Form Mc 176 S - Medi-Cal Status Report (Armenian) Page 2
ADVERTISEMENT
1
2State of California - Health and Human Services Agency
Department of Health Care Services
²Úê ºðÂÆÎÆ Ðºî ö²êî²ÂÔºð ØÆ àôÔ²ðκø
´³ÅÇÝ 2: Üß³Ý ¹ñ»ù §²Ûᦠí³Ý¹³ÏáõÙ í»ñçÇÝ 6 ³ÙëáõÙ ï»ÕÇ áõÝ»ó³Í µáÉáñ ÷á÷áËáõÃÛáõÝÝ»ñÇ
ѳٳñ ¨ µ³ó³ïñ»ù:
öá÷áËáõÃÛáõÝÝ»ñ »Ï³ÙáõïÇ Ù»ç
p
²Ûá
¸áõù ϳ٠һñ ï³ÝÁ µÝ³ÏíáÕ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù ³í»ÉÇ ß³ï ϳ٠³í»ÉÇ ùÇã ·áõÙ³ñ ëï³ó»±É »ù
³ß˳ï³ÝùÇó, áñå»ë »ñ»Ë³ÛÇ Ï³Ù ³ÙáõëÝ³Ï³Ý ³åñáõëï³¹ñ³Ù, ëáóÇ³É³Ï³Ý ³å³ÑáíáõÃÛáõÝÇó,
áñå»ë í»ï»ñ³ÝÝ»ñÇ, ·áñͳ½ñÏáõÃÛ³Ý Ï³Ù ³Ý³ß˳ïáõݳÏáõÃÛ³Ý Ýå³ëï, ÁÝͳ, ß³Ñ Ï³Ù
ß³Ñáõóµ³ÅÇÝ: ÊݹñáõÙ »Ýù µ³ó³ïñ»
p
öá÷áËáõÃÛáõÝÝ»ñ ϳï³ñí³Í ͳËë»ñÇ Ù»ç
²Ûá
¸áõù ϳ٠һñ ï³ÝÁ µÝ³ÏíáÕ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù ÷á÷áËáõÃÛáõÝ Ï³ï³ñ»±É »ù Ù³ÝÏ³Ï³Ý Ï³Ù
ã³÷³Ñ³ëÇ ËݳÙùÇ Ñ³Ù³ñ í׳ñíáÕ ·áõÙ³ñÇ, ³éáÕçáõÃÛ³Ý ³å³Ñáí³·ñáõÃÛ³Ý, ¹³ï³ñ³ÝÇ áñáßٳٵ
í׳ñíáÕ` »ñ»Ë³ÛÇ Ï³Ù ³ÙáõëÝ³Ï³Ý ³åñáõëï³¹ñ³ÙÇ Ï³Ù áõëÙ³Ý í³ñÓÇ Ù»ç: ÊݹñáõÙ »Ýù µ³ó³ïñ»É.
öá÷áËáõÃÛáõÝÝ»ñ Ï»Ýó³Õ³ÛÇÝ å³ÛÙ³ÝÝ»ñáõÙ
p
²Ûá
àñ¨¿ Ù»ÏÁ ÷á˳¹ñí»±É ¿ Ò»ñ ïáõÝ Ï³Ù Ñ»é³ó»±É ¿ ï³ÝÇó, ëÏë»±É ÏáÕ³ÏóÇ Ñ»ï ³åñ»É, ³Ùáõëݳó»±É ¿
ϳ٠»ñ»Ë³ áõÝ»ó»±É ¿: ÊݹñáõÙ »Ýù µ³ó³ïñ»É.
ºÃ» ³Ûá, Ýñ³Ýù ó³ÝϳÝáõ±Ù »Ý §Medi-Cal¦ áõݻݳÉ: [ ] ²Ûá [ ] àã
p
²ÛÉ ÷á÷áËáõÃÛáõÝÝ»ñ
²Ûá
Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³ÙÇ áõÝ»óí³ÍùÇ ã³÷Ç Ù»ç áñ¨¿ ÷á÷áËáõÃÛáõÝ ï»ÕÇ áõÝ»ó»±É ¿ (ûñÇݳÏ`
µ³ÝϳÛÇÝ Ñ³ßíÇ íñ³ »Õ³Í ·áõÙ³ñÇ, Ù»ù»Ý³Ý»ñÇ, ³Ýß³ñÅ ·áõÛùÇ ¨ ³ÛÉÝ), Ýñ³Ýó Ý»ñ·³ÕóÛÇÝ
ϳñ·³íÇ׳ÏÁ ϳ٠³éáÕçáõÃÛ³Ý ³ÛÉ ³å³Ñáí³·ñáõÃÛ³Ý Ýå³ëïÝ»ñÇ ã³÷Á ÷áËí»±É ¿:
ÊݹñáõÙ »Ýù µ³ó³ïñ»É.
p
гßٳݹ³Ù
²Ûá
Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù Ùï³íáñ ϳ٠ýǽÇÏ³Ï³Ý Ñ³ßٳݹ³ÙáõÃÛáõÝ ëï³ó»±É ¿: ºÃ» ³Ûá, á±í:
p
ÐÕÇ
²Ûá
Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù ÑÕdzó»±É ¿: ºÃ» ³Ûá, á±í:
ÌÝݹ³µ»ñáõÃÛ³Ý ³ÏÝϳÉíáÕ ³Ùë³ÃÇíÁ:
ø³ÝDZ »ñ»Ë³ ¿ ëå³ëíáõÙ:
´³ÅÇÝ 3: êïáñ³·ñáõÃÛáõÝ ¨ ѳëï³ïáõÙ
ºë ѳëϳÝáõÙ »Ù, áñ »Ï³ÙáõïÇ, áõÝ»óí³ÍùÇ ¨/ϳ٠³ÛÉ Ï³ñ·Ç µáÉáñ ÷á÷áËáõÃÛáõÝÝ»ñÇ Ù³ëÇÝ »ë å³ñï³íáñ »Ù
ï»ÕÛ³Ï å³Ñ»É ßñç³ÝÇÝ: λÕÍ íϳÛáõÃÛáõÝ ï³Éáõ ѳٳñ å³ï³ë˳ݳïíáõÃÛ³Ý »ÝóñÏí»Éáõ ëå³éݳÉÇùÇ ï³Ï
»ë ѳÛï³ñ³ñáõÙ »Ù, áñ í»ñÁ ïñ³Ù³¹ñí³Í µáÉáñ ï»Õ»ÏáõÃÛáõÝÝ»ñÁ ×ßÙ³ñï³óÇ »Ý ¨ ³Ýë˳É:
êïáñ³·ñáõÃÛáõÝ`________________________________ лé³Ëáë (
)__________________
²Ùë³ÃÇí`______________
ìϳÛÇ ëïáñ³·ñáõÃÛáõÝÁ`__________________________ лé³Ëáë (
) __________________ ²Ùë³ÃÇí`______________
(ºÃ» ³ÝÓÁ ëïáñ³·ñáõÃÛ³Ý ÷á˳ñ»Ý Ýß³Ý ¿ ¹ñ»É)
Üå³ëï³éáõÇ ³ÝáõÝÇó ѳݹ»ë
»ÏáÕÇ ëïáñ³·ñáõÃÛáõÝÁ`___________________ гñ³µ»ñáõÃÛáõÝÁ Ýå³ëï³éáõÇ Ñ»ï___________ ²Ùë³ÃÇí`______________
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal