返回翻译表格主页​​ 

Medi-Cal 资格部门 (MCED) 表格按表格编号的字母顺序列示如下，并已翻译成波斯语。​​ 

PDF 填写和打印表格可以在线填写并打印为硬拷贝，然后签名并邮寄或亲自提交给资格审查工作人员进行处理。​​ 

DHCS 表格：波斯语​​ 

• DHCS 0001 (01/08) (Far) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity​​ 
• DHCS 0002 (01/08) (Far) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals​​ 
• DHCS 0005 (02/08) (Far) – Receipt of Citizenship or Identity Documents​​ 
• DHCS 0007 (12/07) (Far) – Acceptable Citizenship and Identity Documents​​ 
• DHCS 0008 (01/08) (Far) – 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 0004 (06/07) (Far) – Request for California Birth Record​​ 
• DHCS 0005 (02/08) (Far) – Receipt of Citizenship or Identity Documents​​ 
• DHCS 0006 (08/07) (Far) – Proof of Citizenship and Identity​​ 
• DHCS 0007 (12/07) (Far) – Acceptable Citizenship and Identity Documents​​ 
• DHCS 0008 (01/08) (Far) – 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) (Far) – Affidavit of Identity for U.S. Citizen or National Children Under 18​​ 
• DHCS 0011 (06/08) (Far) – Proof of Acceptable Citizenship or Identity Documents​​ 
• MC 0021 (04/07) (Far) – Medi-Cal to Healthy Families Bridging Consent Form​​ 

MC 形式：波斯语​​ 

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

MC 信息通知：波斯语​​ 

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