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State of California – Health and Human Services Agency

Department of Health Care Services

0= h d eoq f g]n h v Cs^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v Cc]t]a d ltotlj ; o8q ; [5 d 7q o

le]a [ gfa d oh v pmu j g xa o rq o ]tg,n v C s^ n x t-k-q o -k;ltstia 4

9q j C xtdv[2v,7eIh v CIj ; ,

Healthy Families/Medi-Cal

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sh v Cdko

xt9eg0f0vCmj k ode]a C d;fdk7n o .[7eIh v C0= 0 vC]6 d mj k oD .o]ts;j k Cg;]kou h F ]6 d 0vCmj k o9twfh I a [ dko75 h , 7vC 9kd

Medi-Cal

grn j v ln [ 8+ w fh I a [

c[[g8a , lj ; oF sh v Cdkoxt9e7k;8u h 0 vCmj k o9t8h v Cwfh I a [ s^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C

Medi-Cal.

Medi-Cal

c]t1a h C 1n o ]tltotlj ; o8q ; [5 d 7q o le]a [ ]6 d 0vCmj k oD 9q j C vj k o0h k C]5 j , ou h g rn j v -k[]kp]tvPf8n j , D

gfa d oh v pm5 d 7q o 8h v CltcfCs^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C

4h k ;j k 7k;8u h w fh . [[a o mb d dkogdu f 0vC]6 d 0h k rtg9q h k F 0h k rtg9q h k

c]t]a d ltotlj ; o8q ; [5 d 7q o c,j o [+ L

pa C 8h v Cwfh 9 a f sks^ a d 4ko1a h C 1n o ]a d ltotlj ; o8q ; [5 d 7q o vu d [+ L

[+ D gfa d oh v pgs^ q j k ou h [+ 8h v C9a f sks^ a d 4koG

4h k ;j k ]6 d 0vCmj k ovkp5 8 j e d;j k

xu c ]tmj k owfh x tdv[2v, c]tg-a o -n j

gfa d oh v pmu j , u G

.o.[7eIh v C

s^ n 2 v,7eIh v CIj ; ,

•

Medi-Cal

Healthy Families/

]kpwfh x tda o la C 7q o gru h , 8b j ,

(SSI)

Medi-Cal

rh v ,fh ; p;a o mu c ]tlt4komu j g du f 0vC]6 d mj k oF

–

mj k od+ [ + 9 egxa o 8h v C9a f sks^ a d 4ko1a h C 1n o ]a d ltotlj ; o8q ; [5 d 7q o D

)

g,fy c 7

– Medicare (

.[7eIh v C mu j g -a o -n j .lj o u h d + c ,j o s^ a d 4ko1a h C 1n o ]a d ltotlj ; o8q ; [5 d 7q o

xtda o la C 7q , le]a [ z6 h r y d ko

(

(SSDI)

–

)

g[h a P [eokoxtda o la C 7q o c]txtda o ra p z6 h ] vf-u ; y f

0vC]6 d mj k oD

–

vu C 8k,7;k,ry d ko0vCg0q k

(RSI – Title II)

9tgIa f co;.f 4h k ;j k ]6 d 0vC0h k rtg9q h k vkp5

xu 0 b h o wxL

•

[5 d 7q o mu j , u v kp5 8 j e d;j k

-b j C Ih v C0= [ = ] y d ko

gfa d mu j v kp5

xu 0 b h o wx 8h v C9a f skgvdtlko1a h C dkogxa o rq o ]tg,n v C

fh k odkopy o pv,0vC[5 d 7q o mu j v kp5 [ + g 4y C dtlPo

c]t1a h C 1n o ]a d tlotlj ; o8q ; [5 d 7q o D g[y j C |h k

gfa d mu j g du f 9kdz6 h p y C mu j 1 6 j . o37Cdko

•

Medi-Cal

mj k o8h v Cdkogvdtlkodkogxa o rq o ]tg,n v C c]t]a d ltot

•

gfa d mu j 1 6 j . o[h k ov5 x t4a , F 37Cdko-j ; pgs^ n v ]6 d [5 o meF s^ n 3 7Cdko

lj ; o8q ; [5 d 7q o lt[a [ 8q ; 9y C [+ L

Kin-Gap

c,j o D sh v Cdko7k;8u h 8 h v Cdkogvdtlkodkogxa o rq o ]tg,n v C

gfa d mu j 1 6 j . o37Cdkogfa d oh v pmu j 4 n d xt4y h ,

•

(Abandoned

c]tdko1a h C 1n o ]a d ltotlj ; o8q ; [5 d 7q o lt[q [ 8q ; 9y C F s^ n l t[a [ legoq k

Baby Program)

•

z6 h I a [ zq o xt3spf.o37Cdko

-b j C ,u d koIa [ IvC3fpvq C dkomu j g xa o z6 h v vd.sh D

CalWORKs

9tgIa f co;.f 4h k ;j k ]6 d 0vC0h k rtg9q h k [+ c ,j o rq o ]tg,n v C

0h k rtg9q h k lk,kflq j C gvdtlko1a h C 1n o dkogxa o rq o ]tg,n v C

ltstia 4 L

c]t]a d ltotlj ; o8q ; [5 d 7q o mkCwxltou w fh [ + L

4h k ;j k ]6 d 0vCmj k o[+ c ,j o rq o ]tg,n v C s^ n xt-k-q o ltstia 4 F mj k orPCc8j

wfh D mkC7k;8u h 9 tgIa f legoq k c]tlq j C legoq k oa h o da [ 7n o .sh m j k oD s^ n F

8h v C9a f skgvdtlkoc[[fP;da o -b j C mj k og7u p 9a f sk.sh c 8j d j v oD

mj k olk,kfoegvq k gvdtlko0vCmj k owxmu j s h v Cdkola C 7q ,

[+ , u s pa C xj P ocxCD

lq C g7ktxt9eg0f0vCmj k od+ w fh D 9q j C 0= . sh g ry j o gIa f legoq k gvdtlko

c]tgvq k gvdtlko7n o ma o mu D

xt-k-q o -k;ltstia 4 ];,g4y C [5 d 7q o mu j g du f .ovtg,]y d a o -k,q ;

];,g4y C

(

0h k rtg9q h k 9egxa o 8h v C9a f sks^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C

gdktltg;o

)

c]t [5 d 7q o .fob j C mu j , k9kd \6 j g dktovmgmu o ,kgia P okD

c]t1a h C 1n o ]a d ltotlj ; o8q ; [5 d 7q o s^ k pd;j k |b j C 7a h C [+ L

9tgIa f co;.f 4h k ;j k 0h k rtg9q h k [+ , u s ^ a d 4ko1a h C 1n o dkogxa o

[+ D mj k orPCc8j 8 h v C9a f sks^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C

rq o ]tg,n v C0vC]6 d 0h k rtg9q h k L

c]t]a d ltotlj ; o8q ; [5 d 7q o rPC7a h C fP;gmq j k oa h o

4h k ;j k ]6 d 0vCmj k ogdu f .oia 4 7k]y 2 = g oa P F sh v Cdko7k;8u h v kflk,kfsk

9tgIa f co;.f 4h k ;j k 0h k rtg9q h k wfh 9 j k p7j k xy j o xq ; l5 0 trk[ c]t

[a o mb d dkogdu f 0vCmj k owfh D

(

[a o mb d dkogdu f d+ c ,j o s^ a d 4ko1a h C 1n o

7j k xq ; c0h ; le]a [ ]6 d 0vC0h k rtg9q h k .o0totde]a C 0= g vq k gvdtlko

dkogxa o rq o ]tg,n v CD

)

1a h C 1n o dkogxa o rq o ]tg,n v Cc]t]a d lototlj ; o8q ; [5 d 7q o L

9q j C xtdv[ 2v,Ih v C0= [ a o mb d dkogdu f .oia 4 7k]y 2 = g oa P

9kdoa h o F 9q j C lq j C

4h k ;j k mj k o,u 7 j k .-h 9 j k pfh k ol5 0 trk[.o0tot0= g vq k gvdtlkodkogxa o

s^ n 4 n g vq k 2v,ou h w xmu j s h v Cdkola C 7q , lq C g7kt.og0f 0vCmj k oD 4h k ;j k [+ l k,k

rq o ]tg,n v Cc]tdko1a h C 1n o ]a d ltotlj ; o8q ; [5 d 7q o le]a [ ]6 d 0vCmj k oF

fsk[a o mb d dkogdu f 0vCmj k owfh F mj k o9e8h v Cwfh 9 a f sk s^ a d 4ko1a h C 1n o dko

mkC

vkf-j ; p9j k p.[[y ] gda [ 7j k .sh m j k owfh D

Medi-Cal

gxa o rq o ]tg,n v Cvu d va o ob j C D 9q j C g[y j C |h k

le]a [ ]kpdkogvdtlkomu j p v,Ia [ wfh D

9q j C 3mi4k,rtcod [= ] y d koz6 h I a [ zq o xt3spfmu j d q , [= ] y d ko l5 0 trk[

grn j v 0= g vq k 7e8v[8j k CMG

(916) 403-2007.

9q j C 4k,7k;8u h 0 vCmj k o dj P ;da [ dkosks^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C

4h k ;j k ]6 d 0vCmj k o[+ w fh g du f .oia 4 7k]y 2 = g oa P D 9q j C 8y f 8+ 7 k;8u h grn j v g[y j C ;j k

g0q k g9q h k wfh 7 q h o rq [ [a o mb d dkogdu f mu j d q C da [ ]6 d 0vCmj k o s^ n [ + dj v omu j m j k o

9t9j k p7j k le]a [ .[1a h C 1n o dkogdu f D

DHCS 0008 (01/08) – Laotian

Page 1 of 3

Form Dhcs 0008 - California Proof Of Citizenship And Identity Requirements (Laotian) - Health And Human Services Agency

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