Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Korean) Page 8

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State of California—Health and Human Services Agency
Department of Health Care Services
파트 7— 검사들
County Use Only
이 어린이는 질환, 부상, 또는 의학적인 상태로 인해 검사를 받은 적이 있습니까/받을 예정입니까?
(MC 220) signed
예
만일 ‘예’이면, 다음에 관해 저희에게 알려 주십시오:
아니오
검사를 언제 받았습니까/
어디서 검사를
누가 이 어린이에게
검사의 종류
받을 것입니까?
받았습니까?
이 검사를 받도록
(월, 연도)
(시설의 이름)
했습니까?
EKG
(심장 검사)
Treadmill
(운동 검사)
Cardiac
Catheterization
Biopsy
(Name of Body Part)
Speech/Language
Hearing Test
Vision Test
IQ Test
EEG
(뇌파 검사)
HIV Test
Blood Test
(Not HIV)
Breathing Test
X-Ray
(Name of Body Part)
MRI/CAT Scan
(Name of Body Part)
만일 이 어린이가 다른 검사들을 받았으면, 파트 9 — 참조에 그것들을 기록하십시오.
파트 8 — 근무 경력
(MC 220) signed
이 어린이는 일을 한 적이 있습니까?
예
만일 ‘예’이면, 다음을 완성하십시오:
아니오
근무한 일자들
고용주의 이름
주소 (지번, 거리)
시
주
우편번호
전화번호
감독자의 이름
페이지 8 / 9
MC 223C_KOR_0611

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