Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Hmong) Page 2

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State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
NQE LUS TSEEB TXHAWB KEV THOV
County Number
Aid Code
Case Number
MEDI-CAL RAU ME NYUAM XWB—
NEEG TSIS NTO 18 XYOO
NTU 1—NCAUJ LUS TXOG TUS KHEEJ
A. Tus Me Nyuam Npe (lub npe, npe nruab nrab, lub xeem)
B. Tus Zauv Social Security
C. Hnub Yug
D. Zeej Xeeb
F. Kev Loj Nyhav
E. Kev Loj Siab
  
Zeej Tub
Zeej Ntxhais
Taws__________ Ntiv__________
G. Tus me nyuam nyob nrog leej twg?
Npe
Kev Sib Txheeb
Xov Tooj
Tsis Muaj
Xov Tooj
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb Tsam Zip
H. Chaw Xa Ntawv (yog txawv chaw nyob)
Xeev
Zauv Cim Cheeb Tsam Zip
Chaw Nyob (zauv, kev)
Zos
I. Tus tib neeg ua ntawv thov rau tus me nyuam
Npe
Kev Sib Txheeb
Xov Tooj
Tsis Muaj
Xov Tooj
Xov Tooj Kaw Tseg Lus
Tus neeg uas tseg lus nrog lub npe
J. Tus me nyuam ua ntawv thov hais thiab nyeem tau hom/yam lus twg tau zoo tshaj plaws?
NTU 2—TUS ME NYUAM COV KAB MOB, KEV RAUG MOB, LOS YOG KAB MOB KEV NKEEG
County Use Only
Pib mob thaum twg?
A. Tus me nyuam muaj cov kab mob, kev raug mob, los yog kab mob kev nkeeg twg?
(hli/xyoo)
Nplooj 2 ntawm 9
MC 223C_HMO_0611

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