State of California – Health and Human Services Agency
Department of Health Care Services
ﺩﺭﻳﺎﻓﺖ ﻣﺪﺍﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻳﺎ ﻫﻮﻳﺖ
: ﺯﻣﺎﻧﻲ ﻛﻪ ﺷﻤﺎ ﻣﺪﺭﻙ/ﻣﺪﺍﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ/ﻳﺎ ﻫﻮﻳﺖ ﻳﻚ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺDSH/FQHC/ﺩﺳﺘﻮﺭﺍﻟﻌﻤﻞ ﺑﺮﺍﻱ ﻛﺎﺭﻣﻨﺪﺍﻥ ﻛﺎﻧﺘﻲ
.ﺫﻳﻨﻔﻊ ﺭﺍ ﺩﺭﻳﺎﻓﺖ ﻣﻲ ﻛﻨﻴﺪ٬ ﺑﺎﻳﺴﺘﻲ ﺍﻳﻦ ﻓﺮﻡ ﺭﺍ ﭘﺮ ﻛﻨﻴﺪ
:ﻣﺪﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ/ﻫﻮﻳﺖ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺ ﺫﻳﻔﻔﻊ
:ﺗﺎﺭﻳﺦ ﺗﻮﻟﺪ
ﻧﺎﻡ
ﻧﺎﻡ ﻣﻴﺎﻧﻲ
ﻧﺎﻡ ﺧﺎﻧﻮﺍﺩﮔﻲ
:ﺁﺩﺭﺱ
ﺧﻴﺎﺑﺎﻥ
ﺷﻬﺮ
ﺍﻳﺎﻟﺖ
ﻛﺪ ﭘﺴﺘﻲ
:ﻧﺎﻡ ﻭﺍﻟﺪ ﺍﮔﺮ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺ ﺫﻳﻨﻔﻊ ﺧﺮﺩﺳﺎﻝ ﺍﺳﺖ
ﻧﺎﻡ
ﻧﺎﻡ ﻣﻴﺎﻧﻲ
ﻧﺎﻡ ﺧﺎﻧﻮﺍﺩﮔﻲ
: ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺ ﺫﻳﻨﻔﻊBIC/CIN
:ﻧﺎﻡ ﻣﺪﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ/ﻫﻮﻳﺘﻲ ﻛﻪ ﺩﻳﺪﻳﺪ
:ﻧﺎﻡ ﻣﺪﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ/ﻫﻮﻳﺘﻲ ﻛﻪ ﺩﻳﺪﻳﺪ
:(ﺍﻳﻦ ﻣﺪﺭﻛﻲ ﺑﻮﺩ ﻛﻪ ﺩﻳﺪﻳﺪ )ﻳﻜﻲ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ
:(ﺍﻳﻦ ﻣﺪﺭﻛﻲ ﺑﻮﺩ ﻛﻪ ﺩﻳﺪﻳﺪ )ﻳﻜﻲ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ
(ﻧﺴﺨﻪ ﺍﺻﻠﻲ )ﻧﻪ ﻓﺘﻮﻛﭙﻲ ﻳﺎ ﻛﭙﻲ ﻧﻮﺗﺎﺭﻱ ﺷﺪﻩ
(ﻧﺴﺨﻪ ﺍﺻﻠﻲ )ﻧﻪ ﻓﺘﻮﻛﭙﻲ ﻳﺎ ﻛﭙﻲ ﻧﻮﺗﺎﺭﻱ ﺷﺪﻩ
ﻳﻚ ﻛﭙﻲ ﻛﻪ ﺍﺯ ﻃﺮﻑ ﺍﺩﺍﺭﻩ ﺻﺎﺩﺭ ﻛﻨﻨﺪﻩ ﺗﺎﻳﻴﺪ ﺷﺪﻩ
ﻳﻚ ﻛﭙﻲ ﻛﻪ ﺍﺯ ﻃﺮﻑ ﺍﺩﺍﺭﻩ ﺻﺎﺩﺭ ﻛﻨﻨﺪﻩ ﺗﺎﻳﻴﺪ ﺷﺪﻩ
:(ﺍﻳﻦ ﻣﺪﺭﻙ ﺑﻪ ﺍﻳﻦ ﺻﻮﺭﺕ ﺩﺭﻳﺎﻓﺖ ﺷﺪ )ﻳﻜﻲ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ
:(ﺍﻳﻦ ﻣﺪﺭﻙ ﺑﻪ ﺍﻳﻦ ﺻﻮﺭﺕ ﺩﺭﻳﺎﻓﺖ ﺷﺪ )ﻳﻜﻲ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ
ﺍﺯ ﻃﺮﻳﻖ ﭘﺴﺖ
ﺍﺯ ﻃﺮﻳﻖ ﭘﺴﺖ
(ﺑﻄﻮﺭ ﺣﻀﻮﺭﻱ )ﺍﺯ ﻃﺮﻑ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺ ﺫﻳﻨﻔﻊ
(ﺑﻄﻮﺭ ﺣﻀﻮﺭﻱ )ﺍﺯ ﻃﺮﻑ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺ ﺫﻳﻨﻔﻊ
:ﻧﺎﻡ
:ﻧﺎﻡ
ﺑﻄﻮﺭ ﺣﻀﻮﺭﻱ )ﺍﺯ ﻃﺮﻑ ﺳﺮﭘﺮﺳﺖ٬ ﳕﺎﻳﻨﺪﻩ ﻣﺠﺎﺯ٬ ﻳﺎ ﻋﻀﻮ
ﺑﻄﻮﺭ ﺣﻀﻮﺭﻱ )ﺍﺯ ﻃﺮﻑ ﺳﺮﭘﺮﺳﺖ٬ ﳕﺎﻳﻨﺪﻩ ﻣﺠﺎﺯ٬ ﻳﺎ ﻋﻀﻮ
(ﻓﺎﻣﻴﻞ ﻣﺮﺍﻗﺒﺖ ﻛﻨﻨﺪﻩ
(ﻓﺎﻣﻴﻞ ﻣﺮﺍﻗﺒﺖ ﻛﻨﻨﺪﻩ
()ﻧﺎﻡ ﻭ ﺭﺍﺑﻄﻪ ﺑﺎ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺ ﺫﻳﻨﻔﻊ
()ﻧﺎﻡ ﻭ ﺭﺍﺑﻄﻪ ﺑﺎ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺ ﺫﻳﻨﻔﻊ
ﻳﻚ ﻓﺘﻮﻛﭙﻲ ﺍﺯ ﺭﻭﻱ ﻣﺪﺍﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ/ﻳﺎ ﻫﻮﻳﺖ ﺩﺭﻳﺎﻓﺖ ﺷﺪﻩ ﺍﺯ ﻃﺮﻑ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺ ﺫﻳﻨﻔﻊ ﺗﻬﻴﻪ ﻛﻨﻴﺪ٬ ﻧﺴﺨﻪ ﺍﺻﻠﻲ ﻣﺪﺭﻙ/ﻣﺪﺍﺭﻙ ﺭﺍ ﺑﻪ ﺣﺎﻣﻞ
/ﺁﻧﻬﺎ ﺑﺎﺯﮔﺮﺩﺍﻧﻴﺪ ﻭ ﻳﻚ ﻛﭙﻲ ﺍﺯ ﺭﺳﻴﺪ ﺍﻣﻀﺎﺀ ﺷﺪﻩ ﺭﺍ ﺑﻪ ﻭﻱ ﺑﺪﻫﻴﺪ. ﺯﻣﺎﻧﻲ ﻛﻪ ﻣﺪﺭﻛﻲ ﺍﺯ ﻃﺮﻑ ﻛﺎﺭﻣﻨﺪ ﺗﻌﻴﲔ ﻛﻨﻨﺪﻩ ﻭﺍﺟﺪ ﺷﺮﺍﻳﻂ ﺑﻮﺩﻥ ﺩﺭﻳﺎﻓﺖ ﻣﻲ ﺷﻮﺩ٬ ﺍﮔﺮ ﺁﻥ ﻣﺪﺭﻙ
ﺑﺎﻳﺴﺘﻲ ﺍﻳﻦDSH/FQHC ﻣﺪﺍﺭﻙ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﺑﺎﺷﻨﺪ٬ ﺩﻓﺘﺮ ﺧﺪﻣﺎﺕ ﺍﺟﺘﻤﺎﻋﻲ ﻛﺎﻧﺘﻲ ﺑﻪ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﻨﺪﻩ ﻳﺎ ﺷﺨﺺ ﺫﻳﻨﻔﻊ ﺭﺳﻴﺪ ﺁﻥ ﺭﺍ ﺍﻃﻼﻉ ﻣﻲ ﺩﻫﺪ. ﻛﺎﺭﻣﻨﺪﺍﻥ
.ﺭﺳﻴﺪ ﻭ ﻛﭙﻲ ﻫﺎﻱ ﻣﺪﺭﻙ/ﻣﺪﺍﺭﻙ ﺩﺭﻳﺎﻓﺖ ﺷﺪﻩ ﺭﺍ ﺑﻪ ﺩﻓﺘﺮ ﻣﺴﺌﻮﻝ ﺧﺪﻣﺎﺕ ﺍﺟﺘﻤﺎﻋﻲ ﻛﺎﻧﺘﻲ ﺑﻔﺮﺳﺘﻨﺪ
County/DSH/FQHC Staff reads and signs below.
I declare under penalty of perjury under the laws of the State of California that the information above is true
and correct.
Date:
Signature of County/DSH/FQHC Staff
Name of County/DSH/FQHC Staff
(print):
First
Middle
Last
Information:
Name of agency
County
Telephone number
E-mail
County fills out this box
Case No:
Case Name:
DHCS 0005 (02/08) – Farsi
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