Form Dhcs 0001 - California U.s. Citizens And Nationals Applying For Medi-Cal Must Show Proof Of Citizenship And Identity (Korean) - Health And Human Services Agency Page 4

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State of California – Health and Human Services Agency
Department of Health Care Services
시민권 진술서를 제출하지 않은 16 세 미만의 자녀에
인디언 혈통 정도 증명서 또는 기타 미국
대해서는 다음의 서류를 대신 제출할 수 있습니다.
아메리칸 인디언/알래스카 원주민 부족
증명 서류
자녀의 부모, 보호자 또는 자녀를 돌보는 친척이
서명했고 출생지와 출생일이 표시된 자녀의 신원
미국 해안경비대 상선 선원 신분증
진술서
직원 신분증, 고등학교 졸업장 또는 대학 학위증, 결혼
자녀의 부모, 보호자 또는 자녀를 돌보는 친척이
증명서, 이혼 확인서, 재산 양도/소유 증서와 같은 3 건
서명했고 출생지와 출생일이 표시된 Medi-Cal 신청서
이상의 확인 서류
또는 Healthy Families/Medi-Cal 통합 신청서
16 세 미만의 자녀에 대한 클리닉, 의사 또는
병원의 기록
18 세 미만의 자녀가 학생증이나 운전면허증이 없는
경우에는 부모, 보호자 또는 자녀를 돌보는 친척이 서명한
16 세 미만의 자녀에 대한 학교, 유아원 또는 보육원의
자녀의 신원 진술서를 제출할 수 있습니다.
기록(성적표 포함). 카운티는 이러한 기록을
교육기관에 확인합니다.
주: 유효 기간이 만료된 신원 서류도 신원 증명서로
요양소 거주 장애인에 대한 요양소 책임자 또는
인정됩니다.
관리자가 서명한 진술서
DHCS 0001 (01/08) – Korean
Page 4 of 4

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