Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Hmong) Page 8

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State of California—Health and Human Services Agency
Department of Health Care Services
NTU 7—COV KEV NTSUAS
County Use Only
Tus me nyuam puas tau muaj los yog puas yuav muaj tej kev ntsuas kab mob, ntsuas kev raug mob los yog ntsuas
kab mob kev nkeeg twg?
(MC 220) signed
Muaj
Yog muaj, qhia rau peb txog cov nram no:
Tsis muaj
Ntsuas tiav/yuav ntsuas
Ntsuas nyob rau
Leej twg xa tus me
Hom Kev Ntsuas
rau thaum twg?
qhov twg?
nyuam no mus rau
(hli, xyoo)
(lub chaw npe)
txoj kev ntsuas no?
EKG
(Ntsuas Plawv)
Treadmill
(Ntsuas Kev Qoj Ib Ce)
Cardiac
Catheterization
Biopsy
(Name of Body Part)
Speech/Language
Hearing Test
Vision Test
IQ Test
EEG
(Ntsuas Hlwb Dhia)
HIV Test
Blood Test
(Not HIV)
Breathing Test
X-Ray
(Name of Body Part)
MRI/CAT Scan
(Name of Body Part)
Yog tus me nyuam tau muaj lwm hom kev ntsuas, sau cov kev ntsuas rau ntawm Ntu 9—Cov Ncauj Lus
NTU 8—KEEB KWM KEV UA HAUJ LWM
(MC 220) signed
Tus me nyuam puas tau ua dua hauj lwm?
Tau
Yog tau, teb kom tiav cov nram no:
Tsis tau
Cov Hnub Ua Hauj Lwm
Chaw Hauj Lwm Npe
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim
Cheeb Tsam Zip
Xov Tooj
Thawj Tswj Xyuas Hauj Lwm Npe
Nplooj 8 ntawm 9
MC 223C_HMO_0611

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