Form Dhcs 0001 - California U.s. Citizens And Nationals Applying For Medi-Cal Must Show Proof Of Citizenship And Identity (Vietnamese) - Health And Human Services Agency Page 4
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4State of California – Health and Human Services Agency
Department of Health Care Services
Tröôø n g hôï p treû döôù i 16 tuoå i khoâ n g ñöa ra Tôø Khai Chöù n g Theä
Theû Thöông Gia Haø n g Haû i do Sôû Phoø n g Veä Duyeâ n Haû i
Veà Quoá c Tòch (Affidavit of Citizenship), quyù vò coù theå noä p :
Hoa Kyø caá p
Moä t Baû n Khai Chöù n g Theä veà caê n cöôù c cuû a treû do cha
Töø ba giaá y tôø xaù c minh trôû leâ n , thí duï nhö theû ID nhaâ n
meï , giaù m hoä , hoaë c ngöôø i thaâ n chaê m soù c kyù teâ n coù ñeå
vieâ n , baè n g trung hoï c hoaë c ñaï i hoï c , giaá y giaù thuù , giaá y
ngaø y vaø nôi sinh
pheù p ly dò, vaø giaá y chuû quyeà n /ñöù n g teâ n baá t ñoä n g saû n
Ñôn xin Medi-Cal hoaë c ñôn xin chung Healthy
Hoà sô cuû a phoø n g khaù m , baù c só, hoaë c beä n h vieä n ñoá i vôù i
Families/Medi-Cal cho thaá y ngaø y vaø nôi sinh cuû a treû , vaø
treû em döôù i 16 tuoå i
do cha meï , giaù m hoä , hoaë c ngöôø i thaâ n chaê m soù c kyù teâ n .
Hoà sô nhaø tröôø n g, maã u giaù o , hoaë c nhaø treû , keå caû thoâ n g
tín baï , ñoá i vôù i treû em döôù i 16 tuoå i . Quaä n seõ lieâ n laï c vôù i
Ñoá i vôù i treû döôù i 18 tuoå i , coù theå duø n g moä t Baû n Khai Chöù n g
nhaø tröôø n g ñeå kieå m tra.
Theä veà caê n cöôù c cuû a treû do cha meï , giaù m hoä , hoaë c ngöôø i
thaâ n chaê m soù c kyù teâ n neá u khoâ n g coù theå ID nhaø tröôø n g hoaë c
Ñoá i vôù i ngöôø i bò khuyeá t taä t ñang soá n g trong moä t cô sôû
baè n g laù i xe.
chaê m soù c nhö nhaø ôû , moä t Baû n Khai Chöù n g Theä do giaù m
ñoá c hoaë c quaû n ñoá c kyù teâ n
Ghi Chuù : Giaá y tôø caê n cöôù c ñaõ heá t haï n vaã n ñöôï c chaá p nhaä n
laø m baè n g chöù n g veà caê n cöôù c .
DHCS 0001 (01/08) – Vietnamese
Page 4 of 4
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