State of California – Health and Human Services Agency
Department of Health Care Services
ﻣﺪﺍﺭﻙ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻳﺎ ﻫﻮﻳﺖ
Medi-Cal
ﻛﻪ ﺳﻴﺘﻲ ﺯﻥ ﻳﺎ ﺗﺎﺑﻊ ﺍﻳﺎﻻﺕ ﻣﺘﺤﺪﻩ ﻫﺴﺘﻨﺪ ﺑﺎﻳﺪ ﺳﻨﺪ
ﻳﻚ ﻗﺎﻧﻮﻥ ﺟﺪﻳﺪ ﻣﻲ ﮔﻮﻳﺪ ﻛﻪ ﺑﻴﺸﺘﺮ ﻣﺘﻘﺎﺿﻴﺎﻥ ﻭ ﺍﺳﺘﻔﺎﺩﻩ ﻛﻨﻨﺪﮔﺎﻥ
.ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻳﺎ ﻫﻮﻳﺖ ﺧﻮﺩ ﺭﺍ ﺍﺭﺍﺋﻪ ﺩﻫﻨﺪ
.ﻛﺎﻧﺘﻲ ﻣﺪﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ/ﻳﺎ ﻫﻮﻳﺖ ﺷﺨﺺ ﺯﻳﺮ ﺭﺍ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ ﺩﺭﻳﺎﻓﺖ ﻭ ﻣﺮﻭﺭ ﻛﺮﺩﻩ ﺍﺳﺖ
:ﻧﺎﻡ ﻣﺘﻘﺎﺿﻲ ﻳﺎ ﺍﺳﺘﻔﺎﺩﻩ ﻛﻨﻨﺪﻩ
ﻧﺎﻡ ﺧﺎﻧﻮﺍﺩﮔﻲ
ﻧﺎﻡ ﻣﻴﺎﻧﻲ
ﻧﺎﻡ
:ﺗﺎﺭﻳﺦ ﺗﻮﻟﺪ
:ﻧﺎﻡ ﺳﻨﺪ ﻫﻮﻳﺘﻲ ﻛﻪ ﺩﻳﺪﻩ ﺍﻳﺪ
:ﻧﺎﻡ ﺳﻨﺪ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻛﻪ ﺩﻳﺪﻩ ﺍﻳﺪ
ﺗﺼﻮﻳﺐ ﺷﺪﻩ. ﻣﺪﺭﻙ ﻫﻮﻳﺘﻲ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ ﺑﻌﻨﻮﺍﻥ ﻳﻚ
ﺗﺼﻮﻳﺐ ﺷﺪﻩ. ﻣﺪﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ
ﺳﻨﺪ ﻫﻮﻳﺖ ﭘﺬﻳﺮﻓﺘﻪ ﻣﻲ ﺷﻮﺩ. ﻻﺯﻡ ﻧﻴﺴﺖ ﻛﻪ ﺑﺮﺍﻱ ﺷﺨﺺ
ﺑﻌﻨﻮﺍﻥ ﻳﻚ ﺳﻨﺪ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﭘﺬﻳﺮﻓﺘﻪ ﻣﻲ ﺷﻮﺩ. ﻻﺯﻡ ﻧﻴﺴﺖ
.ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﺑﺎﻻ ﺩﻭﺑﺎﺭﻩ ﻣﺪﺭﻛﻲ ﺍﺭﺍﺋﻪ ﺩﻫﻴﺪ
.ﻛﻪ ﺑﺮﺍﻱ ﺷﺨﺺ ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﺑﺎﻻ ﺩﻭﺑﺎﺭﻩ ﻣﺪﺭﻛﻲ ﺍﺭﺍﺋﻪ ﺩﻫﻴﺪ
ﺭﺩ ﺷﺪﻩ. ﺳﻨﺪﻱ ﻫﻮﻳﺘﻲ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ ﻗﺎﺑﻞ ﻗﺒﻮﻝ
ﺭﺩ ﺷﺪﻩ. ﺳﻨﺪﻱ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﻧﻴﺴﺖ. ﺷﻤﺎ
ﻧﻴﺴﺖ. ﺷﻤﺎ ﺑﺎﻳﺪ ﻳﻚ ﻣﺪﺭﻙ ﺩﻳﮕﺮ ﻫﻮﻳﺖ ﺗﺴﻠﻴﻢ ﻛﻨﻴﺪ. ﻳﻚ
ﺑﺎﻳﺪ ﻳﻚ ﻣﺪﺭﻙ ﺩﻳﮕﺮ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﺗﺴﻠﻴﻢ ﻛﻨﻴﺪ. ﻳﻚ ﻟﻴﺴﺖ
.ﻟﻴﺴﺖ ﺍﺳﻨﺎﺩ ﻫﻮﻳﺖ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﺑﻪ ﭘﻴﻮﺳﺖ ﺍﺭﺍﺋﻪ ﻣﻲ ﺷﻮﺩ
.ﺍﺳﻨﺎﺩ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﺑﻪ ﭘﻴﻮﺳﺖ ﺍﺭﺍﺋﻪ ﻣﻲ ﺷﻮﺩ
ﻫﻤﻪ ﻣﺪﺍﺭﻙ ﺑﺎﻳﺪ ﺍﺻﻞ ﻣﺪﺭﻙ ﺑﻮﺩﻩ ﻳﺎ ﺭﻭﻧﻮﺷﺖ ﻫﺎﺋﻲ
ﻫﻤﻪ ﻣﺪﺍﺭﻙ ﺑﺎﻳﺪ ﺍﺻﻞ ﻣﺪﺭﻙ ﺑﻮﺩﻩ ﻳﺎ ﺭﻭﻧﻮﺷﺖ ﻫﺎﺋﻲ
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ﺑﺎﺷﻨﺪ ﻛﻪ ﺑﻪ ﮔﻮﺍﻫﻲ ﺳﺎﺯﻣﺎﻥ ﺻﺎﺩﺭ ﻛﻨﻨﺪﻩ ﺭﺳﻴﺪﻩ
ﺑﺎﺷﻨﺪ ﻛﻪ ﺑﻪ ﮔﻮﺍﻫﻲ ﺳﺎﺯﻣﺎﻥ ﺻﺎﺩﺭ ﻛﻨﻨﺪﻩ ﺭﺳﻴﺪﻩ
.ﺍﺳﺖ. ﻓﺘﻮﻛﭙﻲ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﻧﻴﺴﺖ
.ﺍﺳﺖ. ﻓﺘﻮﻛﭙﻲ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﻧﻴﺴﺖ
ﺷﺨﺺ ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﺑﺎﻻ ﺩﺭﺧﻮﺍﺳﺖ ﻫﺎﻱ ﺟﺪﻳﺪ ﻣﺮﺑﻮﻁ ﺑﻪ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ ﻫﻮﻳﺖ ﺭﺍ ﺍﳒﺎﻡ ﺩﺍﺩﻩ ﺍﺳﺖ ﺯﻳﺮﺍ ﻣﺪﺍﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ
.ﻫﻮﻳﺖ ﺍﻭ ﻫﺮ ﺩﻭ ﺑﻪ ﺗﺼﻮﻳﺐ ﺭﺳﻴﺪﻩ ﺍﻧﺪ
ﺷﺨﺺ ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﺑﺎﻻ ﺩﺭﺧﻮﺍﺳﺖ ﻫﺎﻱ ﺟﺪﻳﺪ ﻣﺮﺑﻮﻁ ﺑﻪ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ ﻫﻮﻳﺖ ﺭﺍ ﺍﳒﺎﻡ ﻧﺪﺍﺩﻩ ﺍﺳﺖ ﺯﻳﺮﺍ ﻳﻜﻲ ﻳﺎ ﻫﺮ ﺩﻭﻱ ﻣﺪﺍﺭﻙ
.ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ/ﻳﺎ ﻫﻮﻳﺖ ﻭﻱ ﺭﺩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﻳﺎ ﺍﺭﺍﺋﻪ ﻧﺸﺪﻩ ﺍﺳﺖ
.ﺍﮔﺮ ﻫﺮ ﮔﻮﻧﻪ ﺳﺆﺍﻟﻲ ﺩﺍﺭﻳﺪ ﻟﻄﻔﺄ ﺑﺎ ﺩﻓﺘﺮ ﺧﺪﻣﺎﺕ ﺍﺟﺘﻤﺎﻋﻲ ﻛﺎﻧﺘﻲ ﺧﻮﺩ ﺑﻪ ﺷﻤﺎﺭﻩ ﺗﻠﻔﻦ ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﭘﺎﺋﲔ ﲤﺎﺱ ﺑﮕﻴﺮﻳﺪ
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 eligibility worker
Name of eligibility worker
(print):
First
Middle
Last
Telephone number:
County:
County fills out this box
Case No:
Case Name:
DHCS 0011 (06/08) – Farsi
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