Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal (Vietnamese) Page 7

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PHAÀ N V—CHÖÕ KYÙ VAØ CHÖÙ N G NHAÄ N
Theo hình phaï t veà toä i khai man cuû a luaä t phaù p cuû a Hôï p Chuû n g Quoá c Hoa Kyø vaø Tieå u Bang California, toâ i xaù c nhaä n raè n g thoâ n g tin trong baû n Xaù c Nhaä n Theâ m veà Döõ
Kieä n naø y laø ñuù n g vaø chính xaù c .
Ngaø y
Chöõ Kyù cuû a Ñöông Ñôn
Chöõ Kyù cuû a Ngöôø i Laø m Chöù n g (Neá u ñöông ñôn kyù teâ n baè n g caù c h ñieå m chæ)
Ngaø y
Chöõ kyù cuû a ngöôø i giuù p ñöông ñôn ñieà n maã u ñôn naø y
Ngaø y
Quyù vò seõ caà n phaû i kyù moä t baû n cho pheù p tieá t loä thoâ n g tin cho moã i y vieä n , beä n h vieä n vaø cô sôû khaù m /xeù t nghieä m maø
quyù vò ñaõ lieä t keâ vaø cho moã i baù c só maø quyù vò ñaõ tôù i khaù m chöõ a beä n h ôû beâ n ngoaø i y vieä n hoaë c beä n h vieä n . Nhaâ n
vieâ n quaä n cuû a quyù vò seõ cung caá p theâ m cho quyù vò caù c maã u ñieà n maø quyù vò caà n kyù teâ n .
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MC 223 (Vietnamese) (10/09)

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