Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Armenian) Page 4

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State of California—Health and Human Services Agency
Department of Health Care Services
2. ÐÇÙݳñÏáõÃÛ³Ý ³Ýí³ÝáõÙÁ
ÐÇÙݳñÏáõÃÛ³Ý Ñ»é³ËáëÇ Ñ³Ù³ñÁ
County Use Only
(MC 220) signed
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
C. ºñ»Ë³Ý ѳ׳Ëáõ±Ù ϳ٠ѳ׳˻±É ¿ áñ¨¿ ïÇåÇ Ý³Ë³¹åñáó³Ï³Ý, ó»ñ»Ï³ÛÇÝ ËݳÙùÇ ¨/ϳ٠»ñϳñ³óí³Í
ųٻñáí ¹åñáó³Ï³Ý Íñ³·ñÇ:
(MC 220) signed
²Ûá
ºÃ» §²Ûá¦, ËݹñáõÙ »Ýù Éñ³óÝ»É Ñ»ï¨Û³ÉÁ.
àã
Ìñ³·ñÇ ³Ýí³ÝáõÙÁ
лé³ËáëÇ Ñ³Ù³ñÁ
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
àõ±Ù ¹ÇÙ»É
г׳˻Éáõ ûñ»ñÁ
D. ºñ»Ë³Ý ¹åñáó ѳ׳Ëáõ±Ù ϳ٠ѳ׳˻±É ¿
ºÃ» §²Ûá¦, ËݹñáõÙ »Ýù Éñ³óÝ»É Ñ»ï¨Û³ÉÁ.
²Ûá
ºÃ» §àã¦, ³Ýó»ù H µ³ÅÝÇÝ
àã
1. ¸åñáóÇ ³Ýí³ÝáõÙÁ
лé³ËáëÇ Ñ³Ù³ñÁ
(MC 220) signed
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
àõëáõóãÇ ³ÝáõÝÁ
(MC 220) signed
2. ¸åñáóÇ ³Ýí³ÝáõÙÁ
лé³ËáëÇ Ñ³Ù³ñÁ
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
àõëáõóãÇ ³ÝáõÝÁ
E. ¸åñáóÁ ѳïáõÏ Ñ³ñÙ³ñ»óáõÙÝ»ñ ϳï³ñ»±É ¿ »ñ»Ë³ÛÇ Ñ³Ù³ñ (ûñÇݳÏ` ѳñÙ³ñ»óí³Í ϳÑáõÛù,
ѳñóÏÝ»ñ ³Ýí³ë³ÛɳÏÇ Ñ³Ù³ñ, Éñ³óáõóÇã ûųݹ³ÏáõÃÛáõÝ Ï³Ù áõß³¹ñáõÃÛáõÝ):
²Ûá
ºÃ» §²Ûá¦, DZÝã ïÇåÇ Ñ³ñÙ³ñ»óáõÙ:
àã
F. ºñ»Ë³Ý Áݹ·ñÏí³±Í ¿ ѳïáõÏ ÏñÃ³Ï³Ý Íñ³·ñáõÙ:
²Ûá
ºÃ» §²Ûá¦, DZÝã ïÇåÇ Ñ³ïáõÏ ÏñÃ³Ï³Ý Íñ³·ñáõÙ:
àã
MC 223C_ARM_0611
¾ç 4` 9 ¿çÇó

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