Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Hmong) Page 6

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State of California—Health and Human Services Agency
Department of Health Care Services
NTU 5—NCAUJ LUS TXOG KAB MOB KEV NKEEG
County Use Only
A. Tus me nyuam puas tau mus cuag tsev kho mob los yog tuam tsev kho mob rau tej kab mob, kev raug mob los
yog kab mob kev nkeeg twg 12 lub hlis dhau los?
Tau
Yog tsis tau, hla mus rau Ntu 6. Yog tau, thov teb cov ncauj lus nram Tsis tau:
Tsis tau
1. Tuam Tsev Kho Mob/Chaw Kho Mob Npe
Cov Hnub
Cov Hom Kev Mus Cuag
Hnub mus
Hnub tawm
Pw Kho Mob (pw ib hmos)
Kho Mob Tag Mus Tsev
(xa mus tsev tib hnub)
Ntsib Chav Kho Mob Kub Ceev
(MC 220) signed
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim
Cheeb Tsam Zip
Xov Tooj
Tuam Tsev Kho Mob/Chaw Kho Mob Tus Zauv Cim
Qhov Laj Thawj Mus Cuag
Tus me nyuam tau cov kev kho mob twg?
Tus me nyuam ntsib tus (cov) kws kho mob twg hauv lub tuam tsev kho mob Tsis tau tsis tu ncua?
2. Tuam Tsev Kho Mob/Chaw Kho Mob Npe
Cov Hnub
Cov Hom Kev Mus Cuag
(MC 220) signed
Hnub mus
Hnub tawm
Pw Kho Mob (pw ib hmos)
Kho Mob Tag Mus Tsev
(xa mus tsev tib hnub)
Ntsib Chav Kho Mob Kub Ceev
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim
Cheeb Tsam Zip
Xov Tooj
Tuam Tsev Kho Mob/Chaw Kho Mob Tus Zauv Cim
Qhov Laj Thawj Mus Cuag
Tus me nyuam tau cov kev kho mob twg?
Tus me nyuam ntsib tus (cov) kws kho mob twg hauv lub tuam tsev kho mob no tsis tu ncua?
Nplooj 6 ntawm 9
MC 223C_HMO_0611

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