Form Mc 176 S - Medi-Cal Status Report (Hmong)
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1
2State of California - Health and Human Services Agency
Department of Health Care Services
TSAB NTAWV QHIA MEDI-CAL
CEEB TOOM: XEEV TXOJ CAI KOM KOJ YUAV TSUM TAU TEB DAIM NTAWV QHIA THAUM NRAB XYOO
KOJ YUAV TSUM TAU XA DAIM NTAWV NO ROV QAB TUAJ TSIS PUB DHAU __________ THIAJ LI YUAV TAU MEDI-CAL
MUS TXUAS NTXIV. THOV SAU THIAB SIV KUA MEM.
Hnubtim: ____________________________________
Tus case number: _____________________________
Tus ceev ntabntawv: ___________________________
Tus worker number: ___________________________
Tus xovtooj: __________________________________
Caij ua haujlwm: ______________________________
Tsis txhob teb daim ntawv no yog hais tias cov neeg uas tau Medi-Cal hauv koj tsev neeg tsuas yog cov neeg
muaj 65 xyoos rov saud, dig muag, cov me nyuam uas muaj 21 xyoos rov hauv, tau kev pab los ntawm CalWORKs los
sis yog ib tug neeg uas nws tau qhia rau nws tus neeg tuav ntaub ntawv hauv Medi-Cal tias nws lub cev xeeb tub los
sis nws lub cev ua tsis taus.
Yuav kom koj tseem tau Medi-Cal, koj yuav tsum tau teb daim ntawv no yog hais tias koj yog ib leeg niam ib
leeg txiv uas tau kev pab los ntawm Medi-Cal. Qhia rau peb txog cov kev hloov uas koj muaj rau 6 lub hlis tas los no.
Yog hais tias koj xav tau kev pab teb daim ntawv no, hu rau koj tus neeg tuav ntaub ntawv. Koj tus neeg tuav ntaub
ntawv lub npe thiab tus xov tooj muaj nyob rau saud.
Seem 1: Yog hais tias koj tsis muaj kev hloov dab tsi rau 6 lub hlis tas los no es yuav tau qhia:
•
Soj ntsuam cov nqe lus nyob rau Seem 2 (mus rau sab nraum qab).
•
Yog hais tias tsis muaj qhia txog kev hloov dab tsi, kos lub thawv no
p Tsis muaj kev hloov
•
TSIS TXHOB teb Seem 2.
•
Mus rau Seem 3 nyob rau sab nraum qab. Koj yuav tsum tau kos npe thiab sau hnub tim rau daim
ntawv no.
•
Xa daim ntawv uas teb meej mus rau lub nras tsis pub dhau hnub tim nyob rau sab saum toj ntawm
daim ntawv no.
•
Siv lub hnab ntawv uas twb muaj chaw nyob xa rov tuaj tas rau ntawd lawm. Tsis tas lo nqi xa.
Yog hais tias koj MUAJ ib co kev hloov rau 6 lub hlis tas los no es yuav tau qhia
•
Mus rau sab nraum qab. Teb Seem 2.
•
Mus rau Seem 3. Koj yuav tsum tau kos npe thiab sau hnub tim rau daim ntawv no.
•
Xa daim ntawv uas teb meej mus rau lub nras tsis pub dhau hnub tim nyob rau sab saum toj ntawm daim
ntawv no.
•
Tsis txhob xa ntaub ntawv dab tsi li tuaj nrog.
•
Siv lub hnab ntawv uas twb muaj chaw nyob xa rov tuaj tas rau ntawd lawm. Tsis tas lo nqi xa.
NCO NTSOOV: KOJ YUAV TSUM TAU KOS NPE RAU SAB NRAUM QAB NTAWM DAIM NTAWV NO
MUS RAU SAB NRAUM QAB u
MC 176 S (Hmong) (03/09)
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