- Qualified Disabled Working Individual (QDWI) Income Sheet-Instructions (MC 176 QDWI, 05/07)
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ເອກະສານການເຮັດວຽກຂອງບຸກຄົນພິການທີ່ມີຄຸນວຸດທິ (QDWI) (MC 176 QDWI-2, 05/07)
- ການສົ່ງຕໍ່ຜູ້ຮັບຜົນປະໂຫຍດ Medicare (QMB). (MC 176 QMB-3, 05/07)
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Qualified Medicare Beneficiary (QMB)/Speciified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Sheet Work Sheet for All Applicants: Individual(s), Couple(s), and Child(ren) (LTC Individual in MFBU) (5MB/QI)/16MB
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Qualified Medicare Beneficiary (QMB)/Speciified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI)ໃບວຽກການມີສິດໄດ້ຮັບລາຍໄດ້, ເດັກນ້ອຍທີ່ສະໝັກດ້ວຍ ຫຼືບໍ່ມີພໍ່ແມ່ທີ່ບໍ່ມີສິດ (MC 176-2B QMB/SLMB/QI, 05/00)
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Qualified Medicare Beneficiary (QMB)/Speciified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI)ໃບວຽກການມີສິດໄດ້ຮັບລາຍໄດ້, ຄູ່ຜົວເມຍ ຫຼືຜູ້ສະໝັກທີ່ມີຄູ່ສົມລົດທີ່ບໍ່ມີສິດ, ມີ ຫຼືບໍ່ມີລູກ (MC 176-2A QMB,9MB/SL)
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Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Property Individual (QI) Sheet, Adult (MC 176 PA QMB/SLMB/QI, 09/08)
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Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Property Individual (QI) Sheet, Child (MC 176 PC QMB/SLMB/QI, 05/07)
- ໃບສະໝັກຜູ້ໃຫ້ບໍລິການທີ່ມີຄຸນສົມບັດສຳລັບການເຂົ້າຮ່ວມການມີສິດສົມມຸດຕິຖານ (MC 311, 10/07)
- ລາຍງານປະຈໍາໄຕມາດສໍາລັບການປິ່ນປົວອາການຊັກ ແລະການຜ່າຕັດທາງຈິດທີ່ຄຸ້ມຄອງ (DHCS 1011, 11/22)
ກັບໄປທີ່ Forms Index
