Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal (Hmong) Page 3

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9.
Koj puas tau mus kho mob ntawm lwm tus kws kho mob sab nraud uas tsis yog hauv lub (cov) tsev kho mob me los sis (cov)
County Use Only
❑
❑
tsev kho mob loj uas koj twb tau sau lawm hauv 12 lub hlis tas los?
Tau
Tsis tau
Yog TSIS TAU, mus rau nqe 10. Yog TAU, thov teb cov hauv qab no kom ntxaws, yog tias tau mus kho mob ntawm ntau tshaj
MC 220
❑
ib tug kws kho mob thov teb nplooj 8 rau tag nrho lwm cov lus qhia ntxiv:
Signed
Kws kho mob lub (cov) npe
Tus kws kho mob tus xov tooj
Tus zauv cim tus neeg mob/tsev kho mob me los sis ua ib tug tswv cuab
(
)
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?
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:
10. Thov sau rau hauv qab no yog tias koj tau muaj cov kev ntsuam xyuas li hauv qab no hauv 12 lub hlis tas los. Nco ntsoov
kos tau los yog tsis tau nyob ib sab ntawm txhua qhov kev ntsuam xyuas. (YOG TWB TAU MUAB TUS KWS KHO MOB,
LUB TSEV KHO MOB ME, LOS SIS LUB TSEV KHO MOB LOJ QHOV CHAW NYOB LAWM, TSUAS SAU LUB NPE
THIAB HNUB TIM LAWM XWB.)
NPE THIAB CHAW NYOB NTAWM LUB CHAV FAI UA HAUJ LWM,
HOM KEV NTSUAM
TSIS
HNUB TIM
TAU
LUB TSEV KHO MOB ME, LOS SIS LUB TSEV KHO MOB LOJ UAS
XYUAS UAS UA
TAU
(HLI/XYOO)
UA QHOV KEV NTSUAM XYUAS
Npe
Ntsuam xyuas lub plawv
MC 220
❑
Qhov chaw nyob ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
(electrocardiogram)
Signed
(EKG)
Nroog
Xeev
Zauv Cheeb Tsam
Npe
Lub tshuab khiav (Treadmill)
❑
MC 220
Qhov chaw nyob ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
(Ntsuam xyuas lub plawv
Signed
thaum khiav)
Nroog
Xeev
Zauv Cheeb Tsam
Npe
❑
MC 220
Qhov chaw nyob ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
Yees Hauv Siab (Chest X-ray)
Signed
Nroog
Xeev
Zauv Cheeb Tsam
Npe
MC 220
❑
Qhov chaw nyob ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
Ntsuas Kev Ua Pa
(PFT)
Signed
Nroog
Xeev
Zauv Cheeb Tsam
Npe
MC 220
❑
Qhov chaw nyob ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
Ntsuas Ntshav
Signed
Nroog
Xeev
Zauv Cheeb Tsam
Npe
❑
MC 220
Qhov chaw nyob ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
Lwm yam
(Qhia seb yog dab tsi)
Signed
Nroog
Xeev
Zauv Cheeb Tsam
Nplooj 3 ntawm 8
MC 223 (Hmong) (10/09)

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