Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Chinese) Page 2

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State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
County Number
Aid Code
Case Number
僅限用於MEDI-CAL兒童申請人的事實
補充聲明 —18歲以下
第1部分——個人資料
A. 兒童姓名（名，中間名，姓）
B. Social Security號碼
C. 出生日期
D. 性別
F. 體重（磅）
E. 身高
  
英尺__________ 英寸__________
男
女
G. 該兒童和誰一同生活？
關係
電話號碼
姓名
無電話
家庭住址（街道，門牌號）
城市
州
郵編
H. 郵寄地址（若與家庭地址不一致）
州
郵編
地址（街道，門牌號）
城市
I. 兒童的代理申請人
姓名
關係
電話號碼
無電話
留言電話號碼
收留言人的姓名
J. 兒童代理申請人最擅長讀說哪種語言/方言？
第2部分——兒童的病、傷或健康狀況
County Use Only
何時開始的？ 
A. 該兒童的病、傷或健康狀況怎樣？
（月/年）
MC 223C_CHI_0611
第2頁，共9頁

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