Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal (Armenian) Page 3
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89.
ì»ñçÇÝ 12 ³ÙëáõÙ ¸áõù ³ñ¹»Ý Ò»ñ Ýß³Í ÏÉÇÝÇϳ(Ý»ñ)Çó ϳ٠ÑÇí³Ý¹³Ýáó(Ý»ñ)Çó ¹áõñë áñ¨¿ μÅßÏÇ ³Ûó»É»±É »ù:
County Use Only
❑
❑
³Ûá
áã
ºÃ» àâ, ³Ýó»ù 10-ñ¹ ѳٳñÇÝ: ºÃ» ²Úà, ËݹñáõÙ »Ýù ÉñÇí å³ï³ëË³Ý»É Ñ»ï¨Û³ÉÇÝ. »Ã» Ù»ÏÇó ³í»ÉÇ μÅßÏÇ »ù
❑
MC 220
³Ûó»É»É, ËݹñáõÙ »Ýù Éñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñÁ Ýᯐ 8-ñ¹ ¿çáõÙ:
Signed
´ÅßÏÇ/μÅÇßÏÝ»ñÇ ³ÝáõÝ(Ý»ñ)Á
´ÅßÏÇ Ñ»é³ËáëÇ Ñ³Ù³ñÁ
ÐÇí³Ý¹Ç/ÏÉÇÝÇϳÛÇ Ï³Ù ³Ý¹³ÙÇ Ñ³Ù³ñÁ
(
)
ÎÉÇÝÇϳÛÇ/ÑÇí³Ý¹áݳóÇ Ð²êòºÜ (ѳٳñÁ,÷áÕáóÁ, ë»ÝÛ³ÏÝ»ñÁ)
ù³Õ³ùÁ
ݳѳݷÁ
÷áëï³ÛÇÝ Çݹ»ùëÁ
²é³çÇÝ ³Ûó»ÉáõÃÛ³Ý ³Ùë³ÃÇíÁ
ì»ñçÇÝ ³Ûó»ÉáõÃÛ³Ý ³Ùë³ÃÇíÁ
гçáñ¹ ųٳ¹ñáõÃÛ³Ý ³Ùë³ÃÇíÁ
²Ûó»ÉáõÃÛ³Ý/³Ûó»ÉáõÃÛáõÝÝ»ñÇ Ýå³ï³ÏÁ
Âí»ù Ò»ñ ëï³ó³Í ´àÈàð
´àÈàð ¹»Õ»ñÁ`
Âí»ù Ò»ñ ëï³ó³Í ´àÈàð
´àÈàð μáõÅáõÙÝ»ñÁ ¨ ³Û¹ μáõÅáõÙÝ»ñÁ ëï³Ý³Éáõ ³Ùë³Ãí»ñÁ`
10.
ÊܹñáõÙ »Ýù ëïáñ¨ Ýß»É, »Ã» í»ñçÇÝ 12 ³Ùëí³ ÁÝóóùáõÙ ¸áõù ³Ýó»É »ù Ñ»ï¨Û³É ëïáõ·áõÙÝ»ñÇó áñ¨¿ Ù»ÏÁ: ØÇ
Ùáé³ó»ù Ûáõñ³ù³ÝãÛáõñ ëïáõ·Ù³Ý ¹ÇÙ³ó Ýß³Ý ¹Ý»É §³Ûᦠϳ٠§á㦠í³Ý¹³ÏáõÙ: (ºÂº ´ÄÞÎÆ, ÎÈÆÜÆβÚÆ Î²Ø
(ºÂº ´ÄÞÎÆ, ÎÈÆÜÆβÚÆ Î²Ø
ÐÆì²Ü¸²ÜàòÆ Ð²êòºÜ ²ð¸ºÜ ÜÞìºÈ ¾ ìºðÀ, ÜÞºø
ÐÆì²Ü¸²ÜàòÆ Ð²êòºÜ ²ð¸ºÜ ÜÞìºÈ ¾ ìºðÀ, ÜÞºø ØƲÚÜ
ØƲÚÜ ²ÜàôÜÀ ºì ²Øê²ÂÆìÀ:)
²ÜàôÜÀ ºì ²Øê²ÂÆìÀ:)
Àܸàôܲð²ÜÆ, ÎÈÆÜÆβÚÆ Î²Ø ÐÆì²Ü¸²ÜàòÆ ²Üì²ÜàôØÀ ºì
Àܸàôܲð²ÜÆ, ÎÈÆÜÆβÚÆ Î²Ø ÐÆì²Ü¸²ÜàòÆ ²Üì²ÜàôØÀ ºì
²Øê²ÂÆìÀ
²Øê²ÂÆìÀ
βî²ðì²Ì êîàô¶àôØÀ
βî²ðì²Ì êîàô¶àôØÀ
²Úà
²Úà
àâ
àâ
вêòºÜ, àðîºÔ ²ÜòºÈ ºø êîàô¶àôØÀ
вêòºÜ, àðîºÔ ²ÜòºÈ ºø êîàô¶àôØÀ
(²ØÆêÀ/î²ðÆÜ)
(²ØÆêÀ/î²ðÆÜ)
²Ýí³ÝáõÙÁ
❑
MC 220
¾É»Ïïñ³ëñï³·ñáõÃÛáõÝ
¾É»Ïïñ³ëñï³·ñáõÃÛáõÝ
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ, ë»ÝÛ³ÏÝ»ñÁ)
(EKG)
Signed
ù³Õ³ùÁ
ݳѳݷÁ
÷áëï³ÛÇÝ Çݹ»ùëÁ
²Ýí³ÝáõÙÁ
❑
MC 220
äïïíáÕ í³½ùáõÕÇ
äïïíáÕ í³½ùáõÕÇ
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ, ë»ÝÛ³ÏÝ»ñÁ)
(ͳÝñ³μ»éÝí³Í ëñïÇ ëïáõ·áõÙ)
Signed
ù³Õ³ùÁ
ݳѳݷÁ
÷áëï³ÛÇÝ Çݹ»ùëÁ
²Ýí³ÝáõÙÁ
❑
MC 220
ÎñÍù³í³Ý¹³ÏÇ é»Ýï·»ÝÛ³Ý
ÎñÍù³í³Ý¹³ÏÇ é»Ýï·»ÝÛ³Ý
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ, ë»ÝÛ³ÏÝ»ñÁ)
ѻﳽáïáõÃÛáõÝ
ѻﳽáïáõÃÛáõÝ
Signed
ù³Õ³ùÁ
ݳѳݷÁ
÷áëï³ÛÇÝ Çݹ»ùëÁ
²Ýí³ÝáõÙÁ
❑
MC 220
ÞÝã³éáõÃÛ³Ý ëïáõ·áõÙ
ÞÝã³éáõÃÛ³Ý ëïáõ·áõÙ
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ, ë»ÝÛ³ÏÝ»ñÁ)
(PFT)
Signed
ù³Õ³ùÁ
ݳѳݷÁ
÷áëï³ÛÇÝ Çݹ»ùëÁ
²Ýí³ÝáõÙÁ
❑
MC 220
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ, ë»ÝÛ³ÏÝ»ñÁ)
²ñÛ³Ý Ñ»ï³½áïáõÃÛáõÝÝ»ñ
²ñÛ³Ý Ñ»ï³½áïáõÃÛáõÝÝ»ñ
Signed
ù³Õ³ùÁ
ݳѳݷÁ
÷áëï³ÛÇÝ Çݹ»ùëÁ
²Ýí³ÝáõÙÁ
❑
MC 220
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ, ë»ÝÛ³ÏÝ»ñÁ)
²ÛÉ
²ÛÉ
(Ýß»ù)
Signed
ù³Õ³ùÁ
ݳѳݷÁ
÷áëï³ÛÇÝ Çݹ»ùëÁ
¾ç 3` 8 ¿çÇó
MC 223 (Armenian) (10/09)
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