ພະແນກການມີສິດໄດ້ຮັບ Medi-Cal ແປແບບຟອມ: ຫວຽດນາມ
ແບບຟອມຂອງພະແນກການມີສິດໄດ້ຮັບ Medi-Cal (MCED) ມີລາຍຊື່ຂ້າງລຸ່ມນີ້, ຕາມຕົວອັກສອນ, ຕາມຕົວເລກແບບຟອມ ແລະໄດ້ຖືກແປເປັນພາສາຫວຽດນາມ.
ແບບຟອມຕື່ມຂໍ້ມູນ PDF ແລະພິມອາດຈະສໍາເລັດອອນໄລນ໌ແລະພິມອອກເປັນ hardcopy ເພື່ອເຊັນແລະສົ່ງໃນໄປສະນີຫຼືສົ່ງດ້ວຍຕົນເອງກັບພະນັກງານທີ່ມີສິດໄດ້ຮັບການດໍາເນີນການ.
ແບບຟອມ DHCS: ຫວຽດນາມ
- DHCS 0001 (01/08) (Vie) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity
- DHCS 0002 (01/08) (Vie) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals
- DHCS 0005 (02/08) (Vie) – Receipt of Citizenship or Identity Documents
- DHCS 0007 (12/07) (Vie) – Acceptable Citizenship and Identity Documents
- DHCS 0008 (01/08) (Vie) – Proof of Citizenship and Identity Requirements for Children Who Are U.S. Citizens or Nationals Filling Out the Healthy Families
- DHCS 0009 (09/07) (Vie) – Affidavit of Identity for U.S. Citizen or National Children Under 18
- DHCS 0011 (06/08) (Vie) – Proof of Citizenship or Identity Documents
MC Forms: ຫວຽດນາມ
- MC 0021 (04/07) (Vie) – Medi-Cal to Healthy Families Bridging Consent Form
- MC 176 S (03/09) (Vie) – Medi-Cal Status Report
- MC 209 (05/12) (Vie) – ການປ່ຽນແປງການຄຸ້ມຄອງ Medi-Cal ຂອງທ່ານໃນລະຫວ່າງການຖືພາ ແລະ ຫຼັງຈາກທີ່ທ່ານເກີດລູກ
- MC 210 RV (05/11) (Vie) – Medi-Cal Annual Redetermination
- MC 219 (11/15) (Vie) – Important Information for Persons Requesting Medi-Cal
- MC 223 C (06/11) (Vie) – Supplemental Statement of Facts for Medi-Cal Child Applicant Only – Under Age 18
- MC 223 (10/09) (Vie) – Applicant’s supplemental statement of facts for Medi-Cal Adult Applicant Only
- MC 239 DRA-6 (02/10) (Vie) – Information Notice – Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration
- MC 264 (09/11) (Vie) – Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet
- MC 371 (06/09) (Vie) – Additional Family Members Requesting Medi-Cal
- ໃບປິວ MC 372 (12/21) (Vie) – ໂຄງການປິ່ນປົວມະເຮັງເຕົ້ານົມ ແລະ ມະເຮັງປາກມົດລູກ (BCCTP)
- MC 4035 (04/08) (Vie) – Medi-Cal Consent Form
ແຈ້ງການຂໍ້ມູນຂ່າວສານ MC: ຫວຽດນາມ
- ແຈ້ງການຂໍ້ມູນ MC 003 (05/13) (Vie) – ການກວດຄັດກອງ, ການວິນິດໄສ ແລະ ການປິ່ນປົວແຕ່ຫົວທີ ແລະ ເປັນໄລຍະ