Form Mc 176 S - Medi-Cal Status Report (Arabic)
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1
2State of California - Health and Human Services Agency
Department of Health Care Services
MEDI-CAL
ﺗﻘﺮﻳﺮ ﺍﻟﺤﻻﺔ ﺑﺒﺮﻧﺎﻣﺞ
ﻋﻠﻴﻚ ﻗﺎﻧﻮﻥ ﺍﻟﻮﻻﻳﺔ ﺇﺁﻤﺎﻝ ﺗﻘﺮﻳﺮ ﺣﻻﺔ ﻓﻲ ﻣﻨﺘﺼﻒ ﺍﻟﺴﻨﺔ
ﻢ ﺘ
ﺤ ُ ﻳ
:
ﺗﻨﺒﻴﻪ
.
ﻟﻼﺳﺘﻤﺮﺍﺭ ﻓﻲ ﺑﺮﻧﺎﻣﺞ
ﻳﺘﻌﻴﻦ ﺇﺭﺟﺎﻉ ﻩﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ ﺑﺤﻠﻮﻝ
MEDI-CAL
.
ﻳﺮﺟﻰ ﺍﻟﻄﺒﺎﻋﺔ ﻭﺍﺳﺘﺨﺪﺍﻡ ﺍﻟﺤﺒﺮ
،ﻓﻤﺎ ﺃﺁﺜﺮ
ً ﺎ ﻣ
ﺎ ﻋ
ﻳﺒﻠﻐﻮﻥ ﻣﻦ ﺍﻟﻌﻤﺮ
ﻩﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ ﺇﺫﺍ ﺁﺎﻥ ﺍﻷﺷﺨﺎﺹ ﺍﻟﻮﺣﻴﺪﻭﻥ ﺑﺄﺳﺮﺗﻚ ﺍﻟﺬﻳﻦ ﻳﺘﻠﻘﻮﻥ ﺇﻋﺎﻧﺎﺕ ﺑﺮﻧﺎﻣﺞ
ﺑﻤﻞء
ﻻ ﺗﻘﻢ
65
Medi-Cal
ﻣﻮﻇﻒ
ﺑﻻﻔﻌﻞ
ﺃﻭ ﺍﻣﺮﺃﺓ ﺃﺧﺒﺮﺕ
CalWORKs
ﺮﻧﺎﻣﺞ
ﺃﻭ ﻣﻤﻦ ﻳﺘﻠﻘﻮﻥ ﺇﻋﺎﻧﺎﺕ ﺑ
ً ﺎ ﻣ
ﺎ ﻋ
ﺃﻭ ﻣﻦ ﺍﻷﻃﻔﺎﻝ ﺩﻭﻥ ﺳﻦ
ﻣﻦ ﺍﻟﻤﻜﻔﻮﻓﻴﻦ
ﺃﻭ
Medi-Cal
21
.
ﺈﻋﺎﻗﺘﻪ
ﺑ
ﺫﻟﻚ ﺍﻟﻤﻮﻇﻒ
ﺃﺧﻄﺮ
ً ﺎ
ﺼ
ﺨ
ﺷ
ﻋﻦ ﺣﻤﻠﻬﺎ ﺃﻭ
، ﻳﺘﺤﺘﻢ ﻋﻠﻴﻚ ﻣﻞء ﻩﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ
ﻟﻤﻮﺍﺻﻠﺔ ﺍﻻﺷﺘﺮﺍﻙ ﻓﻲ ﺑﺮﻧﺎﻣﺞ
ﺃﺧﺒﺮﻧﺎ ﻋﻦ ﺍﻟﺘﻐﻴﺮﺍﺕ ﺍﻟﺘﻲ
.
ﻳﺘﻠﻘﻰ ﺇﻋﺎﻧﺎﺕ
ً ﺍ ﺪ
ﻟ ﺍ ﻭ
ﺇﺫﺍ ﺁﻨﺖ
Medi-Cal
Medi-Cal
ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ
ﺗﻮﺿﻴﺢ
ﺗﻢ
.
ﺇﺫﺍ ﺁﻨﺖ ﺑﺤﺎﺟﺔ ﻟﻠﻤﺴﺎﻋﺪﺓ ﻓﻲ ﻣﻞء ﻩﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ، ﺍﺗﺼﻞ ﺑﻻﻤﻮﻇﻒ ﺍﻟﺨﺎﺹ ﺑﻚ
.
ﺃﺷﻬﺮ ﺍﻟﻤﺎﺿﻴﺔ
ﺧﻼﻝ ﺍﻟـ
ﺗﻌﺮﺿﺖ ﻟﻬﺎ
6
.
ﻭﺭﻗﻢ ﻩﺎﺗﻔﻪ ﺃﻋﻼﻩ
:
ﺗﺮﻳﺪ ﺇﺧﻄﺎﺭﻧﺎ ﺑﻬﺎ
ﺃﺷﻬﺮ ﺍﻷﺧﻴﺮﺓ
ﺃﻱ ﺗﻐﻴﻴﺮﺍﺕ ﺧﻼﻝ ﺍﻟـ
ﻩﻨﺎﻙ
ﻜﻦ
ﻳ
ﺇﺫﺍ ﻟﻢ
:
ﺍﻟﻘﺴﻢ
6
1
.(
ﺍﻧﺘﻘﻞ ﺇﻟﻰ ﺍﻟﺠﺎﻧﺐ ﺍﻟﺨﻠﻔﻲ
)
ﺭﺍﺟﻊ ﺍﻟﻌﻨﺎﺻﺮ ﺍﻟﻤﺬﺁﻮﺭﺓ ﻓﻲ ﺍﻟﻘﺴﻢ
•
2
ﻻ ﺗﻮﺟﺪ ﺗﻐﻴﻴﺮﺍﺕ
ﻜﻦ ﻩﻨﺎﻙ ﺗﻐﻴﻴﺮﺍﺕ ﺗﺮﻳﺪ ﺍﻹﺑﻼﻍ ﻋﻨﻬﺎ، ﻓﺤﺪﺩ ﻩﺬﺍ ﺍﻟﻤﺮﺑﻊ
ﺇﺫﺍ ﻟﻢ ﻳ
•
.
ﺍﻟﻘﺴﻢ
ﺑﻤﻞء
ﻻ ﺗﻘﻢ
•
2
.
ﻳﺘﻌﻴﻦ ﺗﻮﻗﻴﻊ ﻩﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ ﻭﺗﺄﺭﻳﺨﻬﺎ
.
ﻋﻠﻰ ﺍﻟﺠﺎﻧﺐ ﺍﻟﺨﻠﻔﻲ
ﺍﻧﺘﻘﻞ ﺇﻟﻰ ﺍﻟﻘﺴﻢ
•
3
.
ﺃﺭﺟﻊ ﺍﻻﺳﺘﻤﺎﺭﺓ ﺍﻟﻤﺴﺘﻮﻓﺎﺓ ﺇﻟﻰ ﺍﻟﻤﻘﺎﻃﻌﺔ ﺑﺤﻠﻮﻝ ﺍﻟﺘﺎﺭﻳﺦ ﺍﻟﻤﻮﺿﺢ ﺃﻋﻠﻰ ﻩﺬﻩ ﺍﻟﺼﻔﺤﺔ
•
.
ﻻ ﻳﻠﺰﻡ ﺍﺳﺘﺨﺪﺍﻡ ﻃﻮﺍﺑﻊ
.
ً ﺎ ﻘ ﺒ
ﺴ ﻣ
ﻓﻖ ﺍﻟﻤﻮﺿﺢ ﻋﻠﻴﻪ ﺍﻟﻌﻨﻮﺍﻥ
ﺍﺳﺘﺨﺪﻡ ﺍﻟﻈﺮﻑ ﺍﻟﻤﺮ
•
:
ﺗﺮﻳﺪ ﺇﺧﻄﺎﺭﻧﺎ ﺑﻬﺎ
ﺃﺷﻬﺮ ﺍﻷﺧﻴﺮﺓ
ﺗﻐﻴﻴﺮﺍﺕ ﺧﻼﻝ ﺍﻟـ
ﻩﻨﺎﻙ
ﺇﺫﺍ ﺁﺎﻧﺖ
6
.
ﻗﻢ ﺑﻤﻞء ﺍﻟﻘﺴﻢ
.
ﺍﻧﺘﻘﻞ ﺇﻟﻰ ﺍﻟﺠﺎﻧﺐ ﺍﻟﺨﻠﻔﻲ
2
.
ﻳﺘﻌﻴﻦ ﺗﻮﻗﻴﻊ ﻩﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ ﻭﺗﺄﺭﻳﺨﻬﺎ
3 .
ﺍﻧﺘﻘﻞ ﺇﻟﻰ ﺍﻟﻘﺴﻢ
.
ﺤﻠﻮﻝ ﺍﻟﺘﺎﺭﻳﺦ ﺍﻟﻤﻮﺿﺢ ﺃﻋﻠﻰ ﻩﺬﻩ ﺍﻟﺼﻔﺤﺔ
ﺃﺭﺟﻊ ﺍﻻﺳﺘﻤﺎﺭﺓ ﺍﻟﻤﺴﺘﻮﻓﺎﺓ ﺇﻟﻰ ﺍﻟﻤﻘﺎﻃﻌﺔ ﺑ
.
ﺃﻳﺔ ﻣﺴﺘﻨﺪﺍﺕ
ﻻ ﻞ ﺳ
ﺮ ُ ﺗ
.
ﻻ ﻳﻠﺰﻡ ﺍﺳﺘﺨﺪﺍﻡ ﻃﻮﺍﺑﻊ
.
ً ﺎ ﻘ ﺒ
ﺴ ﻣ
ﺍﺳﺘﺨﺪﻡ ﺍﻟﻈﺮﻑ ﺍﻟﻤﺮﻓﻖ ﺍﻟﻤﻮﺿﺢ ﻋﻠﻴﻪ ﺍﻟﻌﻨﻮﺍﻥ
ﻳﺘﻌﻴﻦ ﺍﻟﺘﻮﻗﻴﻊ ﻋﻠﻰ ﻇﻬﺮ ﻩﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ
:
ﺗﺬﺁﺮ
ﺍﻧﺘﻘﻞ ﺇﻟﻰ ﺍﻟﺠﺎﻧﺐ ﺍﻟﺨﻠﻔﻲ
MC 176 S Arabic (03/09)
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