Dhcs 4073 - California Child Health And Disability Prevention (Chdp) Program Pre-Enrollment Application (Hmong) - Health And Human Services Agency
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1State of California—Health and Human Services Agency
D epartment of Health Care Services
Children’s Medical Services Branch
KEV TIVTHAIV MENYUAM KEV NOJQAB HAUSHUV THIAB TEEBMEEM HAUV KEV LOJHLOB (CHDP)
DAIM NTAWV THOV KEV PABCUAM
Cov kev qhia rau Niamtxiv lossis tus Neeg Mob:
• Yuav kom koj tau txais txoj kev kuaj mob uas tsis tau them nqi li hnub no, koj yuavtsum tau teb cov lus nug uas hais hauv
daim ntawv no. Tej uas koj teb hauv no yuav muab ceev tsis pub leejtwg pom. No yog ib txoj kev pabcuam pub dawb xwb.
Tus neeg mob lub hnub nyoog puas yog qis dua 19 xyoos?
Yog
Tsis yog
Koj tsevneeg muaj pestsawg leej?
$
$
Ib hli
Ib xyoo
• Tej zaum koj lossis koj tus menyuam yuav tau txais kev fajseeb khomob los ntawm Medi-Cal lossis Healthy Families mus ntxiv.
Kuv xav thov kev fajseeb khomob ntxiv los ntawm Medi-Cal lossis Healthy Families.
Xav
Tsis xav
Yog koj teb tias xav rau lolus nug no, luag yuav xa ib daim ntawv thov tuaj rau koj fias li ob peb hnub tomntej no. Thov fias thiab
muab xa rovqab tuaj sai. Yog koj teb tias tsis xav rau lolus nug no (lossis koj teb tias xav tabsis tsis xa daim ntawv thov rovqab tuaj),
tus tibneeg ntawd cov kev khomob, kho hniav, thiab kho qhovmuag yuav xaus rau lub hlis tomntej ntawd tshwj tias lub nroog Phab
Pabcuam Kev Nojqab Haushuv (Department of Social Services) qhia tuaj rau koj hais tias nws tsis yog li ntawd xwb.
Kev Qhia Txog Tus Neeg Mob
Muaj
Tsis muaj
Yog muaj, cov lej hauv daim BIC card yog licas (yog paub)?
Tus neeg mob npe—Xeem
Npe
Npe Nrab
Hnub yug (hli/hnub/xyoo)
Yo
g
Tus neeg mob tus lej social security (SSN) (taumyeem muab xwb)
Txivneej
Pojniam
Yog koj tsis muaj tsev nyob, khij qhov no. Qhia saib nyob cheebtsam twg rau hauv “Chaw nyob” thiab qhia lub “Chaw xa ntawv”.
Chaw nyob
Hoob tsev
Nroog
Xeev
ZIP code
Lub nroog (County) uas koj nyob
Chaw xa ntawv (yog txawv li koj lub chaw nyob)
Hoob tsev
Nroog
Xeev
ZIP code
Niam npe—Xeem
Npe Leej
Npe Nrab
Cov tibneeg mob uas tsis tau muaj ib lub xyoos, teb kab no.
Yog tsis tau muaj ib lub xyoos, tus menyuam puas nrog leej niam nyob lub hlis uas yug nws los?
Muaj
Tsis muaj
Leej niam hnub yug (hli/hnub/xyoo)
Leej niam daim BIC card lossis tus lej Medi-Cal lossis lej social security
Kev Qhia Txog Niamtxiv/Tus Saib Xyuas
Niamtxiv/tus saib xyuas npe lossis tus dhau ua neeg laus lawm—Xeem
Npe
Npe Nrab
Xovtooj hauv tsev
Xovtooj tom haujlwm
Xovtooj xaxov
(
)
(
)
(
)
Yam lus uas koj hais tom tsev yog yam lus dabtsi?
Koj nyeem tau yam ntawv dabtsi zoo tshaj?
Kev lees paub
Kuv thov txoj kev kuaj mob CHDP hnub no. Kuv lees paub tias kuv tau nyeem thiab totaub daim ntawv no. Kuv lees hais tias
cov lus teb no yeej muaj tseeb, yog, thiab teb ntxawg.
Niamtxiv/tus saib xyuas lossis tus dhau ua neeg laus lawm suam npe
Txheeb tus mob licas
Hnubtim
Ib tus neeg muaj cai mus xyuas tau nws cov ntaub ntawv. Tus uas teev cov ntaub ntawv no yog lub Department of Health Services, MS 8100, P.O. Box
Department of Health Care Services
997413, Sacramento, CA 95899-7413. Tej zaum luag yuav xa ib copy ntawm daim ntawv qhia no mus rau lub nroog uas koj nyob Phab Pabcuam Kev Nojqab
Haushuv (Department of Social Services) thiab yuav muab khaws nrog koj tus menyuam cov ntaub ntawv teev kev khomob hauv CHDP.
DHCS 4073 (Hmong) (11/07)
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