Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Hmong) Page 7

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State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
Yog koj xav tau chaw sau ntxiv, thov siv Ntu 9 —Ncauj Lus (nplooj 9). Thov nco ntsoov kos npe rau ib Tsab Ntawv
Pom Zoo Tso Tawm Ntaub Ntawv (MC 220) rau (cov) tuam tsev kho mob/chaw kho mob uas koj teev qhia rau nplooj 6.
B. Tus me nyuam puas tau mus ntsib ib tug kws kho mob/kws kho ib ce uas tsis teev muaj rau ntawm Seem A hauv 12
lub hlis dhau los?
(MC 220) signed
1. Kws Kho Mob los yog Kws Kho Ib Ce Npe
Xov Tooj
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb
Tsam Zip
Thawj Zaug Ntsib
Hnub Ntsib Kawg
Hnub Teem Ntsib Tom Ntej
(Cov) Laj Thawj Tuaj Ntsib
Tus me nyuam tau txais yam kev kho mob twg?
(MC 220) signed
2. Kws Kho Mob los yog Kws Kho Ib Ce Npe
Xov Tooj
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb
Tsam Zip
Thawj Zaug Ntsib
Hnub Ntsib Kawg
Hnub Teem Ntsib Tom Ntej
(Cov) Laj Thawj Tuaj Ntsib
Tus me nyuam tau txais yam kev kho mob twg?
County Use Only
NTU 6—COV TSHUAJ SIV
Tus me nyuam puas noj cov tshuaj kws kho mob muab rau tej kab mob, kev raug mob los yog kab mob kev nkeeg
twg dab tsi tam sim no?
Noj
Yog noj, qhia rau peb txog cov nram no:
Tsis noj
Yam Tshuaj Kws Kho
Qhov Laj Thawj Noj
Cov Kev Mob Tshwm Sim Los
Kws Kho Mob Npe
Mob Muab
Yam Tshuaj
Ntawm Cov Tshuaj, yog muaj
Yog tus me nyuam noj lwm yam tshuaj kws kho mob muab ntxiv, sau cov tshuaj rau ntawm Ntu 9—Cov Ncauj Lus
MC 223C_HMO_0611
Nplooj 7 ntawm 9

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