug menyuam, them koomhaum pab kev khomob, lossis kev phob nyiaj rau koj tus kheej
txoj haujlwm (self employment), xa tej tw them nqi lossis tw phob nyiaj no tuaj. Tej tw rau kev phob nyiaj no yuav txo tau tej nyiaj koj
khwv tau tagnrho uas yuav coj los tsomxam txog kev pab ntawv khomob no kom nqis. Tej nyiaj ua haujlwm, tej nyiaj raug mob,
nyiaj ua tsi taus haujlwm tej zaum yuav siv tau los txo tej nyiaj uas coj los tsomxam ntawv khomob kom nqis thiab.
❒ Lwm yam _______________________________________________________________________________________________
Yog koj muaj lus nug lossis xav tau lwm yam ntxiv, thov hu rau tus ceev ntaubntawv khomob rau koj uas npe nyob sau lub kaum sab
xis ntawm daim ntawv no.
Kev cog lus thiab suamnpe: Kuv tau leeg lus tias txhua yam uas hais rau hauv daim ntawv no yog lus tseeb raws li txoj cai hauv lub
Xeev California, tej lus cog tseg, thiab tej ntaubntawv sau no tsi yog dag thiab muaj tseeb tsaw li kuv paub thiab kuv ntseeg. Kuv leeg
lus tias kuv tau txais, tau twm, thiab totaub daim ntawv xa tuaj nrog no uas hu ua “Ntsiab lus tseemceeb txog kev thov ntawv khomob.”
Niamtxiv/tus saixyuas suamnpe X________________________________________________________ Hnubtim ________________
Lawv li txoj cai hauv xeev California, nqi 22, phab 50175, mas yog koj tsi muab tej lus tseeb, tej ntaubntawv uas peb xav tau tuaj
rau peb thiab/lossis yog tias tej lus tseeb, tej ntaubntawv koj muab rau peb coj mus tshawb tsi pom, mas peb yuav tsi kam leg
koj cov ntaubntawv khomob mus ntxiv lossis koj txoj kev pab ntawv khomob yuav raug txiav.
MC 368 Hmong (06/07)
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