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

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SEEM V—KOS NPE THIAB KEV POM ZOO (CERTIFICATION)
Kuv hais tawm raws li kev yuav raug txim yog hais lus dag raws li cov cai hauv Teb Chaws Mis Kas thiab lub Xeev California
tias cov lus qhia uas nyob rau hauv Daim Ntawv Qhia Ntxiv Txog Yam Muaj Tseeb no nws yeej muaj tseeb thiab yog.
Hnub tim
Tus Neeg Thov Kev Pab Kos Npe
Tus Neeg Ua Pov Thawj Kos Npe (Yog hais tias tus neeg thov kev pab kos ib tug cim ua nws lub npe)
Hnub tim
Tus neeg pab teb daim ntawv thov kev pab kos npe
Hnub tim
Koj yuav tsum tau kos npe rau ib daim ntawv tso cai qhia tawm cov lus qhia rau txhua lub
tsev kho mob me, tsev kho mob loj, thiab chaw soj ntsuam uas koj tau muab npe thiab
txhua tus kws kho mob uas koj mus cuag tawm sab nraum lub tsev kho mob me los yog
lub tsev kho mob loj. Koj tus neeg tuav ntaub ntawv hauv lub nras (county) yuav tau muab
ib co ntawv ntxiv rau koj uas koj yuav tau kos npe rau.
Nplooj 7 ntawm 8
MC 223 (Hmong) (10/09)

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