Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Chinese) Page 6

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State of California—Health and Human Services Agency
Department of Health Care Services
第5部分——醫療資訊
County Use Only
A. 該兒童是否在過去12個月中因病、傷或健康狀況去過診所或醫院？
是
如果否，轉到第6部分。如果是，請完整回答以下問題：
否
1. 醫院/診所名稱
日期
就診類型
出院日期
入院日期
住院
（至少在醫院過夜）
門診
（當天回家）
急診
(MC 220) signed
地址（街道、門牌號）
城市
郵編
州
電話號碼
醫院/診所檔案編號
就診原因
該兒童接受了何種治療？
該兒童定期看了醫院的哪位（些）醫生？
2. 醫院/診所名稱
日期
就診類型
(MC 220) signed
出院日期
入院日期
住院
（至少在醫院過夜）
門診
（當天回家）
急診
地址（街道、門牌號）
城市
州
郵編
電話號碼
醫院/診所檔案編號
就診原因
該兒童接受了何種治療？
該兒童定期看了醫院的哪位（些）醫生？
MC 223C_CHI_0611
第6頁，共9頁

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