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

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‫ – التوقيع والمصادقة‬V ‫الجزء‬
‫ أن المعلومات الواردة في هذا البيان اإلضافي للحقائق‬California ‫أ ُ قر تحت عقوبة الحنث باليمين بموجب قوانين الواليات المتحدة األمريكية ووالية‬
.‫صحيحة ودقيقة‬
‫توقيع المتقدم‬
‫التاريخ‬
)‫توقيع الشاهد (إذا و ق ّ ع المتقدم بعالمة‬
‫التاريخ‬
‫التاريخ‬
‫توقيع الشخص الذي يساعد المتقدم على ملء االستمارة‬
‫سوف تحتاج إلى التوقيع على تفويض إلفشاء المعلومات لكل عيادة أو مستشفى أو مرفق اختبار تذكره أو لكل طبيب زرته خارج عيادة أو‬
.‫مستشفى. سوف يمدك أخصائي المقاطعة باستمارات إضافية ستحتاج إلى التوقيع عليها‬
8 ‫صفحة 7 من‬
MC 223 (Arabic) (10/09)

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