Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (Farsi) - Health And Human Services Agency

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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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