Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Hmong) Page 5
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9State of California—Health and Human Services Agency
Department of Health Care Services
G. Koj puas luam muaj tus me nyuam tsab ntawv teev kev kawm ntawv rau tus kheej Individualized Education Plan
(IEP—tsab ntawv uas tus xib fwb teev txog tus me nyuam cov teeb meem thiab teev cov tswv yim yuav los daws cov
County Use Only
teeb meem)?
Muaj
(MC 220) signed
Yog muaj, thov luam ib daim nrog.
Tsis muaj
H. Tus me nyuam puas tau tej yam kev txhawb tswv yim los yog kev pab qhia ntawv tshwj xeeb ntxiv?
Tau
Yog tau, thov teb cov ncauj lus nram no (yog koj xav tau chaw sau ntxiv, koj rhais cov nplooj ntawv ntxiv tau):
Tsis tau
Puas yog tau kev txhawb tswv yim los yog kev pab qhia ntawv ntxiv nyob rau hauv tsev
Yog
Tsis yog
kawm ntawv?
Puas yog tau kev txhawb tswv yim los yog kev pab qhia ntawv ntxiv tawm sab nraum tsev
Yog
Tsis yog
kawm ntawv?
Yog tau, thov teb cov ncauj lus nram no:
Tus Kws Txhawb Tswv Yim los yog Neeg Pab Qhia Ntawv Ntxiv lub npe
Xov Tooj
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb Tsam Zip
Ntsib Heev Npaum Li cas
Hnub Pib Kev Txhawb
Hnub Xaus Kev Txhawb (yog tiav lawm)
I.
Tus me nyuam puas tau tej yam kev kho tshwj xeeb (kho ib ce, kho kev hais lus thiab siv lus, kev siv lub cev ua
hauj lwm) los yog lwm cov kev pab txhawb rau nws cov kab mob los yog kev raug mob? Qhia txog tej kev kho
los ntawm leej niam leej txiv, tus neeg saib xyuas, tus neeg zov los yog nyob rau hauv tsev kawm ntawv.
Tau
Yog tau, thov teb cov ncauj lus nram no txog txoj kev kho:
Tsis tau
1. Tus Kws Kho Lub Npe
Xov Tooj
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb
Tsam Zip
(MC 220) signed
Tus neeg ua ntawv kom kho/tsim txoj kev kho
Hom Kev Kho
Ntsib Heev Npaum Li cas
Hnub Pib Kev Txhawb
Hnub Xaus Kev Txhawb (yog tiav lawm)
2. Tus Kws Kho Lub Npe
Xov Tooj
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb
Tsam Zip
(MC 220) signed
Tus neeg ua ntawv kom kho/tsim txoj kev kho
Hom Kev Kho
Ntsib Heev Npaum Li cas
Hnub Pib Kev Txhawb
Hnub Xaus Kev Txhawb (yog tiav lawm)
MC 223C_HMO_0611
Nplooj 5 ntawm 9
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