Fillable EsckI CUn DMNwg Pl; Btman Min Gac BBaak; (Department of Health Care Services)

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EsckI CUn DMNwg Pl; Btman Min Gac BBaak; (Department of Health Care Services)

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esckþI CUn dMNwg pþl; B½t’man
min Gac bBa¢ak; GtþsBaØaN/sBa¢ati shrdæ Gaem:rik (U.S.)
tam ry³ Social Security Administraton )an eT
State of California - Health and Human Services Agency
Department of Health Care Services
MC 239 DRA-6 Cambodian (2/10)
Notice Date: _________________________________
Case Number: ________________________________
Worker Name: ________________________________
Worker Number: ______________________________
Worker Telephone Number: _____________________
Oce Hours: _________________________________
esckþI CUn dMNwg enH KW edIm,I CRmab elak Gñk fa eyIg ´ min Gac bBa¢ak; sBa¢ati nig GtþsBaØaN shrdæ Gaem:rik rbs; elak Gñk tam ry³ SOCIAL
SECURITY ADMINISTRATION (SSA) )an eT. dMNwg enH Tak; Tg cMeBaH buKÁl TaMg Lay xag eRkam enH³
dak; eQµaH enA TI enH
c,ab; shB½n§ tRmÚv Gñk dak; Bakü suM nig Gñk TTYl GtßRbeyaCn_ Medi-Cal Edl min elIk Elg eT Edl GH Gag fa xøÜn KW Ca RbCaBlrdæ b¤ CnCati
shrdæ Gaem:rik [ pþl; Psþútag GMBI sßanPaB nig GtþsBaØaN Ca RbCaBlrdæ/CnCati . sRmab; mnusS PaK eRcIn kar enH eFVI eLIg eday bBa¢ak;
B½t’man eTA nwgRksYg SSA. k¾ b:uEnþ SSA min Gac bBa¢ak; fa elak Gñk KW Ca RbCa Blrdæ b¤ CnCati shrdæ Gaem:rik )an eT.
enA kñúg ry³ eBl 90 éf¶ elak Gñk RtÚv pþl; Éksar sm ehtu sm pl bBa¢ak; BI sBa¢ati nig GtþsBaØaN shrdæ Gaem:rik rbs; elak Gñk eTA kan;
Gñk cat;kar sMNuM erOg RbcaM Rsúk rbs; elak Gñk. elak Gñk RtÚvEt eFVI dUecñaH edIm,I TTYl GtßRbeyaCn_ Medi-Cal eBj elj.
• ry³eBl 90 éf¶ enH cab; epþIm R)aMBIr éf¶ eRkay BI éf¶ cuH esckþI CUn dMNwg enH.
• esckþI CUn dMNwg enH Gm P¢ab; eday B½t’man sþI GMBI Éksar Na xøH Edl Gac TTYl )an Ca smehtusmpl. sUm emIl “RbCaBlrdæ
shrdæ Gaem:rik nig Cn Cati Gaem:rik Edl dak; Bakü suM Medi-Cal RtÚv Et bgðaj Psþútag sBa¢ati nig GtþsBaØaN (smÁal; xøÜn) (DHCS
0001)” b¤ “Psþútag én sBa¢ati nig GtþsBaØaN - tRmÚvkar fµI sRmab; Gñk TTYl GtßRbeyaCn_ Medi-Cal Edl Ca RbCaBlrdæ shrdæ
Gaem:rik b¤ CnCati Gaem:rik (DHCS 0002).”
• Rbsin ebI elak Gñk man siT§i TTYl GtßRbeyaCn_ Medi-Cal eBj elj eRkA BI lkçxNÐ enH elak Gñk nwg TTYl GtßRbeyaCn_ TaMg enH enA
kñúg ry³ eBl 90 éf¶ enaH.
• Rbsin ebI sala Rsúk min TTYl Éksar BI elak Gñk eT GtßRbeyaCn_ rbs; elak Gñk nwg RtÚv )an bnßy eTA Ca GtßRbeyaCn_ man kRmit
bnÞab; BI ry³ eBl 90 éf¶ enaH put kMNt;. eyIg min bnßy GtßRbeyaCn_ rbs; elak Gñk \LÚv enH eT. Rbsin ebI GtßRbeyaCn_ rbs;
elak Gñk RtÚv )an bnßy na GnaKt eyIg ´ nwg epJI esckþI CUn dMNwg mYy eTot sþI GMBI erOg enaH.
GtßRbeyaCn_ man kRmit KW Fana r:ab;rg cMeBaH Et esvakmµ se®gÁaH bnÞan; esvakmµ Tak; Tg nwg kar man épÞ eBaH ehIy nig kar Ef TaM d¾ man ry³ eBl
yUr. Rbsin ebI elak Gñk min R)akd fa sßanPaB Na mYy KW Ca PaB Gasnñ esvakmµ Tak; Tg nwg kar man épÞ eBaH b¤ kar Ef TaM d¾ man ry³ eBl yUr
sUm Tak; Tg eBTü pþl; kar Ef TaM suxPaB rbs; elak Gñk.
elak Gñk k¾ Gac Tak; Tg kariyal½y SSA edIm,I edaH Rsay bBaða enH. Rbsin ebI SSA yl; RBm edIm,I Ek bnÞan; kMNt;ehtu rbs; xøÜn edIm,I qøúH
bBa©aMg BI sBa¢ati nig GtþsBaØaN rbs; elak Gñk elak Gñk RtÚv Et R)ab; Gñk cat;kar sMNuM erOg RbcaM Rsúk rbs; elak Gñk. sala Rsúk nwg epJI sMeNI
suM eTA eK mþg eTot edIm,I bBa¢ak; BI sBa¢ati nig GtþsBaØaN shrdæ Gaem:rik rbs; elak Gñk.
esckþI CUn dMNwg enH KW RtÚv )an tRmÚv eday Welfare and Institutions Code section 14011.2.
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EsckI CUn DMNwg Pl; Btman Min Gac BBaak; (Department of Health Care Services)

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Completed 30 July 2020

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