Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Armenian)
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9State of California—Health and Human Services Agency
Department of Health Care Services
Èð²òàôòÆâ îìÚ²ÈܺðÆ îð²Ø²¸ðØ²Ü òàôòàôØܺð`
ܲʲîºêì²Ì §MEDI-CAL¦-Æ ØƲÚÜ ºðºÊ²` ØÆÜâºì
18 î²ðºÎ²Ü, ¸ÆØàÔÆ Ð²Ø²ð (MC 223C)
ØÆÜâºì ëÏë»ÉÁ ϳñ¹³ó»ù ëïáñ¨ ß³ñ³¹ñí³Í ´àÈàð ï»Õ»ÏáõÃÛáõÝÝ»ñÁ: ºÃ» áñ¨¿ ѳñó áõÝ»ù ³Ûë
ûñÃÇÏÇ Ù³ëÇÝ, ϳ٠»Ã» Ò»½ û·ÝáõÃÛáõÝ ¿ ѳñϳíáñ ³ÛÝ Éñ³óÝ»Éáõ ѳñóáõÙ, ËݹñáõÙ »Ýù ½³Ý·³Ñ³ñ»É
Ò»ñ ßñç³Ý³ÛÇÝ ëáóÇ³É³Ï³Ý Í³é³ÛáõÃÛáõÝÝ»ñÇ í³ñãáõÃÛáõÝ:
î»Õ»ÏáõÃÛáõÝÝ»ñÁ, áñáÝù ¸áõù ïñ³Ù³¹ñ»Éáõ »ù ³Ûë ûñÃÇÏÇ íñ³, û·ï³·áñÍí»Éáõ »Ý California
Department of Social Services-Ç, Disability Determination Service Division-Ç ÏáÕÙÇó: ºñ»Ë³ÛÇ §Medi-Cal¦-Ç
¹ÇÙáõÙÇ Ï³å³ÏóáõÃÛ³Ùµ ѳßٳݹ³ÙáõÃÛ³Ý í»ñ³µ»ñÛ³É áñáßáõÙÁ ϳ۳óÝ»Éáõ ¿ ³Û¹ ÑÇÙݳñÏáõÃÛáõÝÁ:
àñå»ë½Ç »ñ»Ë³ÛÇ ·áñÍÝ ³ñ³· ݳÛíÇ, Ñݳñ³íáñÇÝ ã³÷ ÉñÇí Éñ³óñ»ù ³Ûë ûñÃÇÏÁ:
²Ûë ûñÃÇÏÇ íñ³ Ýßí³Í µáÉáñ ѳñó»ñÁ í»ñ³µ»ñáõÙ »Ý »ñ»Ë³ÛÇÝ. Ýñ³° Ù³ëÇÝ ï»Õ»ÏáõÃÛáõÝÝ»ñ
ïñ³Ù³¹ñ»ù, ³ÛÉ á°ã Ò»ñ Ù³ëÇÝ:
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Ø»ù»Ý³·ñ»ù ¨ ïå»ù Ñëï³Ï` ·É˳ï³é»ñáí:
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ÈñÇí å³ï³ë˳ݻù µáÉáñ ѳñó»ñÇÝ:
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гñó»ñÁ µ³ó ÙÇ ÃáÕ»ù: ºÃ» å³ï³ë˳ÝÝ»ñÁ ã·Çï»ù, í³Ý¹³ÏÁ ¹³ï³ñÏ ÙÇ ÃáÕ»ù:
¶ñ»ù §ãϳ¦, §ã·Çï»Ù¦ ϳ٠§ãÇ í»ñ³µ»ñáõÙ¦:
5-ñ¹` §´ÅßÏ³Ï³Ý ï»Õ»ÏáõÃÛáõÝÝ»ñ¦, Ù³ëÇ Ûáõñ³ù³ÝãÛáõñ µ³ÅÝáõÙ ÙdzÛÝ Ù»Ï ÑÇí³Ý¹³Ýáó/ÏÉÇÝÇϳ ϳÙ
Ù»Ï µÅÇßÏ/Ù³ëݳ·»ï Ýß»ù`
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ÑÇí³Ý¹³ÝáóÇ/ÏÉÇÝÇϳÛÇ Ï³Ù µÅßÏÇ/Ù³ëݳ·»ïÇ ÉñÇí ³ÝáõÝÁ.
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ѳëó»Ý.
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»ñ»Ë³ÛÇ ÑÇí³Ý¹³ÝáóÇ/ÏÉÇÝÇϳÛÇ Ñ³Ù³ñÁ:
ºÃ» ¹ÇÙáÕÁ ÙÇÝ㨠18 ï³ñ»Ï³Ý »ñ»Ë³ ã¿, ³å³ ¸áõù å»ïù ¿ ѳïáõÏ ã³÷³Ñ³ëÝ»ñÇ Ñ³Ù³ñ
ݳ˳ï»ëí³Í ûñÃÇÏÝ û·ï³·áñÍ»ù (MC 223), áñÁ ϳñáÕ »ù ëï³Ý³É Ò»ñ ßñç³Ý³ÛÇÝ ëáódzɳϳÝ
ͳé³ÛáõÃÛáõÝÝ»ñÇ í³ñãáõÃÛáõÝÇó:
§ î»Õ»ÏáõÃÛáõÝÝ»ñÇ µ³ó³Ñ³ÛïÙ³Ý ³ñïáÝáõÃ۳ݦ (MC 220) Ù³ëÇÝ
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ÊݹñáõÙ »Ýù ³Ûë ûñÃÇÏÇ íñ³ Ò»ñ Ýß³Í Ûáõñ³ù³ÝãÛáõñ µÅßÏÇ, ÑÇí³Ý¹³ÝáóÇ,
ÏÉÇÝÇϳÛÇ Ï³Ù Ù³ëݳ·»ïÇ Ñ³Ù³ñ Ù»Ï §î»Õ»ÏáõÃÛáõÝÝ»ñÇ µ³ó³Ñ³ÛïÙ³Ý
³ñïáÝáõÃÛáõݦ (MC 220) ïñ³Ù³¹ñ»É:
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MC 220-Ç §´³ó³Ñ³ÛïáõÙÝ ³ñïáÝáÕ ³ÝÓÁ¦ ïáÕÇ íñ³ ѳñϳíáñ ¿ Ò»ñ ³ÝáõÝáí
ëïáñ³·ñ»É (³ÛÉ á°ã »ñ»Ë³ÛÇ) ¨ Ýß³Ý ¹Ý»É ѳٳå³ï³ëË³Ý í³Ý¹³ÏáõÙ (³Ýã³÷³Ñ³ë
³ÝÓÇ ÍÝáÕ, ËÝ³Ù³Ï³É Ï³Ù ³ÛÉ ³ÝÓÝ³Ï³Ý Ý»ñϳ۳óáõóÇã): êïáñ³·ñ»ù
Ûáõñ³ù³ÝãÛáõñ MC 220-Ý. ÙÇ° ëïáñ³·ñ»ù ÙdzÛÝ Ù»ÏÁ, ³å³ å³ï׻ݳѳݻù:
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ºÃ» ë˳Éí»ù, ѳñϳíáñ ¿ ¹ÇÙ»É ßñç³ÝÇÝ ¨ µ³ó³Ñ³ÛïÙ³Ý Ýáñ ûñÃÇÏ í»ñóÝ»É:
§î»Õ»ÏáõÃÛáõÝÝ»ñÇ µ³ó³Ñ³ÛïÙ³Ý ³ñïáÝáõÃ۳ݦ (MC 220) íñ³ ßïñÇË-Ù³ïÇïáí
çÝçáõ٠ϳ٠áõÕÕáõÙ ÙÇ° ϳï³ñ»ù:
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ºÃ» µ³ó³Ñ³ÛïÙ³Ý Ã»ñÃÇÏÁ ëïáñ³·ñáÕÁ §X¦-áí ϳ٠§Ýß³Ýáí¦ å»ïù ¿ ëïáñ³·ñÇ,
³å³ §X¦-Ç Ï³Ù §Ýß³ÝǦ Ñ»ï å»ïù ¿ íϳÛÇ ëïáñ³·ñáõÃÛáõÝÁ ¹ñíÇ ¨ ÝßíÇ íϳÛÇ
³éÝãáõÃÛáõÝÁ ï»Õ»ÏáõÃÛáõÝÁ µ³ó³Ñ³ÛïáÕ ³ÝÓÇ Ñ»ï:
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12 ï³ñ»Ï³ÝÁ µáÉáñ³Í Ûáõñ³ù³ÝãÛáõñ »ñ»Ë³ å»ïù ¿ Çñ ë»÷³Ï³Ý §î»Õ»ÏáõÃÛáõÝÝ»ñÇ
µ³ó³Ñ³ÛïÙ³Ý ³ñïáÝáõÃÛáõÝÁ¦ (MC 220) ëïáñ³·ñÇ, »Ã» Ýñ³ ѳßٳݹ³ÙáõÃÛáõÝÁ
ϳåí³Í ¿ §²Ýã³÷³Ñ³ëÝ»ñÇ Ñ³Ù³Ó³ÛÝáõÃ۳ݦ Íñ³·ñáí ïñ³Ù³¹ñíáÕ
ͳé³ÛáõÃÛáõÝÝ»ñÇ Ñ»ï: ²Ýã³÷³Ñ³ëÁ å»ïù ¿ ëïáñ³·ñÇ MC 220-Á, ¨ §ØdzÛÝ
³Ýã³÷³Ñ³ëÝ»ñÇ Ñ³Ù³Ó³ÛÝáõÃÛ³Ý Í³é³ÛáõÃÛáõÝÝ»ñ¦ í³Ý¹³ÏáõÙ å»ïù ¿ Ýß³Ý ¹ñíÇ:
гßٳݹ³ÙáõÃÛ³Ý ÑÇÙùáí §Medi-Cal¦-Ç Ñ³Ù³ñ ¹ÇÙáÕ Ûáõñ³ù³ÝãÛáõñ »ñ»Ë³ÛÇ Ñ³Ù³ñ ³é³ÝÓÇÝ
MC 223C ¿ å³Ñ³ÝçíáõÙ: êÏë»ù Éñ³óÝ»É Ã»ñÃÇÏÁ 2-ñ¹ ¿çÇó:
¾ç 1` 9 ¿çÇó
MC 223C_ARM_0611
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