Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Armenian) Page 3
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9State of California—Health and Human Services Agency
Department of Health Care Services
Ø²Ê 3ª κԺÎÀÔÂÚÀÔÜܺРSOCIAL SECURITY-Æ/SSI-Æ Ø²ÊÆÜ
County Use Only
A. ì»ñçÇÝ »ñÏáõ ï³ñí³ ÁÝóóùáõÙ »ñ»Ë³Ý ¹ÇÙ»±É ¿ Social Security-Ç Ñ³ßٳݹ³ÙáõÃÛ³Ý Ï³Ù
Supplemental Security Income-Ç (SSI) ѳßٳݹ³ÙáõÃÛ³Ý Ýå³ëïÝ»ñ ëï³Ý³Éáõ ѳٳñ:
²Ûá
ºÃ» §²Ûá¦, ËݹñáõÙ »Ýù å³ï³ëË³Ý»É Ñ»ï¨Û³É ѳñóÇÝ, »Ã» §àã¦, ³Ýó»ù 4-ñ¹ Ù³ëÇÝ:
Àã
B. Social Security-Ç Ï³Ù SSI-Ç Ñ³ßٳݹ³ÙáõÃÛ³Ý ¹ÇÙáõÙÁ`
Ø»ñÅí»±É ¿
²Ùë³ÃÇíÁ _________
ÀݹáõÝí»±É ¿
²Ùë³ÃÇíÁ _________
гÛïÝÇ ã¿
ܳÛíáõ±Ù ¿
²Ùë³ÃÇíÁ _________
´áÕáù³ñÏíáõ±Ù ¿
²Ùë³ÃÇíÁ _________
C. àñáßáõÙÇó Ñ»ïá »ñ»Ë³ÛÇ ³éáÕç³Ï³Ý ËݹÇñ(Ý»ñ)Á í³ïóñ³ó»±É ¿(»Ý):
²Ûá
ºÃ» §²Ûá¦, ËݹñáõÙ »Ýù µ³ó³ïñ»É
àã
D. Social Security-Ç/SSI-Ç Ñ³ßٳݹ³ÙáõÃÛ³Ý Ù»ñÅáõÙÇó Ñ»ïá »ñ»Ë³ÛÇ Ùáï áñ¨¿ Ýáñ ³éáÕç³Ï³Ý
ËݹÇñ ³é³ç³ó»±É ¿:
²Ûá
ºÃ» §²Ûá¦, DZÝã ËݹÇñÝ»ñ ¨ »±ñµ »Ý ëÏëí»É:
àã
Ø²Ê 4ª κԺÎÀÔÂÚÀÔÜܺРвÎÀÔÎ ²Ô´ÚÀÔÐܺÐÆ ºÌ ¸ÄÐÀÒÆ Ø²ÊÆÜ
A. êïáñ¨ Ýßí³Í ÑÇÙݳñÏáõÃÛáõÝÝ»ñÇó áñ¨¿ Ù»ÏÁ ëïáõ·»±É ϳ٠·Ý³Ñ³ï»±É ¿ »ñ»Ë³ÛÇÝ, ϳ٠³Û¹
ÑÇÙݳñÏáõÃÛáõÝÝ»ñÇó áñ¨¿ Ù»ÏÁ »ñ»Ë³ÛÇ í»ñ³µ»ñÛ³É µÅßÏ³Ï³Ý ïíÛ³ÉÝ»ñ ϳ٠ï»Õ»ÏáõÃÛáõÝÝ»ñ áõÝDZ:
²Ûá
àã
Þñç³Ý³ÛÇÝ Ï»ÝïñáÝÝ»ñ (Regional Centers)
²Ûá
àã
γÉÇýáéÝdzÛÇ Ù³ÝÏ³Ï³Ý Í³é³ÛáõÃÛáõÝÝ»ñ (California Children’s Services)
²Ûá
àã
¼³ñ·³óÙ³Ý Ñ³ñóáõÙ ·Ý³Ñ³ïÙ³Ý Ï»ÝïñáÝ (Developmental Evaluation Center)
§Î³Ý³Ûù, Ýáñ³ÍÇÝÝ»ñ ¨ »ñ»Ë³Ý»ñ¦ (WIC) Íñ³·Çñ (Women, Infants, and Children
²Ûá
àã
Program)
²Ûá
àã
Ðá·»µáõÅ³Ï³Ý ÑÇÙݳñÏáõÃÛáõÝ (Mental Health Agency)
²Ûá
àã
àñ¨¿ ³ÛÉ ÑÇÙݳñÏáõÃÛáõÝ
(MC 220) signed
B. ºÃ» §²Ûᦠ»ù å³ï³ëË³Ý»É í»ñÁ Ýßí³Í ѳñó»ñÇó áñ¨¿ Ù»ÏÇÝ, Éñ³óñ»ù Ñ»ï¨Û³ÉÁ.
1. ÐÇÙݳñÏáõÃÛ³Ý ³Ýí³ÝáõÙÁ
ÐÇÙݳñÏáõÃÛ³Ý Ñ»é³ËáëÇ Ñ³Ù³ñÁ
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
ÊáñÑñ¹³ïáõÇ, ѳٳϳñ·Çã ³ß˳ï³ÏóÇ, Ù³ëݳ·»ïÇ ¨ ³ÛÉÝ, ³ÝáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
êïáõ·Ù³Ý ϳ٠·Ý³Ñ³ïÙ³Ý ï»ë³ÏÁ, »Ã» ϳï³ñí»É ¿ (ûñÇݳÏ` ï»ëáÕáõÃÛáõÝ, ÉëáÕáõÃÛáõÝ, Ëáëù, ýǽÇϳϳÝ,
Ñá·»µ³Ý³Ï³Ý)
êïáõ·Ù³Ý ϳ٠·Ý³Ñ³ïÙ³Ý ³Ùë³ÃÇíÁ
ºñ»Ë³ÛÇ ID ѳٳñÁ ϳ٠ѳÛóÇ Ñ³Ù³ñÁ
¾ç 3` 9 ¿çÇó
MC 223C_ARM_0611
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