Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Armenian) Page 8

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State of California—Health and Human Services Agency
Department of Health Care Services
Ø²Ê 7ª ÊÎÀÔ¶ÀÔØܺÐÀ
County Use Only
ºñ»Ë³Ý Çñ ÑÇí³Ý¹áõÃÛáõÝÝ»ñÇ, íݳëí³ÍùÝ»ñÇ Ï³Ù ³éáÕç³Ï³Ý ËݹÇñÝ»ñÇ Ñ³Ù³ñ µÅßÏ³Ï³Ý ëïáõ·áõÙÝ»ñ ³Ýó»±É
¿ ϳ٠³ÝóÝ»Éáõ± ¿£
(MC 220) signed
²Ûá
ºÃ» §²Ûá¦, Ýß»ù Ñ»ï¨Û³ÉÁ.
àã
º±ñµ ¿ ϳï³ñí»É ϳÙ
àñï»±Õ ¿ ϳï³ñí»É ëïáõ·áõÙÁ
à±í ¿ »ñ»Ë³ÛÇÝ áõÕ³ñÏ»É ³Û¹
êïáõ·Ù³Ý ï»ë³ÏÁ
ϳï³ñí»Éáõ ëïáõ·áõÙÁ
(µáõÅÑÇÙݳñÏáõÃÛ³Ý ³Ýí³ÝáõÙÁ)
ëïáõ·Ù³ÝÁ
(³ÙÇëÁ, ï³ñÇÝ)
EKG
(êñïÇ ëïáõ·áõÙ)
Treadmill (êïáõ·áõÙ
í³ñÅáõÃÛáõÝÝ»ñ ϳï³ñ»ÉÇë)
Cardiac
Catheterization
Biopsy
(Name of Body Part)
Speech/Language
Hearing Test
Vision Test
IQ Test
EEG
(¾É»Ïïñ³áõÕ»Õݳ·ñáõÃÛáõÝ)
HIV Test
Blood Test
(Not HIV)
Breathing Test
X-Ray
(Name of Body Part)
MRI/CAT Scan
(Name of Body Part)
ºÃ» »ñ»Ë³Ý ³ÛÉ ëïáõ·áõÙÝ»ñ ¿ ³Ýó»É, Ãí»ù ¹ñ³Ýù 9-ñ¹` §ÜßáõÙÝ»ñ¦, µ³ÅÝáõÙ:
Ø²Ê 8ª ²ÞʲβÜزÚÆÜ ÎºÜʲ¶ÐÀÔÂÚÀÔÜ
(MC 220) signed
ºñ»Ë³Ý »ñµ¨¿ ³ßË³ï»±É ¿:
²Ûá
ºÃ» §²Ûá¦, Éñ³óñ»ù Ñ»ï¨Û³ÉÁ.
àã
²ß˳ï»Éáõ ³Ùë³Ãí»ñÁ
¶áñͳïáõÇ ³ÝáõÝÁ
öáÕáóÇ Ñ³ëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
лé³ËáëÇ Ñ³Ù³ñÁ
ì»ñ³Ï³óáõÇ ³ÝáõÝÁ
¾ç 8` 9 ¿çÇó
MC 223C_ARM_0611

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