State of California—Health and Human Services Agency
Department of Health Care Services
NQE LUS TSEEB TXHAWB KEV THOV MEDI-CAL RAU
ME NYUAM XWB—NEEG TSIS NTO 18 (MC 223C) XYOO
COV LUS QHIA TEB
Nyeem TAG NRHO cov lus nram no UA NTEJ koj pib. Yog koj muaj tej lus nug txog tsab ntawv no,
los yog koj xav tau neeg pab koj teb tsab ntawv no, thov hu rau lub chaw lis dej num pab kev noj
kev haus hauv koj lub cheeb nroog.
California Department of Social Services, Disability Determination Service Division yuav siv cov ncauj lus
uas koj teb rau hauv tsab ntawv no. Lub koom haum ntawd yuav txiav txim txog tus me nyuam txoj kev
tsis taus raws li tsab ntawv thov Medi-Cal. Kom pab cov tes dej num lis tus me nyuam cov ntaub ntawv
ceev dua, teb tsab ntawv no kom ntau npaum li koj teb tau.
Tag nrho cov nqe lus nug ntawm tsab ntawv no yog nug txog tus me nyuam – teb cov lus txog nws, tsis
yog teb txog koj tus kheej.
• Ntaus ntawv los yog sau kom meej meej
• Teb tag nrho cov nqe lus nug kom tiav
• Tsis txhob hla cov nqe lus nug. Yog koj tsis paub cov lus teb, tsis txhob kav liam tsis
sau dab tsi. Sau “tsis muaj,” “tsis paub,” los yog “tsis muaj feem xyuam”.
Tsuas sau ib lub tuam tsev kho mob/chaw kho mob los yog ib tug kws kho mob/kws kho ib ce rau ib seem
twg ntawm Ntu 5 – Ncauj Lus Txog Kab Mob Kev Nkeeg. Nco ntsoov qhia txog cov nram no:
• Lub tuam tsev kho mob/chaw kho mob thiab kws kho mob/kws kho ib ce lub npe
tag nrho
• Chaw nyob
• Tus me nyuam lub tuam tsev kho mob/chaw kho mob tus xov tooj.
Yog tus neeg ua ntawv thov tsis yog ib tug me nyuam tsis nto hnub nyoog 18 xyoo, koj yuav
tsum tau siv tsab ntawv thov kev pab uas npaj rau cov neeg laus (MC 223), uas koj mus muab tau
ntawm lub chaw lis dej num pab kev noj kev haus hauv koj lub cheeb nroog.
Ncauj lus txog Tsab Ntawv Pom Zoo Tso Tawm Ntaub Ntawv (MC 220)
• Thov muaj ib Tsab Ntawv Pom Zoo Tso Tawm Ntaub Ntawv (Authorization for Release
of Information) (MC 220) rau ib tug kws kho mob, ib lub tuam tsev kho mob, ib lub chaw
kho mob, los yog ib tug kws kho ib ce twg uas koj teev qhia rau hauv tsab ntawv no.
• Koj yuav tsum kos koj lub npe (tsis yog tus me nyuam lub npe) rau ntawm kab ntawv
“Kev Tso Tawm Ntaub Ntawv Rau Tib Neeg (Individual Authorizing Disclosure)” ntawm
tsab ntawv MC 220 thiab kos rau kem tsim nyog (Leej niam leej txiv ntawm tus me
nyuam tsis nto hnub nyoog, Tus neeg saib xyuas, los yog Lwm tus neeg sawv cev).
Kos npe rau txhua tsab ntawv MC 220—tsis txhob kos npe rau ib tsab ces muab luam.
• Yog koj ua yuam kev, koj yuav tsum hu cuag lub cheeb nroog kom tau tsab ntawv tso
tawm ntaub ntawv tshiab. Tsis txhob siv tshuaj dawb so tawm los yog kos kho Tsab
Ntawv Pom Zoo Tso Tawm Ntaub Ntawv (MC 220).
• Yog tus neeg kos npe rau tsab ntawv tso tawm ntaub ntawv yuav tsum kos tus tsiaj
ntawv “X” los yog tso “tus cim”, tus tsiaj ntawv “X” los yog “tus cim” yuav tsum muaj tus
neeg kos npe ua pov thawj pom thiab teev qhia txoj kev sib txheeb ntawm tus neeg pov
thawj thiab tus neeg tso tawm ntaub ntawv.
• Txhua tus me nyuam uas muaj hnub nyoog 12 xyoos yuav tsum kos nws lub npe rau
Tsab Ntawv Pom Zoo Tso Tawm Ntaub Ntawv (MC 220) yog lawv txoj kev tsis taus muaj
feem xyuam nrog cov kev pab los ntawm txoj kev pab Me Nyuam Kev Tso Cai (Minor
Consent). Tus me nyuam yuav tsum kos npe rau tsab ntawv MC 220 thiab yuav tsum
kos rau kem “Me Nyuam Tso Cai Rau Kev Pab Xwb (Minor Consent Services Only)”.
Yuav tsum muaj ib tsab ntawv MC 223C rau ib tug me nyuam twg uas xav thov Medi-Cal rau txoj
kev tsis taus. Pib teb tsab ntawv ntawm Nplooj 2.
Nplooj 1 ntawm 9
MC 223C_HMO_0611