العودة إلى النماذج المترجمة الصفحة الرئيسية

نماذج قسم أهلية ميدي-كال (MCED) مدرجة أدناه، مرتبة أبجديًا، حسب رقم النموذج، وقد تمت ترجمتها إلى لغة الهمونغ. 

يمكن ملء وطباعة النماذج بصيغة PDF عبر الإنترنت وطباعتها على نسخة ورقية للتوقيع عليها وإرسالها بالبريد أو تقديمها شخصيًا إلى موظف الأهلية لمعالجتها.

نماذج DHCS: الهمونغ

• DHCS 0001 (01/08) (Hmo) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity
• DHCS 0002 (01/08) (Hmo) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals
• DHCS 0005 (02/08) (Hmo) – Receipt of Citizenship or Identity Documents
• DHCS 0007 (12/07) (Hmo) – Acceptable Citizenship and Identity Documents
• DHCS 0008 (01/08) (Hmo) – Proof of Citizenship and Identity Requirements–For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application
• DHCS 0009 (09/07) (Hmo) – Affidavit of Identity for U.S. Citizen or National Children Under 18
• DHCS 0011 (06/08) (Hmo) – Proof of Acceptable Citizenship or Identity Documents

نماذج MC: همونغ

• MC 0021 (04/07) (Hmo) – Medi-Cal to Healthy Families Bridging Consent Form
• MC 176 S (03/09) (Hmo) – Medi-Cal Status Report
• MC 209 (05/12) (Hmo) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth
• MC 210 PS (05/07) (Hmo) – Property Supplement
• MC 210 RV (05/11) (Hmo) – Medi-Cal Annual Redetermination
• MC 219 (11/15) (Hmo) – Important Information for Persons Requesting Medi-Cal 
• MC 223 C (06/11) (Hmo) – Supplemental Statement of Facts for Medi-Cal Child Applicant Only – Under Age 18
• MC 223 (10/09) (Hmo) – Applicant’s supplemental statement of facts for Medi-Cal Adult Applicant Only
• MC 239 DRA-6 (02/10) (Hmo) – Info Notice – Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration
• MC 264 (09/11) (Hmo) – Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet
• MC 371 (06/09) (Hmo) – Additional Family Members Requesting Medi-Cal
• MC 372 (12/21) (Hmo) – Breast and Cervical Cancer Treatment Program (BCCTP) Flyer
• MC 4035 (04/08) (Hmo) – Medi-Cal Consent Form

إشعارات معلومات MC: همونغ

•  MC Information Notice 003 (05/13) (Hmo) – Early and Periodic Screening, Diagnosis, and Treatment Services