Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal (Armenian)
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8State of California—Health and Human Services Agency
Department of Health Care Services
¸ÆØàð¸Æ ÎàÔØÆò Èð²òàôòÆâ îìÚ²ÈܺðÆ îð²Ø²¸ðزÜ
¸ÆØàð¸Æ ÎàÔØÆò Èð²òàôòÆâ îìÚ²ÈܺðÆ îð²Ø²¸ðزÜ
County Use Only
ºðÂÆÎ` §MEDI-CAL¦-Æ Ð²Ø²ð
ºðÂÆÎ` §MEDI-CAL¦-Æ Ð²Ø²ð
County Number/Aid Code/Case Number
—
—
زê I` ²ÜÒÜ²Î²Ü îºÔºÎàôÂÚàôÜܺð
زê I` ²ÜÒÜ²Î²Ü îºÔºÎàôÂÚàôÜܺð
1a. ¸ÇÙáñ¹Ç ³ÝáõÝÁ (³½·³ÝáõÝÁ, ³ÝáõÝÁ, ÙÇçÇÝ ³ÝáõÝÁ)
1b. êáóÇ³É³Ï³Ý ³å³ÑáíáõÃÛ³Ý
1c. ÌÝݹ۳Ý
ѳٳñÁ
³Ùë³ÃÇíÁ
/
/
—
—
1d. ú·ï³·áñÍíáÕ ³ÛÉ ³ÝáõÝÝ»ñÁ (³½·³ÝáõÝÁ, ³ÝáõÝÁ, ÙÇçÇÝ ³ÝáõÝÁ)
1e. ê»éÁ
1f. гë³ÏÁ
1g. ø³ßÁ
❑ ³ñ³Ï³Ý
ýáõï
ýáõÝï
¹ÛáõÛÙ
❑ Ç·³Ï³Ý
2a. î³Ý ѳëó»Ý
ù³Õ³ùÁ
ݳѳݷÁ
÷áëï³ÛÇÝ Çݹ»ùëÁ
2b. öáëï³ÛÇÝ Ñ³ëó»Ý (»Ã» ï³ñμ»ñ ¿)
ù³Õ³ùÁ
ݳѳݷÁ
÷áëï³ÛÇÝ Çݹ»ùëÁ
¼³Ý·³Ñ³ñ»Éáõ
3.
ò»ñ»Ï³ÛÇÝ Ñ»é³ËáëÇ Ñ³Ù³ñÁ
Üß³Ý ¹ñ»ù, »Ã»`
ѳٳñ É³í³·áõÛÝ
❑
Ñ»é³Ëáë ãϳ
ųٳݳÏÁ
❑
(
)
(
)
ÙdzÛÝ áõÕ»ñÓÝ»ñ ÁݹáõÝáÕ Ñ»é³Ëáë ¿
4b. ¸áõù μ³Ý³íáñ
»Ã» ²Úà, óñ·Ù³ÝãÇ ³ÝáõÝÁ`
¼³Ý·³Ñ³ñ»Éáõ
4a. ¸áõù ³Ý·É»ñ»Ý Ëáëáõ±Ù »ù:
ѳٳñ É³í³·áõÛÝ
óñ·Ù³ÝÇã áõÝ»±ù:
ųٳݳÏÁ
❑
❑
❑
³Ûá
áã
³Ûá
ºÃ» ²Úà, ³Ýó»ù II Ù³ëÇÝ:
ºÃ» ²Úà, ³Ýó»ù II Ù³ëÇÝ:
❑
³ñ·Ù³ÝãÇ Ñ»é³ËáëÇ Ñ³Ù³ñÁ`
áã
ºÃ» àâ, DZÝã É»½íáí/É»½áõÝ»ñáí »ù ËáëáõÙ:
ºÃ» àâ, DZÝã É»½íáí/É»½áõÝ»ñáí »ù ËáëáõÙ:
(
)
زê II` ´ÄÞÎ²Î²Ü îºÔºÎàôÂÚàôÜܺð
زê II` ´ÄÞÎ²Î²Ü îºÔºÎàôÂÚàôÜܺð
County Use Only
5.
²Ýó³Í »ñÏáõ (2) ï³ñí³ ÁÝóóùáõÙ ¸áõù ¹ÇÙ»±É »ù §²Ý³ß˳ïáõݳÏáõÃÛ³Ý Ñ³Ù³ñ ëáóÇ³É³Ï³Ý ³å³ÑáíáõÃ۳ݦ
ϳ٠§²Ý³ß˳ïáõݳÏáõÃÛ³Ý Ñ³Ù³ñ Éñ³óáõóÇã ³å³ÑáíáõÃÛ³Ý »Ï³ÙáõïǦ (SSI) Ýå³ëïÝ»ñ ëï³Ý³Éáõ ѳٳñ:
❑
❑
³Ûá
áã
ºÃ» ²Úà, ËݹñáõÙ »Ýù å³ï³ëË³Ý»É Ñ»ï¨Û³ÉÇÝ.
a. Ò»ñ ëáóÇ³É³Ï³Ý ³å³ÑáíáõÃÛ³Ý Ï³Ù ³Ý³ß˳ïáõݳÏáõÃÛ³Ý SSI-Ç ¹ÇÙáõÙÁ`
❑
❑
❑
❑
❑
ѳëï³ïí»±É ¿
Ù»ñÅí»±É ¿
ݳÛÙ³Ý ÁÝóóùáõ±Ù ¿
·³Ý·³ï³ñÏÙ³Ý Ù»±ç ¿
³ÝѳÛï ϳñ·³íÇ׳Ïáõ±Ù ¿
b. ºÃ» ³ÛÝ Ñ³ëï³ïí»É ϳ٠ٻñÅí»É ¿, Ýß»ù ëáóÇ³É³Ï³Ý ³å³ÑáíáõÃÛ³Ý Ï³Ù ³Ý³ß˳ïáõݳÏáõÃÛ³Ý SSI-Ç Ò»ñ
¹ÇÙáõÙÇ Ï³å³ÏóáõÃÛ³Ùμ ϳ۳óí³Í ³Ù»Ý³í»ñçÇÝ áñáßÙ³Ý ³Ùë³ÃÇíÁ:
❑
❑
c. Ò»ñ ³éáÕç³Ï³Ý ËݹÇñ(Ý»ñ)Á í³ïóñ³ó»±É ¿/»Ý í»ñÁ` 5b-áõÙ Ýßí³Í ³Ùë³ÃíÇó Ñ»ïá:
³Ûá
áã
ºÃ» ²Úà, ËݹñáõÙ »Ýù μ³ó³ïñ»É:
d. Ò»½ Ùáï Üàð ³éáÕç³Ï³Ý ËݹÇñ(Ý»ñ) ³é³ç³ó»±É ¿/»Ý í»ñÁ` 5b-áõÙ Ýßí³Í ³Ùë³ÃíÇó Ñ»ïá, áñÁ/áñáÝù âβð/
âβÚÆÜ ëáóÇ³É³Ï³Ý ³å³ÑáíáõÃÛ³Ý Ï³Ù ³Ý³ß˳ïáõݳÏáõÃÛ³Ý SSI-Ç Ò»ñ ¹ÇÙáõÙÇ Ï³å³ÏóáõÃÛ³Ùμ ϳ۳óí³Í
❑
❑
áñáßÙ³Ý å³ÑÇÝ:
³Ûá
áã
ºÃ» ²Úà, DZÝã ³éáÕç³Ï³Ý ËݹÇñ(Ý»ñ)
.
6
Âí»ù ³ÛÝ μáÉáñ ³éáÕç³Ï³Ý ËݹÇñÝ»ñÁ (ýǽÇÏ³Ï³Ý Ï³Ù Ñ᷻ϳÝ), áñáÝù Ò»½ ÃáõÛÉ ã»Ý ï³ÉÇë ³ß˳ï»É ϳ٠Ñá· ï³Ý»É Ò»ñ ³ÝÓݳϳÝ
ϳñÇùÝ»ñÇ Ù³ëÇÝ: (²ÝÑñ³Å»ßïáõÃÛ³Ý ¹»åùáõÙ` ËݹñáõÙ »Ýù Éñ³óáõóÇã ûñà Ïó»É;)
ºð´ ¾ êÎêìºÈ
ºð´ ¾ êÎêìºÈ
²èàÔæ²Î²Ü ÊܸÆð(ܺð)À
²èàÔæ²Î²Ü ÊܸÆð(ܺð)À
(³ÙÇëÁ/ï³ñÇÝ)
(³ÙÇëÁ/ï³ñÇÝ)
¾ç 1` 8 ¿çÇó
MC 223 (Armenian) (10/09)
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