ພະແນກການມີສິດໄດ້ຮັບ Medi-Cal ແປແບບຟອມ: ພາສາມົ້ງ
ແບບຟອມຂອງພະແນກການມີສິດໄດ້ຮັບ Medi-Cal (MCED) ມີລາຍຊື່ຂ້າງລຸ່ມນີ້, ຕາມຕົວອັກສອນ, ຕາມຕົວເລກແບບຟອມ ແລະໄດ້ຖືກແປເປັນພາສາມົ້ງ.
ແບບຟອມຕື່ມຂໍ້ມູນ PDF ແລະພິມອາດຈະສໍາເລັດອອນໄລນ໌ແລະພິມອອກເປັນ hardcopy ເພື່ອເຊັນແລະສົ່ງໃນໄປສະນີຫຼືສົ່ງດ້ວຍຕົນເອງກັບພະນັກງານທີ່ມີສິດໄດ້ຮັບການດໍາເນີນການ.
ແບບຟອມ DHCS: ມົ້ງ
- 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
MC Forms: ມົ້ງ
- 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
MC Information Notices: ເຜົ່າມົ້ງ
- MC Information Notice 003 (05/13) (Hmo) – Early and Periodic Screening, Diagnosis, and Treatment Services