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

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State of California—Health and Human Services Agency
Department of Health Care Services
2. Koom Haum Npe
Koom Haum Tus Xov Tooj
County Use Only
(MC 220) signed
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 ntawd Lub
Xov Tooj
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
C. Tus me nyuam puas tau koom nrog tej kev kawm ua ntej pib kawm ntawv, chaw zov me nyuam thiab/los yog cov kev
txhawb kev kawm tom qab kawm ntawv tag?
(MC 220) signed
Tau
Yog tau, thov teb cov ncauj lus nram no:
Tsis tau
Kev Kawm Npe
Xov Tooj
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb
Tsam Zip
Tus Neeg Hu Cuag
Cov Hnub Tau Koom Nrog
D.
Tus me nyuam puas tau mus kawm ntawv?
Yog tau, thov teb cov ncauj lus nram no:
Tau
Yog tsis tau, hla mus rau Seem H
Tsis tau
1. Lub Tsev Kawm Ntawv Npe
Xov Tooj
(MC 220) signed
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb
Tsam Zip
Tus Xib Fwb Lub Npe
(MC 220) signed
2. Lub Tsev Kawm Ntawv Npe
Xov Tooj
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb
Tsam Zip
Tus Xib Fwb Lub Npe
E. Lub tsev kawm ntawv puas muab tej yam kev txhawb tshwj xeeb rau tus me nyuam (piv txwv: rooj tog zaum yooj
yim, cov lag tsev rau cov rooj muaj log, kev pab txhawb ntxiv, los yog kev saib xyuas ntxiv)?
Muab
Yog muab, muab cov hom kev txhawb dab tsi?
Tsis muab
F. Tus me nyuam puas koom cov kev kawm ntawv tshwj xeeb?
Koom
Yog koom, koom nrog cov hom kev kawm ntawv tshwj xeeb twg?
Tsis koom
MC 223C_HMO_0611
Nplooj 4 ntawm 9

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