Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal (Hmong)
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8State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
TUS NEEG THOV KEV PAB DAIM NTAWV QHIA NTXIV TXOG
YAM MUAJ TSEEB RAU MEDI-CAL
County Number/Aid Code/Case Number
—
—
SEEM I—COV LUS QHIA TXOG NTAWM TUS KHEEJ
1a. Tus neeg thov kev pab lub npe (Xeem, Npe, Npe Nrab)
1b. Tus Zauv Pua Cev
1c. Hnub Yug
(Social Security Number)
/
/
—
—
1d. Lwm lub (cov) npe uas siv (Xeem, Npe, Npe Nrab)
1e. Poj Niam los
1f. Siab Li Cas
1g. Nyhav Li Cas
yog Txiv Neej
Tshwm taw (Feet)
Phaus
❑
Txiv Neej
Nti (Inches)
❑
Poj Niam
2a. Qhov Chaw Nyob
Nroog
Xeev
Zauv Cheeb Tsam
2b. Qhov chaw nyob xa ntawv (yog txawv)
Nroog
Xeev
Zauv Cheeb Tsam
3.
Tus xov tooj hu yav nruab hnub
Lub caij zoo hu tshaj
Kos yog:
❑
Tsis muaj xov tooj
❑
(
)
Xov tooj kaw suab (
)
4b. Koj puas muaj ib tug
Yog MUAJ, tus neeg txhais lus lub npe:
Lub caij zoo hu tshaj
4a. Koj puas hais tau lus Mis kas?
neeg txhais lus?
❑
❑
❑
Tau
Yog TAU, mus rau Seem II
Muaj
Tsis
❑
Tsis tau
Yog TSIS TAU, koj hais tau hom
Tus neeg txhais lus tus xov tooj:
lus twg:
(
)
SEEM II—LUS QHIA TXOG KEV KHO MOB
County Use Only
5.
Koj puas tau thov nyiaj Pab Uas Muaj Kev Ua Tsis Taus (Social Security Disability) los sis Nyiaj Laus Uas Thaum Ib Ce Ua
❑
❑
Tsis Taus (Supplemental Security Income [SSI] Disability) li ntawm 2 xyoos dhau los?
Tau
Tsis Tau
Yog TAU, thov teb cov hauv qab no:
a. Ua li koj daim ntawv thov kev pab rau nyiaj Pab Uas Muaj Kev Ua Tsis Taus (Social Security) los sis Nyiaj Laus Thaum Ib Ce
Ua Tsis Taus (SSI Disability) puas tau:
❑
❑
❑
❑
❑
Muab kev pom zoo?
Raug tsis pom zoo?
Tseem tos?
Tseem thov kom rov xyuas dua?
Tsis paub?
b. Yog tias tau kev pom zoo los sis tsis pom zoo, muab hnub tim uas nyuam qhuav txiav txim rau koj daim ntawv thov nyiaj
Pab Uas Muaj Kev Ua Tsis Taus (Social Security) los sis kev pab Nyiaj Laus Thaum Ib Ce Ua Tsis Taus (SSI disability):
❑
❑
c. Koj qhov mob puas mob loj zog tuaj txij hnub tim uas qhia hauv nqe 5b saud?
Mob
Tsis mob
Yog MOB, thov tshab txhais:
d. Koj puas muaj lwm yam mob TSHIAB txij hnub tim uas qhia hauv nqe 5b, saum toj, uas koj TSIS tau muaj kev txiav txim
rau koj qhov kev thov kev pab Nyiaj Rau Kev Ua Tsis Taus (Social Security) los sis kev pab Nyiaj Laus Thaum Ib Ce Ua Tsis
❑
❑
Taus (SSI disability)?
Muaj
Tsis muaj
Yog MUAJ, muaj (cov) mob dab tsi?
6.
Sau tag nrho cov mob (ib ce los sis kev xav (mental)) uas ua rau koj ua tsis tau hauj lwm los sis saib xyuas tsis tau koj tus kheej. (Thov siv dua lwm
daim ntawv ntxiv, yog tsim nyog.)
PIB THAUM TWG
QHOV (COV) MOB
(Hli/Xyoo)
Nplooj 1 ntawm 8
MC 223 (Hmong) (10/09)
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