Form Mc 176 S - Medi-Cal Status Report (Farsi) Page 2
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2State of California – Health and Human Services
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State of California - Health and Human Services Agency
Department of Health Care Services
ﺑﻪ ﻩﻤﺮﺍﻩ ﺍﻳﻦ ﻓﺮﻡ ﻣﺪﺍﺭﮐﯽ ﺭﺍ ﺍﺭﺳﺎﻝ ﻧﮑﻨﻴﺪ
ﺭﺍ ﺗﻴﮏ ﺑﺰﻧﻴﺪ ﻭﺗﻮﺿﻴﺤﺎﺗﯽ ﺭﺍ ﺍﺭﺍﺋﻪ ﻧﻤﺎﻳﻴﺪ
"
ﺑﻠﯽ
"
،ﻣﺎﻩ ﮔﺬﺷﺘﻪ
6
ﺑﺮﺍی ﺗﻤﺎﻣﯽ ﺗﻐﻴﻴﺮﺍﺕ ﻃﯽ
:
2
ﺑﺨﺶ
ﺮﺑﻮﻁ ﺑﻪ ﺩﺭﺁﻣﺪ
ﺗﻐﻴﻴﺮﺍﺕ ﻣ
ﺁﻳﺎ ﺷﻤﺎ ﻭ ﻳﺎ ﻋﻀﻮی ﺍﺯ ﺧﺎﻧﻮﺍﺩﻩ ﺗﺎﻥ ﺩﺭ ﺍﺯﺍی ﺍﻧﺠﺎﻡ ﮐﺎﺭ، ﺩﺭﻳﺎﻓﺖ ﻧﻘﻪ ﮐﻮﺩک ﻳﺎ ﻧﻔﻘﻪ، ﺳﻮﺷﻴﺎﻝ ﺳﮑﻮﺭﻳﺘﯽ، ﻣﺰﺍﻳﺎی ﺳﺮﺑﺎﺯ ﺳﺎﺑﻖ، ﻣﺰﺍﻳﺎی ﺑﻴﮑﺎﺭی
ﺑﻠﯽ
ﻳﺎ ﺍﺯ ﮐﺎﺭﺍﻓﺘﺎﺩﮔﯽ، ﺑﺎﺯﻧﺸﺴﺘﮕﯽ، ﻩﺪﺍﻳﺎ، ﺑﻬﺮﻩ ﻭ ﻳﺎ ﺳﻮﺩﺳﻬﺎﻡ، ﺩﺭﺁﻣﺪ ﺑﻴﺸﺘﺮ ﻳﺎ ﮐﻤﺘﺮی ﺭﺍ ﺩﺭﻳﺎﻓﺖ ﮐﺮﺩﻩ ﺍﻳﺪ؟
:
ﺗﻮﺿﻴﺢ ﺩﻩﻴﺪ
ً ﺎ ﻔ
ﻄ ﻟ
ﺗﻐﻴﻴﺮﺍﺕ ﻣﺮﺑﻮﻁ ﺑﻪ ﭘﺮﺩﺍﺧﺖ ﻣﺨﺎﺭﺝ
ﺑﻠﯽ
ﯽ، ﻧﻔﻘﻪ ﮐﻮﺩک ﻣﻘﺮﺭ ﺷﺪﻩ ﺍﺯ
ﺩﺭﻣﺎﻧ
-
ﺷﻤﺎ ﻭ ﻳﺎ ﻋﻀﻮی ﺍﺯ ﺧﺎﻧﻮﺍﺩﻩ ﺗﺎﻥ، ﺩﺭ ﻣﺒﻠﻐﯽ ﮐﻪ ﺑﺮﺍی ﻣﺮﺍﻗﺒﺖ ﺍﺯ ﮐﻮﺩک، ﻳﺎ ﺳﻻﻤﻨﺪ، ﺑﻴﻤﻪ ﺑﻬﺪﺍﺷﺘﯽ
ﺁﻳﺎ ﺑﺮﺍی
ﺩﺍﺩﮔﺎﻩ، ﻧﻔﻘﻪ ﻭ ﻳﺎ ﻩﺰﻳﻨﻪ ﻩﺎی ﺗﺤﺼﻴﻠﯽ ﭘﺮﺩﺍﺧﺖ ﻣﯽ ﮐﺮﺩﻳﺪ، ﺗﻐﻴﻴﺮی ﺑﻮﺟﻮﺩ ﺁﻣﺪﻩ ﺍﺳﺖ؟
ﺳﻮی
:
ﺗﻮﺿﻴﺢ ﺩﻩﻴﺪ
ً ﺎ ﻔ
ﻄ ﻟ
ﺗﻐﻴﻴﺮﺍﺕ ﺩﺭ ﻭﺿﻌﻴﺖ ﺯﻧﺪﮔﯽ
ﺑﻠﯽ
ﺩﺍﺭ ﺷﺪﻩ ﺍﺳﺖ؟
ﺧﺎﻧﻮﺍﺭ ﺷﻤﺎ ﺍﺿﺎﻓﻪ ﺷﺪﻩ، ﻭ ﻳﺎ ﺍﺯ ﺧﺎﻧﻪ ﺷﻤﺎ ﺭﻓﺘﻪ ﺍﺳﺖ، ﺍﺯﺩﻭﺍﺝ ﮐﺮﺩﻩ ﻭ ﻳﺎ ﺑﭽﻪ
ﺁﻳﺎ ﮐﺴﯽ ﺑﻪ
:
ﺗﻮﺿﻴﺢ ﺩﻩﻴﺪ
ً ﺎ ﻔ
ﻄ ﻟ
ﺧﻴﺮ
[ ]
ﺑﻠﯽ
[ ]
ﺩﺍﺭﺩ؟
ﺍﮔﺮ ﺑﻠﯽ، ﺁﻳﺎ ﻧﻴﺎﺯ ﺑﻪ
Medi-Cal
:
ﺳﺎﻳﺮ ﺗﻐﻴﻴﺮﺍﺕ
ﺑﻠﯽ
(
ﭘﻮﻝ ﺩﺭ ﺣﺴﺎﺑﻬﺎﺏ ﺑﺎﻧﮑﯽ، ﻭﺳﺎﺋﻞ ﻧﻘﻠﻴﻪ، ﻣﺴﺘﻐﻼﺕ، ﻭﻏﻴﺮﻩ
:
ﺑﻪ ﻋﻨﻮﺍﻥ ﻣﺜﺎﻝ
)
،ﺁﻳﺎ ﺑﺮﺍی ﺷﺨﺼﯽ ﺩﺭ ﺧﺎﻧﻮﺍﺭ ﺷﻤﺎ ﺗﻐﻴﻴﺮی ﺩﺭ ﻣﻴﺰﺍﻥ ﺩﺍﺭﺍﻳﯽ
:
ﺗﻮﺿﻴﺢ ﺩﻩﻴﺪ
ً ﺎ ﻔ
ﻄ ﻟ
ﺩﺭﻣﺎﻧﯽ ﺍﻳﺠﺎﺩ ﺷﺪﻩ ﺍﺳﺖ؟
-
ﻭﺿﻌﻴﺖ ﻣﻬﺎﺟﺮﺗﯽ ﻭ ﻳﺎ ﻣﺰﺍﻳﺎی ﺑﻴﻤﻪ ﺑﻬﺪﺍﺷﺘﯽ
ﺍﺯ ﮐﺎﺭ ﺍﻓﺘﺎﺩﻩ
ﺑﻠﯽ
ﺁﻳﺎ ﺷﺨﺼﯽ ﺩﺭ ﺧﺎﻧﻮﺍﺭ ﺷﻤﺎ ﺩﭼﺎﺭ ﺍﺯ ﮐﺎﺭ ﺍﻓﺘﺎﺩﮔﯽ ﺟﺴﻤﯽ ﻭ ﻳﺎ ﺭﻭﺣﯽ ﺷﺪﻩ ﺍﺳﺖ؟ ﺍﮔﺮ ﺑﻠﯽ، ﭼﻪ ﮐﺴﯽ؟
ﺑﺎﺭﺩﺍﺭ
ﺑﻠﯽ
ﺁﻳﺎ ﺷﺨﺼﯽ ﺩﺭ ﺧﺎﻧﻮﺍﺭ ﺷﻤﺎ ﺑﺎﺭﺩﺍﺭ ﺷﺪﻩ ﺍﺳﺖ؟
ﺍﻧﺘﻈﺎﺭ ﺗﻮﻟﺪ ﭼﻪ ﺗﻌﺪﺍﺩ ﻧﻮﺯﺍﺩ ﺭﺍ ﺩﺍﺭﻳﺪ؟
ﻣﻮﻋﺪ ﻣﻮﺭﺩ ﺍﻧﺘﻈﺎﺭ ﻭﺿﻊ ﺣﻤﻞ ﮐﯽ ﺍﺳﺖ؟
ﮔﻮﺍﻩﯽ
ﺍﻣﻀﺎء ﻭ
:
3
ﺑﺨﺶ
ﻣﻦ، ﺗﺤﺖ ﻣﺠﺎﺯﺍﺕ ﺩﺭ ﻣﻘﺎﺑﻞ ﮔﻮﺍﻩﯽ ﺩﺭﻭﻍ، ﺍﻋﻼﻡ ﻣﯽ ﮐﻨﻢ
.
ﺕ ﺭﺍ ﺑﻪ ﮐﺎﻧﺘﯽ ﮔﺰﺍﺭﺵ ﺩﻩﻢ
ﻳﺎ ﺳﺎﻳﺮ ﺗﻐﻴﻴﺮﺍ
/
ﻣﻦ ﻣﺘﻮﺟﻪ ﻩﺴﺘﻢ ﮐﻪ ﺑﺎﻳﺪ ﺗﻤﺎﻣﯽ ﺗﻐﻴﻴﺮﺍﺕ ﻣﺮﺑﻮﻁ ﺑﻪ ﺩﺭﺁﻣﺪ، ﺍﻣﻮﺍﻝ، ﻭ
.
ﮐﻪ ﺗﻤﺎﻣﯽ ﺍﻃﻼﻋﺎﺕ ﻣﻨﺪﺭﺝ ﺩﺭ ﻓﻮﻕ ﺩﺭﺳﺖ ﻭ ﺻﺤﻴﺢ ﺍﺳﺖ
_____
___________
__________
ﺍﻣﻀﺎء
( ) _____________________
:
ﺷﻤﺎﺭﻩ ﺗﻠﻔﻦ
_________________________
:
ﺗﺎﺭﻳﺦ
_____
_______
__________
ﺍﻣﻀﺎء ﺷﺎﻩﺪ
( ) _____________________
:
ﺷﻤﺎﺭﻩ ﺗﻠﻔﻦ
_________________________
:
ﺗﺎﺭﻳﺦ
(
ﺩﺭ ﺻﻮﺭﺗﻴﮑﻪ ﺷﺤﺺ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻋﻼﻣﺖ ﺍﻣﻀﺎء ﮐﺮﺩﻩ ﺑﺎﺷﺪ
)
ﺍﻣﻀﺎء ﺷﺨﺺ
__________
______
_ :
:
ﺗﺎﺭﻳﺦ
______________
:
ﻧﺴﺒﺖ ﺑﺎ ﺷﺨﺺ ﺫﻳﻨﻔﻊ
____________________
:
ﺑﻪ ﻧﻤﺎﻳﻨﺪﮔﯽ ﺍﺯ ﻃﺮﻑ ﺷﺨﺺ ﺫﻳﻨﻔﻊ
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