Form Mc 176 S - Medi-Cal Status Report (Farsi)
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1
2State of California - Health and Human Services Agency
Department of Health Care Services
State of California-Health and Human Services Agency
ﮔﺰﺍﺭﺵ ﻭﺿﻌﻴﺖ
MEDI-CAL
.
ﻗﻮﺍﻧﻴﻦ ﺍﻳﻻﺘﯽ ﻣﻠﺰﻡ ﻣﯽ ﺩﺍﻧﻨﺪ ﮐﻪ ﻳﮏ ﮔﺰﺍﺭﺵ ﻭﺿﻌﻴﺖ ﻧﻴﻤﻪ ﺳﻻﻪ ﺭﺍ ﺗﮑﻤﻴﻞ ﻧﻤﺎﻳﻴﺪ
ﺗﻮﺟﻪ
:
______
_______
ﮔﺰﺍﺭﺵ ﻭﺿﻌﻴﺖ
.
ﺑﻪ ﻣﺎ ﺍﺭﺳﺎﻝ ﻧﻤﺎﻳﻴﺪ
ﺗﺎﻥ ﺭﺍ ﻧﮕﻬﺪﺍﺭﻳﺪ، ﺑﺎﻳﺪ ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﺗﺎ ﺗﺎﺭﻳﺦ
ﺑﺮﺍی ﺍﻳﻨﮑﻪ ﺑﺘﻮﺍﻧﻴﺪ
MEDI-CAL
______________
MEDI-CAL
.
ﺎﻳﻴﺪ
ﺑﻪ ﺻﻮﺭﺕ ﭼﺎﭘﯽ ﺑﻨﻮﻳﺴﻴﺪ ﻭ ﺍﺯ ﺟﻮﻩﺮ ﺍﺳﺘﻔﺎﺩﻩ ﻧﻤ
ً ﺎ ﻔ
ﻄ ﻟ
.
ﻗﻮﺍﻧﻴﻦ ﺍﻳﻻﺘﯽ ﻣﻠﺰﻡ ﻣﯽ ﺩﺍﻧﻨﺪ ﮐﻪ ﻳﮏ ﮔﺰﺍﺭﺵ ﻭﺿﻌﻴﺖ ﻧﻴﻤﻪ ﺳﻻﻪ ﺭﺍ ﺗﮑﻤﻴﻞ ﻧﻤﺎﻳﻴﺪ
:
ﺗﻮﺟﻪ
_____ (COUNTY STAMP)
_____
.
ﺑﻪ ﻣﺎ ﺍﺭﺳﺎﻝ ﻧﻤﺎﻳﻴﺪ
ﺗﺎﻥ ﺭﺍ ﻧﮕﻬﺪﺍﺭﻳﺪ، ﺑﺎﻳﺪ ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﺗﺎ ﺗﺎﺭﻳﺦ
ﺑﺮﺍی ﺍﻳﻨﮑﻪ ﺑﺘﻮﺍﻧﻴﺪ
______________
MEDI-CAL
.
ﺎﻳﻴﺪ
ﺑﻪ ﺻﻮﺭﺕ ﭼﺎﭘﯽ ﺑﻨﻮﻳﺴﻴﺪ ﻭ ﺍﺯ ﺟﻮﻩﺮ ﺍﺳﺘﻔﺎﺩﻩ ﻧﻤ
ً ﺎ ﻔ
ﻄ ﻟ
:
ﻃﻼﻋﻴﻪ
ﺗﺎﺭﻳﺦ ﺍ
:
ﺷﻤﺎﺭﻩ ﭘﺮﻭﻧﺪﻩ
:
ﻣﺪﺩﮐﺎﺭ
ﻧﺎﻡ
:
ﻣﺪﺩﮐﺎﺭ
ﺷﻤﺎﺭﻩ
:
ﺷﻤﺎﺭﻩ ﺗﻠﻔﻦ ﮐﺎﺭﻣﻨﺪ
:
ﮐﺎﺭﻣﻨﺪ
ﺳﺎﻋﺎﺕ ﮐﺎﺭ
ﺳﺎﻝ ﻳﺎ ﺑﻴﺸﺘﺮﺳﻦ ﺩﺍﺭﻧﺪ، ﻧﺎﺑﻴﻨﺎ ﻩﺴﺘﻨﺪ، ﻭ ﻳﺎ ﮐﻮﺩک
5
ﺩﺭﻳﺎﻓﺖ ﻣﯽ ﮐﻨﻨﺪ ﮐﻪ
ﺍﮔﺮ ﺗﻨﻬﺎ ﺍﺷﺨﺎﺻﯽ ﺩﺭ ﺧﺎﻧﻮﺍﺩﻩ ﺷﻤﺎ
6
Medi-Cal
ﻩﺴﺘﻨﺪ، ﻭ ﻳﺎ ﺷﺨﺼﯽ ﮐﻪ ﺣﺎﻣﻠﮕﯽ ﻭ ﻳﺎ ﺍﺯ ﮐﺎﺭ ﺍﻓﺘﺎﺩﮔﯽ ﺧﻮﺩ ﺭﺍ ﺍﺯ ﻗﺒﻞ ﺑﻪ
ﺳﺎﻝ، ﻭ ﻳﺎ ﺩﺭﻳﺎﻓﺖ ﮐﻨﻨﺪﻩ
CalWORKs
21
21
.
ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﭘﺮ ﻧﮑﻨﻴﺪ
،ﮔﺰﺍﺭﺵ ﺩﺍﺩﻩ ﺍﻧﺪ
ﻣﺪﺩﮐﺎﺭ
Medi-Cal
ﺳﺎﻝ ﻳﺎ ﺑﻴﺸﺘﺮﺳﻦ ﺩﺍﺭﻧﺪ، ﻧﺎﺑﻴﻨﺎ ﻩﺴﺘﻨﺪ، ﻭ ﻳﺎ ﮐﻮﺩک
5
ﺩﺭﻳﺎﻓﺖ ﻣﯽ ﮐﻨﻨﺪ ﮐﻪ
ﺍﮔﺮ ﺗﻨﻬﺎ ﺍﺷﺨﺎﺻﯽ ﺩﺭ ﺧﺎﻧﻮﺍﺩﻩ ﺷﻤﺎ
Medi-Cal
6
ﻩﺴﺘﻨﺪ، ﻭ ﻳﺎ ﺷﺨﺼﯽ ﮐﻪ ﺣﺎﻣﻠﮕﯽ ﻭ ﻳﺎ ﺍﺯ ﮐﺎﺭ ﺍﻓﺘﺎﺩﮔﯽ ﺧﻮﺩ ﺭﺍ ﺍﺯ ﻗﺒﻞ ﺑﻪ
ﺳﺎﻝ، ﻭ ﻳﺎ ﺩﺭﻳﺎﻓﺖ ﮐﻨﻨﺪﻩ
،ﺩﺭﻳﺎﻓﺖ ﻣﯽ ﮐﻨﺪ
ﺍﮔﺮ ﭘﺪﺭ ﻭ ﻳﺎ ﻣﺎﺩﺭی ﻩﺴﺘﻴﺪ ﮐﻪ
________________________
،
ﺟﻬﺖ ﻧﮕﻬﺪﺍﺭی
(
)
CalWORKs
21
Medi
-
Cal
Medi
-
Cal
:
.
ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﭘﺮ ﻧﮑﻨﻴﺪ
،ﮔﺰﺍﺭﺵ ﺩﺍﺩﻩ ﺍﻧﺪ
ﻣﺪﺩﮐﺎﺭ
Medi-Cal
ﺍﮔﺮ ﺑﺮﺍی ﭘﺮ ﮐﺮﺩﻥ ﺍﻳﻦ ﻓﺮﻡ ﻧﻴﺎﺯ ﺑﻪ ﮐﻤﮏ
.
ﻣﺎﻩ ﮔﺬﺷﺘﻪ ﺩﺍﺷﺘﻴﺪ، ﺑﻪ ﻣﺎ ﺍﻃﻼﻉ ﺩﻩﻴﺪ
ﺩﺭ ﻣﻮﺭﺩ ﺗﻐﻴﻴﺮﺍﺗﯽ ﮐﻪ ﻃﯽ
.
ﻣﻠﺰﻡ ﺑﻪ ﭘﺮ ﮐﺮﺩﻥ ﺍﻳﻦ ﻓﺮﻡ ﻩﺴﺘﻴﺪ
6
.
_______________________
.
ﻧﺎﻡ ﻭ ﺷﻤﺎﺭﻩ ﺗﻠﻔﻦ ﻣﺪﺩﮐﺎﺭ ﺷﻤﺎ ﺩﺭ ﺑﺎﻻ ﺩﺭﺝ ﺷﺪﻩ ﺍﺳﺖ
.
ﺩﺍﺭﻳﺪ، ﺑﺎ ﻣﺪﺩﮐﺎﺭﺗﺎﻥ ﺗﻤﺎﺱ ﺣﺎﺻﻞ ﻧﻤﺎﻳﻴﺪ
،ﺩﺭﻳﺎﻓﺖ ﻣﯽ ﮐﻨﺪ
ﺍﮔﺮ ﭘﺪﺭ ﻭ ﻳﺎ ﻣﺎﺩﺭی ﻩﺴﺘﻴﺪ ﮐﻪ
،
ﺟﻬﺖ ﻧﮕﻬﺪﺍﺭی
Medi
-
Cal
Medi
-
Cal
.
ﺍﮔﺮ ﺑﺮﺍی ﭘﺮ ﮐﺮﺩﻥ ﺍﻳﻦ ﻓﺮﻡ ﻧﻴﺎﺯ ﺑﻪ ﮐﻤﮏ
.
ﻣﺎﻩ ﮔﺬﺷﺘﻪ ﺩﺍﺷﺘﻴﺪ، ﺑﻪ ﻣﺎ ﺍﻃﻼﻉ ﺩﻩﻴﺪ
ﺩﺭ ﻣﻮﺭﺩ ﺗﻐﻴﻴﺮﺍﺗﯽ ﮐﻪ ﻃﯽ
.
ﻣﻠﺰﻡ ﺑﻪ ﭘﺮ ﮐﺮﺩﻥ ﺍﻳﻦ ﻓﺮﻡ ﻩﺴﺘﻴﺪ
6
:
ﮔﺬﺷﺘﻪ ﻩﻴﭻ ﮔﻮﻧﻪ ﺗﻐﻴﻴﺮی ﺑﺮﺍی ﮔﺰﺍﺭﺵ ﻧﺪﺍﺭﻳﺪ
ﻣﺎﻩ
ﺍﮔﺮ ﻃﯽ
.
6
________________
1 :
ﺑﺨﺶ
.
ﻧﺎﻡ ﻭ ﺷﻤﺎﺭﻩ ﺗﻠﻔﻦ ﻣﺪﺩﮐﺎﺭ ﺷﻤﺎ ﺩﺭ ﺑﺎﻻ ﺩﺭﺝ ﺷﺪﻩ ﺍﺳﺖ
.
ﺩﺍﺭﻳﺪ، ﺑﺎ ﻣﺪﺩﮐﺎﺭﺗﺎﻥ ﺗﻤﺎﺱ ﺣﺎﺻﻞ ﻧﻤﺎﻳﻴﺪ
______________
.(
ﺑﻪ ﻗﺴﻤﺖ ﭘﺸﺖ ﺻﻔﺤﻪ ﻣﺮﺍﺟﻌﻪ ﮐﻨﻴﺪ
)
ﻓﻬﺮﺳﺖ ﺷﺪﻩ ﺍﻧﺪ ﺭﺍ ﺑﺮﺭﺳﯽ ﻧﻤﺎﻳﻴﺪ
ﻣﻮﺍﺭﺩی ﮐﻪ ﺩﺭ ﺑﺨﺶ
•
2
:
ﮔﺬﺷﺘﻪ ﻩﻴﭻ ﮔﻮﻧﻪ ﺗﻐﻴﻴﺮی ﺑﺮﺍی ﮔﺰﺍﺭﺵ ﻧﺪﺍﺭﻳﺪ
ﻣﺎﻩ
6
ﺍﮔﺮ ﻃﯽ
1 :
ﺑﺨﺶ
.
ﺑﺪﻭﻥ ﺗﻐﻴﻴﺮ
ﺍﮔﺮ ﻩﻴﭻ ﮔﻮﻧﻪ ﺗﻐﻴﻴﺮی ﺑﺮﺍی ﮔﺰﺍﺭﺵ ﻧﺪﺍﺭﻳﺪ، ﺍﻳﻦ ﻣﺮﺑﻊ ﺭﺍ ﺗﻴﮏ ﺑﺰﻧﻴﺪ
•
.
ﻧﮑﻨﻴﺪ
ﺭﺍ ﭘﺮ
ﺑﺨﺶ
•
2
.
:
______
.(
ﺑﻪ ﻗﺴﻤﺖ ﭘﺸﺖ ﺻﻔﺤﻪ ﻣﺮﺍﺟﻌﻪ ﮐﻨﻴﺪ
)
ﻓﻬﺮﺳﺖ ﺷﺪﻩ ﺍﻧﺪ ﺭﺍ ﺑﺮﺭﺳﯽ ﻧﻤﺎﻳﻴﺪ
ﻣﻮﺍﺭﺩی ﮐﻪ ﺩﺭ ﺑﺨﺶ
•
2
.
_____
.
ﻤﺎ ﺑﺎﻳﺪ ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﺗﺎﺭﻳﺦ ﺯﺩﻩ ﻭ ﺍﻣﻀﺎء ﮐﻨﻴﺪ
p
ﺷ
.
ﺩﺭ ﭘﺸﺖ ﺻﻔﺤﻪ ﻣﺮﺍﺟﻌﻪ ﻧﻤﺎﻳﻴﺪ
ﺑﻪ ﺑﺨﺶ
•
3
ﺑﺪﻭﻥ ﺗﻐﻴﻴﺮ
ﺍﮔﺮ ﻩﻴﭻ ﮔﻮﻧﻪ ﺗﻐﻴﻴﺮی ﺑﺮﺍی ﮔﺰﺍﺭﺵ ﻧﺪﺍﺭﻳﺪ، ﺍﻳﻦ ﻣﺮﺑﻊ ﺭﺍ ﺗﻴﮏ ﺑﺰﻧﻴﺪ
•
.
ﻓﺮﻡ ﺗﮑﻤﻴﻞ ﺷﺪﻩ ﺭﺍ ﺗﺎ ﺗﺎﺭﻳﺦ ﻣﻨﺪﺭﺝ ﺩﺭ ﺑﺎﻻی ﺍﻳﻦ ﺻﻔﺤﻪ، ﺑﻪ ﮐﺎﻧﺘﯽ ﺍﺭﺳﺎﻝ ﻧﻤﺎﻳﻴﺪ
.
ﻧﮑﻨﻴﺪ
•
ﺭﺍ ﭘﺮ
ﺑﺨﺶ
•
2
.
__________________
.
ﻧﻴﺎﺯی ﺑﻪ ﺍﻟﺼﺎﻕ ﺗﻤﺒﺮ ﻧﻴﺴﺖ
.
ﺍﺯ ﭘﺎﮐﺖ ﺁﺩﺭﺱ ﺩﺍﺭ ﺿﻤﻴﻤﻪ ﺷﺪﻩ ﺍﺳﺘﻔﺎﺩﻩ ﻧﻤﺎﻳﻴﺪ
•
.
ﻤﺎ ﺑﺎﻳﺪ ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﺗﺎﺭﻳﺦ ﺯﺩﻩ ﻭ ﺍﻣﻀﺎء ﮐﻨﻴﺪ
ﺷ
.
ﺩﺭ ﭘﺸﺖ ﺻﻔﺤﻪ ﻣﺮﺍﺟﻌﻪ ﻧﻤﺎﻳﻴﺪ
ﺑﻪ ﺑﺨﺶ
•
3
.
ﻓﺮﻡ ﺗﮑﻤﻴﻞ ﺷﺪﻩ ﺭﺍ ﺗﺎ ﺗﺎﺭﻳﺦ ﻣﻨﺪﺭﺝ ﺩﺭ ﺑﺎﻻی ﺍﻳﻦ ﺻﻔﺤﻪ، ﺑﻪ ﮐﺎﻧﺘﯽ ﺍﺭﺳﺎﻝ ﻧﻤﺎﻳﻴﺪ
•
_______
___________
.
ﻧﻴﺎﺯی ﺑﻪ ﺍﻟﺼﺎﻕ ﺗﻤﺒﺮ ﻧﻴﺴﺖ
.
ﺍﺯ ﭘﺎﮐﺖ ﺁﺩﺭﺱ ﺩﺍﺭ ﺿﻤﻴﻤﻪ ﺷﺪﻩ ﺍﺳﺘﻔﺎﺩﻩ ﻧﻤﺎﻳﻴﺪ
•
.
ﺩﺍﺭﻳﺪ
:
ﻣﺎﻩ ﮔﺬﺷﺘﻪ ﻩﺮ ﮔﻮﻧﻪ ﺗﻐﻴﻴﺮی ﺑﺮﺍی ﮔﺰﺍﺭﺵ
ﺍﮔﺮ ﻃﯽ
6
_________
___________
ﺩﺍﺭﻳﺪ
.
.
ﺭﺍ ﭘﺮ ﮐﻨﻴﺪ
ﺑﺨﺶ
.
ﻔﺤﻪ ﻣﺮﺍﺟﻌﻪ ﮐﻨﻴﺪ
ﺑﻪ ﻗﺴﻤﺖ ﭘﺸﺖ ﺻ
•
2
:
ﻣﺎﻩ ﮔﺬﺷﺘﻪ ﻩﺮ ﮔﻮﻧﻪ ﺗﻐﻴﻴﺮی ﺑﺮﺍی ﮔﺰﺍﺭﺵ
ﺍﮔﺮ ﻃﯽ
6
.
ﺷﻤﺎ ﺑﺎﻳﺪ ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﺗﺎﺭﻳﺦ ﺯﺩﻩ ﻭ ﺍﻣﻀﺎء ﮐﻨﻴﺪ
.
ﻣﺮﺍﺟﻌﻪ ﮐﻨﻴﺪ
ﺑﻪ ﺑﺨﺶ
•
3
______________
.
ﻓﺮﻡ ﺗﮑﻤﻴﻞ ﺷﺪﻩ ﺭﺍ ﺗﺎ ﺗﺎﺭﻳﺦ ﻣﻨﺪﺭﺝ ﺩﺭ ﺑﺎﻻی ﺍﻳﻦ ﺻﻔﺤﻪ، ﺑﻪ ﮐﺎﻧﺘﯽ ﺍﺭﺳﺎﻝ ﻧﻤﺎﻳﻴﺪ
.
ﺭﺍ ﭘﺮ ﮐﻨﻴﺪ
ﺑﺨﺶ
.
ﻔﺤﻪ ﻣﺮﺍﺟﻌﻪ ﮐﻨﻴﺪ
ﺑﻪ ﻗﺴﻤﺖ ﭘﺸﺖ ﺻ
•
•
2
.
.
ﺷﻤﺎ ﺑﺎﻳﺪ ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﺗﺎﺭﻳﺦ ﺯﺩﻩ ﻭ ﺍﻣﻀﺎء ﮐﻨﻴﺪ
.
ﻣﺮﺍﺟﻌﻪ ﮐﻨﻴﺪ
ﺑﻪ ﺑﺨﺶ
•
.
ﻩﻴﭻ ﮔﻮﻧﻪ ﻣﺪﺍﺭﮐﯽ ﺭﺍ ﺑﻪ ﻩﻤﺮﺍﻩ ﺁﻥ ﺍﺭﺳﺎﻝ ﻧﮑﻨﻴﺪ
3
•
.
ﻓﺮﻡ ﺗﮑﻤﻴﻞ ﺷﺪﻩ ﺭﺍ ﺗﺎ ﺗﺎﺭﻳﺦ ﻣﻨﺪﺭﺝ ﺩﺭ ﺑﺎﻻی ﺍﻳﻦ ﺻﻔﺤﻪ، ﺑﻪ ﮐﺎﻧﺘﯽ ﺍﺭﺳﺎﻝ ﻧﻤﺎﻳﻴﺪ
•
.
ﻧﻴﺎﺯی ﺑﻪ ﺍﻟﺼﺎﻕ ﺗﻤﺒﺮ ﻧﻴﺴﺖ
.
ﺎﻳﻴﺪ
ﺍﺯ ﭘﺎﮐﺖ ﺁﺩﺭﺱ ﺩﺍﺭ ﺿﻤﻴﻤﻪ ﺷﺪﻩ ﺍﺳﺘﻔﺎﺩﻩ ﻧﻤ
•
.
.
ﻩﻴﭻ ﮔﻮﻧﻪ ﻣﺪﺍﺭﮐﯽ ﺭﺍ ﺑﻪ ﻩﻤﺮﺍﻩ ﺁﻥ ﺍﺭﺳﺎﻝ ﻧﮑﻨﻴﺪ
•
.
.
.
ﻧﻴﺎﺯی ﺑﻪ ﺍﻟﺼﺎﻕ ﺗﻤﺒﺮ ﻧﻴﺴﺖ
.
ﺎﻳﻴﺪ
ﺍﺯ ﭘﺎﮐﺖ ﺁﺩﺭﺱ ﺩﺍﺭ ﺿﻤﻴﻤﻪ ﺷﺪﻩ ﺍﺳﺘﻔﺎﺩﻩ ﻧﻤ
•
ﺑﻪ ﻗﺴﻤﺖ ﭘﺸﺖ ﺻﻔﺤﻪ ﻣﺮﺍﺟﻌﻪ ﻧﻤﺎﻳﻴﺪ
ﮐﻨﻴﺪ
ﮐﻪ ﭘﺸﺖ ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﺍﻣﻀﺎء
:
ﺑﺨﺎﻃﺮ ﺩﺍﺷﺘﻪ ﺑﺎﺷﻴﺪ
.
50191
50175
22
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