Form Mc 210 Rv - Medi-Cal Annual Redetermination Form (Hmong)
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4State of California—Health and Human Services Agency
Department of Health Care Services
MEDI-CAL TSAB NTAWV ROV TXIAV TXIM TXHUA XYOO
Koj yuav tsum tau teb daim ntawv no thiab xa mus rau koj lub nras (county)
koj thiaj li tseem yuav tau Medi-Cal!
Zauv Cim Txooj Xwm
Tus Zauv Pua Cev (Social Security Number)
(tsis teb los tau)
(tsis teb los tau)
Sau Tag Nrho Koj Lub Npe
Hnub Yug
(yog hais tias koj tsis tau tsiv tsev, muab daim ntawv nplaum uas
(tsis teb los tau) (hli/hnub/xyoo)
muaj qhov chaw nyob lo rau ntawm no yog tias muaj ib daim)
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Chaw Nyob Tam Sim No, Chav Tsev
(kos ntawm no yog hais tias yog qhov chaw nyob tshiab)
Nroog/Xeev
Zauv Cheeb Tsam
Chaw Nyob Xa Ntawv
Nroog/Xeev
Zauv Cheeb Tsam
(yog tias txawv qhov saud)
Siv mem kua thiab SAU koj cov lus teb. Xyuas kom koj kos npe thiab sau hnub tim rau hauv daim ntawv. Siv lub hnab ntawv uas
twb lo nqi xa tas rau lawm xa rov tuaj. Yog hais tias koj xav tau chaw sau ntxiv, muab ib daim ntawv tso nrog rau daim ntawv no.
Yog hais tias koj muaj lus nug los yog xav tau kev pab teb daim ntawv no, hu rau koj tus neeg ua hauj lwm ntawm tus xov tooj
nyob rau hauv Tsab Ntawv Rov Txiav Txim Txhua Xyoo (Annual Redetermination Notice).
Seem 1.
Nyiaj Tau
(a) Koj los yog ib tug neeg hauv koj tsev neeg puas tau nyiaj los ntawm ib txoj hauj lwm, nyiaj them yug
me nyuam los yog nyiaj them yug txij nkawm, nyiaj laus social security, nyiaj qub tub rog, nyiaj poob
hauj lwm, nyiaj tsis taus, nyiaj so hauj lwm, khoom plig, los yog nyiaj paj laum los yog nyiaj tau los
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ntawm cov paj laum (dividends)?
Tau
Tsis tau
Yog tau, teb hauv qab no thiab sau txhua hom nyiaj tau rau ib kab twg.
Muab daim tw tshev ua hauj lwm tsis ntev los no uas qhia txog cov nyiaj tau ua ntej rho se los yog txiav nqi
tawm, daim ntawv qhia txog cov nyiaj tau los yog cov nyiaj pab, cov tshev uas tau txais los yog ib daim ntawv
sau los ntawm qhov chaw ua hauj lwm tias tau nyiaj li cas, los yog cov ntawv ua se tsaib no. Yog hais tias cov
nyiaj yog tau los ntawm qhov ua hauj lwm rau tus kheej, xa koj daim ntawv ua se tsis ntev los no los yog daim
ntawv qhia txog nyiaj tau thiab cov nqi.
Ua Hauj Lwm Pes
Tau Nyiaj Pes Tsawg
Them Heev Npaum Cas
Tsawg Teev
Lub Npe ntawm Tus Neeg Tau Nyiaj
(ua ntej txiav
(txhua as thiv, txhua hli,
(ib as thiv los
Hom Nyiaj Tau
(nrog rau lub npe thiab xeem)
nqi tawm)
ob zaug ib hlis)
yog ib hlis)
(b) Koj los yog tus neeg hauv koj tsev neeg puas tau nqi tsev, khoom noj, los yog khaub ncaws hnav
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dawb tag nrho?
Tau
Tsis tau
Yog tau, leej twg?
Tau dab tsi dawb?
(c) Lub nqi tsev, nqi fais fab nqi dej, khoom noj, los yog khaub ncaws hnav uas tau dawb puas yog los
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pauj rau qhov uas ua hauj lwm?
Yog
Tsis yog
MC 210 RV HMO (5/11)
Nplooj 1 ntawm 4
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