Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Chinese) Page 7

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State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
如果需要更多書寫空間，請使用第9部分——評論（第9頁）。請別忘記給您在第6頁上列出的醫院/診所
簽署一份 「資訊披露授權表」 (MC 220)。
B. 該兒童是否在過去12個月內接受過任何第A節未曾列出的醫生/治療師的治療？
(MC 220) signed
1. 醫生或治療師姓名
電話號碼
地址（街道、門牌號）
城市
州
郵編
末次就診日期
下次預約日期
首次就診日期
就診原因
該兒童接受了何種治療？
(MC 220) signed
2. 醫生或治療師姓名
電話號碼
地址（街道、門牌號）
城市
州
郵編
首次就診日期
末次就診日期
下次預約日期
就診原因
該兒童接受了何種治療？
第6部分——用藥
County Use Only
該兒童是否因病、因傷或健康問題服用任何處方藥？
是
如果是，說明以下資訊：
否
處方藥
醫生姓名
用藥原因
副作用，若有
如果該兒童使用其他處方藥，請在第9部分（評論）中列出
MC 223C_CHI_0611
第7頁，共9頁

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