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

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State of California – Health and Human Services Agency
Department of Health Care Services
،‫ﺳﺎل ﻛﻪ اظﻬﺎر ﻧﺎﻣﻪ ﺳﻳﺗﻲ زن ﺷﻳﭘﻲ اراﺋﻪ ﻧداده‬
‫ﺑراي ﻛودك زﻳر‬
‫❖ ﮔواﻫﻲ دارا ﺑودن ﺧون ﺳرﺧﭘوﺳﺗﻲ ﻳﺎ ﺳﺎﻳر ﺳواﺑق ﻗﺑﻳﻠﻪ اي‬
16
:‫ﺷﻣﺎ ﻣﻲ ﺗواﻧﻳد اﻳن ﻣدارك را ﺗﺳﻠﻳم ﻛﻧﻳد‬
‫ﻣرﺑوط ﺑﻪ ﺳرﺧﭘوﺳﺗﺎن اﻳﺎﻻت ﻣﺗﺣده/ ﺑوﻣﻳﺎن آﻻﺳﻛﺎ‬
‫❖ ﻛﺎرت ﺷﻧﺎﺳﺎﺋﻲ ﮔﺎرد ﺳﺎﺣﻠﻲ اﻳﺎﻻت ﻣﺗﺣده ﻣوﺳوم ﺑﻪ‬
،‫❖ ﻳك اظﻬﺎر ﻧﺎﻣﻪ ﻣرﺑوط ﺑﻪ ﻫوﻳت ﻛودك ﻛﻪ ﺑﻪ اﻣﺿﺎي واﻟد‬
Merchant
‫ﺳرﭘرﺳت، ﻳﺎ ﺧوﻳﺷﺎوﻧد ﻛودك ﺷﺧص رﺳﻳده و ﺗﺎرﻳﺦ و ﻣﺣل ﺗوﻟد‬
Mariner
‫را ﻧﺷﺎن ﻣﻳدﻫد‬
،‫❖ ﺳﻪ ﻣدرك ﺗﺄﻳﻳد ﻫوﻳت ﻳﺎ ﺑﻳﺷﺗر از ﻗﺑﻳل ﻛﺎرت ﻫﺎي ﺷﻧﺎﺳﺎﺋﻲ اﺳﺗﺧداﻣﻲ‬
‫دﺑﻳرﺳﺗﺎن ﻳﺎ ﻣدارك داﻧﺷﮕﺎﻫﻲ، ﺳﻧد ازدواج، ﺣﻛم طﻼق ﻳﺎ ﺳﻧد‬
‫ﻳﺎ ﺗﻘﺎﺿﺎﻧﺎﻣﻪ ﻣﺷﺗرك‬
‫❖ ﺗﻘﺎﺿﺎﻧﺎﻣﻪ‬
Healthy Families/
Medi-Cal
‫ﻣﺎﻟﻛﻳت/ﻗﺑﺎﻟﻪ زﻣﻳن‬
‫ﻛﻪ ﺗﺎرﻳﺦ و ﻣﺣل ﺗوﻟد ﻛودك را ﻧﺷﺎن ﻣﻲ دﻫد و ﺗوﺳط‬
Medi-Cal
.‫واﻟدﻳن، ﺳرﭘرﺳت، ﻳﺎ ﺧوﻳﺷﺎوﻧد ﻣراﻗب ﻛودك اﻣﺿﺎء ﺷده اﺳت‬
‫❖ ﺳواﺑق ﻣرﺑوط ﺑﻪ ﻛﻠﻳﻧﻳك، ﭘزﺷك، ﻳﺎ ﺑﻳﻣﺎرﺳﺗﺎن ﺑراي اﺷﺧﺎص ﻛﻣﺗر‬
‫ﺳﺎل‬
‫از‬
16
‫ﺳﺎل ﭼﻧﺎﻧﭼﻪ اوراق ﺷﻧﺎﺳﺎﺋﻲ ﻣدرﺳﻪ ﻳﺎ‬
‫ﺑراي اﺷﺧﺎص ﻛﻣﺗر از‬
18
‫❖ ﺳواﺑق ﻣدرﺳﻪ، ﻛودﻛﺳﺗﺎن ﻳﺎ ﻣﻬد ﻛودك، از ﺟﻣﻠﻪ ﻛﺎرﻧﺎﻣﻪ ﻫﺎ ﺑراي‬
‫ﮔواﻫﻳﻧﺎﻣﻪ راﻧﻧدﮔﻲ ﻣوﺟود ﻧﺑﺎﺷد، اظﻬﺎرﻧﺎﻣﻪ ﻫوﻳت ﻛودك ﻛﻪ ﺑﻪ اﻣﺿﺎي‬
‫ﺳﺎل. ﻛﺎﻧﺗﻲ ﺗﺄﻳﻳدﻳﻪ ﺻﺣت ﻣدارك ﻓوق را از ﻣدرﺳﻪ‬
‫اﺷﺧﺎص زﻳر‬
16
‫واﻟد، ﺳرﭘرﺳت ﻳﺎ ﺧوﻳﺷﺎوﻧد ﻣراﻗب ﻛودك رﺳﻳده ﺑﺎﺷد ﻣﻲ ﺗواﻧد ﻣورد‬
.‫ﺧواﻫد ﮔرﻓت‬
.‫اﺳﺗﻔﺎده ﻗرار ﮔﻳرد‬
‫❖ ﺑراي ﻣﻌﻠوﻟﻳﻧﻲ ﻛﻪ در ﻣﺣﻠﻬﺎي ﻣراﻗﺑﺗﻲ ﻣﺳﻛوﻧﻲ زﻧدﮔﻲ ﻣﻲ ﻛﻧﻧد، ﻳك‬
‫ﺗوﺟﻪ: ﻣدارك ﺷﻧﺎﺳﺎﺋﻲ ﻣﻧﻘﺿﻲ ﺷده ﺑﻌﻧوان ﺳﻧد ﻫوﻳت داراي اﻋﺗﺑﺎر‬
‫اظﻬﺎر ﻧﺎﻣﻪ ﻛﻪ ﺑﻪ اﻣﺿﺎي رﺋﻳس ﻳﺎ ﻣدﻳر ﻣﺣل رﺳﻳده اﺳت‬
.‫ﻫﺳﺗﻧد‬
DHCS 0001 (01/08) – Farsi
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