Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Hmong) Page 9

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State of California—Health and Human Services Agency
Department of Health Care Services
Qhia tus me nyuam txoj hauj lwm npe thiab piav me ntsis txog yam hauj lwm nws ua thiab tej teeb meem uas nws tau ntsib thaum ua txoj hauj lwm.
NTU 9—COV NCAUJ LUS
NTU 10—KOS NPE THIAB POV THAWJ
Kuv lees raws txoj cai ncaj ncees hauv State of California tias cov lus teb uas kuv tau teev nyob rau hauv Supplemental Statement of Facts for Medi-Cal form
thiab cov ntaub ntawv muab yeej yog thiab muaj tseeb raws li kuv muaj rab peev xwm paub tau thiab ntseeg tau.
1. Tus neeg ua ntawv thov rau tus me nyuam kos npe
Kev txheeb rau tus me nyuam
Hnub tim
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb
Xov Tooj
Tsam Zip
2. Neeg pov thawj kos npe (yog tsim nyog)
Kev txheeb rau tus neeg ua ntawv thov rau tus
Hnub tim
me nyuam
Chaw Nyob (zauv, kev)
Zos
Xeev
Zauv Cim Cheeb
Xov Tooj
Tsam Zip
Nplooj 9 ntawm 9
MC 223C_HMO_0611

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