ກັບໄປທີ່ໜ້າແປແບບຟອມ Main Page Medi-Cal Eligibility Division (MCED) forms are listed below, alphabetically, by form number and has been translation into Khmer. ແບບຟອມຕື່ມຂໍ້ມູນ PDF ແລະພິມອາດຈະສໍາເລັດອອນໄລນ໌ແລະພິມອອກເປັນ hardcopy ເພື່ອເຊັນແລະສົ່ງໃນໄປສະນີຫຼືສົ່ງດ້ວຍຕົນເອງກັບພະນັກງານທີ່ມີສິດໄດ້ຮັບການດໍາເນີນການ.​​ 

ແບບຟອມ DHCS: ກຳປູເຈຍ​​ 

• DHCS 0001 (01/08) (Cam) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity​​ 
• DHCS 0002 (01/08) (Cam) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals​​  
  
• DHCS 0005 (02/08) (Cam) – Receipt of Citizenship or Identity Documents​​ 
• DHCS 0007 (12/07) (Cam) – Acceptable Citizenship and Identity Documents​​ 
  
• DHCS 0008 (01/08) (Cam) – 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) (Cam) – Affidavit of Identity for U.S. Citizen or National Children Under 18​​ 
• DHCS 0011 (06/08) (Cam) – Proof of Acceptable Citizenship or Identity Documents​​ 

ແບບຟອມ MC: ກຳປູເຈຍ​​ 

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

ແຈ້ງການຂໍ້ມູນຂ່າວສານ MC: ກຳປູເຈຍ​​ 

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