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

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State of California – Health and Human Services Agency
Department of Health Care Services
:‫ﺳﻧﺔ ﻟم ﻳﻘدم ﻛﺗﺎب إﻗرار إﺛﺑﺎت ﻟﺟﻧﺳﻳﺔ، ﻳﻣﻛن ﺗﻘدﻳم‬
‫ﻟطﻔل ﺗﺣت ﻋﻣر‬
‫❖ ﺛﻼﺛﺔ ﺷﻬﺎدات اﺛﺑﺎت او اﻛﺛر، ﻣﺛل ﺑطﺎﻗﺔ اﻟﺗوظﻳف، ﺷﻬﺎدة اﻟﺛﺎﻧوﻳﻪ‬
16
‫اﻟﻌﺎﻣﺔ او اﻟدﺑﻠوم، ﺷﻬﺎدة اﻟزواج، ﺷﻬﺎدة اﻟطﻼق، او اوراق اﺛﺑﺎت‬
‫❖ ﺷﻬﺎدة ﻻﺛﺑﺎت ﺷﺧﺻﻳﺔ اﻟطﻔل ﻣوﻗﻌﻪ ﻣن اﻻﺑوﻳن، اﻷوﺻﻳﺎء، او‬
‫ﻣﻠﻛﻳﺔ‬
‫اﻻﻗﺎرب اﻟﻣﺷرﻓﻳن ﻋﻠﻳﻪ وﺗﺷﻣل ﺗﺎرﻳﺦ وﻣﻛﺎن اﻟوﻻدة‬
‫❖ ﺳﺟﻼت طﺑﻳﺔ ﻣن ﻋﻳﺎدة ، طﺑﻳب، او ﻣﺳﺗﺷﻔﻰ ﻟﻠطﻔل اﻗل ﻣن ﻋﻣر‬
‫و‬
‫او اﻟطﻠب اﻟﻣﺷﺗرك ﺑﻳن‬
‫❖ طﻠب‬
Healthy
Medi-Cal
Medi-Cal
‫ﺳﻧﺔ‬
16
‫واﻟذي ﻳﺛﺑت ﺗﺎرﻳﺦ وﻣﻛﺎن وﻻدة اﻟطﻔل، ﻣوﻗﻊ ﻣن‬
Families
.‫اﻻﺑوﻳن، اﻻوﺻﻳﺎء، او اﻻﻗﺎرب اﻟﻣﺷرﻓﻳن ﻋﻠﻰ اﻟطﻔل‬
‫❖ ﺳﺟﻼت اﻟﻣدرﺳﺔ، اﻟروﺿﺔ، او اﻟﺣﺿﺎﻧﻪ، ﺑﻣﺎ ﻓﻲ ذﻟك اﻟﺷﻬﺎده‬
‫ﺳﻧﺔ. واﻟﻣﻧطﻘﺔ اﻟﻣﺧﺗﺻﺔ ﺳﺗﻌﻣل‬
‫اﻟﻣدرﺳﻳﺔ، ﻟﻠطﻔل اﻗل ﻣن ﻋﻣر‬
16
،‫ﺳﻧﺔ، ﺷﻬﺎدة اﺛﺑﺎت ﻫوﻳﺔ اﻟطﻔل ﻣوﻗﻌﻪ ﻣن اﻟواﻟدﻳن‬
‫ﻟﻠطﻔل ﺗﺣت ﻋﻣر‬
18
.‫ﻋﻠﻰ اﻟﺗﺣﻘق ﻣن ﺻﺣﺔ اﻟﺷﻬﺎدة ﻣن اﻟﻣدرﺳﺔ اﻟﻣﻌﻧﻳﺔ‬
‫اﻻوﺻﻳﺎء، او اﻻﻗﺎرب اﻟﻣﺷرﻓﻳن ﻋﻠﻳﻪ ﻣﻣﻛن ان ﺗﺳﺗﺧدم اذا ﻟم ﻳﺗواﺟد‬
‫❖ ﻟﻼﺷﺧﺎص ﻣن ذوي اﻻﻋﺎﻗﺎت واﻟﻣﻘﻳﻣﻳن ﻓﻲ ﻣراﻛز اﻟرﻋﺎﻳﺔ، ﺷﻬﺎدة‬
.‫اﺛﺑﺎت ﺷﺧﺻﻳﺔ ﻣن اﻟﻣدرﺳﺔ او رﺧﺻﺔ ﺳﻳﺎﻗﺔ‬
‫اﺛﺑﺎت ﻣوﻗﻌﻪ ﻣن ﻣدﻳر او ﻣﺷرف اﻟﻣرﻛز‬
‫ﻣﻼﺣظﺔ: ﺗﻌﺗﺑر أوراق ﺛﺑوﺗﻳﺔ اﻟﻬوﻳﺔ اﻟﺷﺧﺻﻳﺔ اﻟﻣﻧﺗﻬﻳﺔ اﻟﻣدة ﻣﻘﺑوﻟﺔ‬
.‫ﻛﺈﺛﺑﺎت ﻟﻠﻬوﻳﺔ اﻟﺷﺧﺻﻳﺔ‬
DHCS 0001 (01/08) – Arabic
Page 4 of 4

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