Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal (Hmong) Page 8
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8Cov lus teb ntxiv rau nqe lus nug zauv 8 nyob rau nplooj 2, zauv 9 nyob rau nplooj 3, thiab zauv 10 nyob rau nplooj 3. Yog
County Use Only
hais tias koj xav tau chaw sau ntxiv, thov nug koj tus neeg tuav ntaub ntawv hauv lub nras (county) kom muab cov nplooj
ntawv teb ntxiv.
❑
MC 220
Sau lwm cov kws kho mob uas koj mus cuag tawm sab nraum lub (cov) tsev kho mob me los yog lub (cov) tsev kho mob loj uas
koj twb tau sau lawm:
Signed
Lub npe ntawm lub tsev kho mob me/tsev kho mob loj
Tsev kho mob me/tsev kho mob loj tus xov tooj
Tus zauv cim tus neeg mob/tsev kho mob me los sis ua ib tug tswv cuab
(
)
Lub npe ntawm tus (cov) kws kho mob uas tau 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:
Sau lwm cov kws kho mob uas koj mus cuag tawm sab nraum lub (cov) tsev kho mob me los yog lub (cov) tsev kho mob loj uas koj twb tau sau lawm:
MC 220
❑
Kws kho mob lub (cov) npe
Signed
Tus zauv cim tus neeg mob/tsev kho mob me los sis ua ib tug tswv cuab
Tus kws kho mob tus xov tooj
(
)
Lub npe ntawm tus (cov) kws kho mob uas tau 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?
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:
Sau cov kev soj ntsuam ntxiv uas koj tau muaj hauv 12 lub hlis tas los:
NPE THIAB CHAW NYOB NTAWM LUB CHAV FAI UA HAUJ LWM, LUB
MC 220
❑
HNUB TIM
HOM KEV NTSUAM XYUAS
SEV KHO MOB ME, LOS SIS LUB TSEV KHO MOB LOJ UAS UA QHOV
(HLI/XYOO)
KEV NTSUAM XYUAS
Signed
Npe
Qhov chaw nyob ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
Nroog
Xeev
Zauv Cheeb Tsam
MC 220
❑
Npe
Signed
Qhov chaw nyob ntawm lub tsev kho mob me/tsev kho mob loj (zauv tsev, txoj kev, chav nyob)
Nroog
Xeev
Zauv Cheeb Tsam
Nplooj 8 ntawm 8
MC 223 (Hmong) (10/09)
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