Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal (Hmong) Page 2

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7.
Koj puas tau txais kev pab kho mob hauv tsev kho mob me los sis tsev kho mob loj rau koj qhov (cov) mob hauv 12 lub hlis
County Use Only
❑
❑
tas los?
Tau
Tsis tau
❑
MC 220
Yog TAU, thov teb kom tag cov hauv qab no:
Signed
Lub npe ntawm lub tsev kho mob me/tsev kho mob loj
Tus zauv cim tus neeg mob/tsev kho mob me los sis ua ib tug tswv cuab
Tsev kho mob me/tsev kho mob loj tus xov tooj
(
)
Lub npe ntawm tus (cov) kws kho mob uas mus ntsib
QHOV CHAW NYOB ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
Nroog
Xeev
Zauv Cheeb Tsam
Thawj hnub mus ntsib
Hnub kawg mus ntsib
Hnub yuav rov mus ntsib
Qhov mus ntsib yog txheej xwm dab tsi?
❑
❑
Koj puas tau pw ib hmos tim tsev kho mob loj?
Tau
Tsis tau
Yog tau, (cov) hnub nkag:
(cov) hnub tawm:
❑
❑
Puas yog kho koj hauv chav muaj xwm ceev?
Yog
Tsis yog
Yog tias YOG, (cov) hnub uas mus ntsib:
Sau TAG NRHO cov tshuaj uas tau txais:
Sau TAG NRHO cov kev kho mob uas tau txais thiab cov hnub tim uas tau txais cov kev kho mob:
8.
Sau lwm lub tsev kho mob me los sis tsev kho mob loj uas koj tau mus kho mob hauv 12 lub hlis tas los.
❑
MC 220
Lub npe ntawm lub tsev kho mob me/tsev kho mob loj
Signed
Tus zauv cim tus neeg mob/tsev kho mob me los sis ua ib tug tswv cuab
Tsev kho mob me/tsev kho mob loj tus xov tooj
(
)
Lub npe ntawm tus (cov) kws kho mob uas mus ntsib
QHOV CHAW NYOB ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
Nroog
Xeev
Zauv Cheeb Tsam
Thawj hnub mus ntsib
Hnub kawg mus ntsib
Hnub yuav rov mus ntsib
Qhov mus ntsib yog txheej xwm dab tsi?
❑
❑
Koj puas tau pw ib hmos tim tsev kho mob loj?
Tau
Tsis tau
Yog tau, (cov) hnub nkag:
(cov) hnub tawm:
❑
❑
Puas yog kho koj hauv chav muaj xwm ceev?
Yog
Tsis yog
Yog tias YOG, (cov) hnub uas mus ntsib:
Sau TAG NRHO cov tshuaj uas tau txais:
Sau TAG NRHO cov kev kho mob uas tau txais thiab cov hnub tim uas tau txais cov kev kho mob:
Yog koj tau mus kho mob hauv lwm lub tsev kho mob me
los sis tsev kho mob loj hauv 12 lub hlis tas los, teb nplooj 8.
Nplooj 2 ntawm 8
MC 223 (Hmong) (10/09)

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