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Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Hmong) Page 3

State of California—Health and Human Services Agency

Department of Health Care Services

NTU 3—NCAUJ LUS TXOG NYIAJ TSIS TAUS SOCIAL SECURITY/NYIAJ SSI

County Use Only

A. Tus me nyuam puas tau thov cov nyiaj tsis taus Social Security los yog nyiaj tsis taus Supplemental Security

Income (SSI) ob lub xyoos dhau los?



Tau

Yog tau, thov teb rau cov lus nram Tsis tau, yog tsis tau, hla mus rau Ntu 4.



Tsis tau

B. Tsab ntawv thov nyiaj tsis taus Social Security los yog SSI:



_____

________

Pom Zoo Pab

Hnub tim:

Tsis Kam Pab

Hnub tim:



Tsis Paub



_____

________

Tseem Tos Txiav Txim Dua

Hnub tim:

Tseem Tos

Hnub tim:

C. Txij thaum txiav txim tag, tus me nyuam tus (cov) kab mob kev nkeeg puas huam loj heev dua tuaj?



Huam loj

Yog huam loj, thov piav qhia:



Tsis huam

D. Tus me nyuam puas muaj tej teeb meem kab mob kev nkeeg tshiab txij li hnub txiav txim tsis kam muab nyiaj

tsis taus Social Security/SSI pab rau nws?



Muaj



Yog muaj, cov teeb meem yog dab tsi thiab pib muaj thaum twg?

Tsis mu aj

NTU 4—NCAUJ LUS TXOG COV CHIV KEEB THIAB KEV KAWM NTAWV TSHWJ XEEB

A. Cov koom haum nram no puas tau ntsuas los yog tshuaj ntsuam tus me nyuam dhau los, los yog puas muaj ib

lub koom haum twg nram no uas muaj cov ntaub ntawv teev txog kab mob kev nkeeg los yog ntaub ntawv txog

tus me nyuam?



Tau

Tsis tau

Cov Chaw Hauv Cheeb Tsam (Regional Centers)



Tau

Tsis tau

California Chaw Muab Kev Pab Cuam Rau Me Nyuam (California Children’s Services)



Tau

Tsis tau

Chaw Tshuaj Ntsuam Kev Loj Hlob (Developmental Evaluation Center)



Kev Pab Poj Niam, Me Nyuam Mos thiab Me Nyuam Me (Women, Infants, and Children

Tau

Tsis tau

(WIC) Program)



Tau

Tsis tau

Chaw Pab Kev Puas Siab Ntsws (Mental Health Agency)



Tau

Tsis tau

Lwm Lub Koom Haum



(MC 220) signed

B. Yog ib nqe lus saum Tsis tau teb tias Tau, teb cov ncauj lus nram Tsis tau.

1. Koom Haum Npe

Koom Haum Tus Xov Tooj

Chaw Nyob (zauv, kev)

Zos

Xeev

Zauv Cim

Cheeb Tsam Zip

Kwm Tawm Tswv Yim, Neeg Tuav Ntaub Ntawv, Kws Kho Ib Ce, thiab tej tug li

Xov Tooj

ntawd Lub Npe

Hom kev tshuaj ntsuam, yog muaj (piv txwv, ntsuas qhov muag pom kev, qhov ntsej hnov lus, kev hais lus, ib ce, lub hlwb)

Hnub Ntsuas los yog Tshuaj Ntsuam

Tus Me Nyuam Tus Zauv ID los yog Zauv Cim

Nplooj 3 ntawm 9

MC 223C_HMO_0611

Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Hmong) Page 3

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