State of California – Health and Human Services Agency Department of Health Care Services
MEDI-CAL
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ﺔﻘﻓاﻮﻣ ﺔﻤﻴﺴﻗ
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MC 4035 (04/08) – Arabic
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نوﺪﻤﻟا ﻚﻠﻔﻃ لﻼﺧ ﻦﻣ ﺔﻀﻔﺨﻣ وأ ﺔﻴﻧﺎﺠﻣ ﺔﻴﺤﺻ ﺔﻴﻄﻐﺘﻟ ﻼهﺆﻣ نﻮﻜﻳ ﺪﻗ ﻩﻼﻋأ ﻪﻤﺳإ __________________ ﺔﻳﺎﻋر ﺮﻓﻮﻳ ﺞﻣﺎﻧﺮﺑ ﻮهو
(Insert name of program)
ﺔﻴﺤﺻ ﻦﻣ ﺔﻠﻣﺎآ ﺔﻴﻄﻐﺗ ﻰﻠﻋ لﻮﺼﺤﻠﻟ ﻦﻴﻠهﺆﻤﻟا ﺮﻴﻏ لﺎﻔﻃﻸﻟMedi-Calأ ﺞﻣﺎﻧﺮﺑ وHealthy Families. ،ﻚﺘﻘﻓاﻮﻣ ءﺎﻄﻋﺈﺑ ﺖﻤﻗ اذإ
ﺞﻣﺎﻧﺮﺒﻟا ﻚﻟذ ﻰﻟإ ﻚﻠﻔﻄﺑ صﺎﺨﻟا ﺐﻠﻄﻟا لﺎﺳرﺈﺑ مﻮﻘﻨﺴﻓ .
ةرﺎﻤﺘﺳإ لﺎﺳرﺈﺑ ﺎﻨﻟ ﻚﺘﻘﻓاﻮﻣ ءﺎﻄﻋﺈﺑ ﺖﻤﻗ اذإMedi-Cal ا ﺻﺎﺨﻟ اورﺮﻘﻳ ﻲﻜﻟ تﺎﻣﻮﻠﻌﻤﻟا ﺔﻌﺟاﺮﻤﺑ نﻮﻣﻮﻘﻴﺳ ،ﻩﻼﻋأ نوﺪﻤﻟا ﺞﻣﺎﻧﺮﺒﻟا ﻰﻟإ ﻚﻠﻔﻄﺑ ﺔ
ﻚﻠﻔﻃ ﺔﻴﻠهأ . ﺞﻣﺎﻧﺮﺒﻟا ﻦﻋ ﻦﻴﻠﺜﻤﻤﻟا ﺪﺣأ مﻮﻘﻳ فﻮﺳو ،ﻩﻼﻋأ نوﺪﻤﻟا ﺞﻣﺎﻧﺮﺒﻠﻟ ﺐﻠﻃ ﻢﻳﺪﻘﺘﻟ ﺪﻳﺪﺟ ﺐﻠﻃ لﺎﻤآﻹ ﺮﻄﻀﺗ ﻦﻠﻓ ،ﺔﻘﻓاﻮﻤﻟا ءﺎﻄﻋﺈﺑ ﺖﻤﻗ اذإ
ﻴﺠﺴﺘﻟ ﺔﻣزﻼﻟا ﺔﻴﻓﺎﺿﻹا تﺎﻣﻮﻠﻌﻤﻟﺎﺑ كرﺎﺒﺧﻹ ﻚﺑ لﺎﺼﺗﻹﺎﺑﻚﻠﻔﻃ ﻞ.
ﺔﻤﻴﺴﻘﻟا ﻩﺬه ﺦﻳرﺄﺗو ﻊﻴﻗﻮﺗ ﻢﺛو ﻩﺎﻧدأ ﻊﺑﺮﻤﻟا ﻲﻓ ةرﺎﺷإ ﻊﺿو ﻚﻴﻠﻋ ،ﻚﻠﻔﻄﺑ ﺔﺻﺎﺨﻟا تﺎﻣﻮﻠﻌﻤﻟا لﺎﺳرﻹ ﻚﺘﻘﻓاﻮﻣ ءﺎﻄﻋإ ﻲﻓ ﺖﺒﻏر اذإ مﺎه
ﻩﻼﻋأ ﺔﻌﻃﺎﻘﻤﻟا ناﻮﻨﻋ ﻰﻟإ ﺎﻬﻟﺎﺳرإو . لﺎﺼﺗﻹا ﺎﻀﻳأ ﻚﻨﻜﻤﻳو ﻒﻇﻮﻤﺑ Medi-Calلوﺆﺴﻤﻟا ءﺎﻄﻋإ ﻲﻓ ﺐﻏﺮﺗ ﻚﻧﺄﺑ ﺎهرﺎﺒﺧإ وأ ﻩرﺎﺒﺧﻹ ﻚﻨﻋ
ﻘﻓاﻮﻣﻚﺘ.
ﺔﻤﻴﺴﻘﻟا ﻩﺬه عﺎﺟرﺈﺑ ﻢﻘﺗ ﻼﻓ ،ﻚﺘﻘﻓاﻮﻣ ءﺎﻄﻋإ ﻲﻓ ﺐﻏﺮﺗ ﻻ ﺖﻨآ اذإ .ﻂﻌﺗ ﻢﻟ ﺔﻘﻓاﻮﻤﻟا نا رﺎﺒﺘﻋإ ﻢﺘﻴﻓ ،ﺔﻤﻴﺴﻘﻟا ﻩﺬه عﺎﺟرﺈﺑ ﻢﻘﺗ ﻢﻟ اذإ . لﺎﺳرإ ﻢﺘﻳ ﻦﻟ
ةرﺎﻤﺘﺳإMedi-Calﺐﻠﻃ ﻢﻳﺪﻘﺘﺑ ﺖﻤﻗ اذإ ﻻإ ﺔﻌﻃﺎﻘﻤﻟا ﺞﻣاﺮﺑ لﻼﺧ ﻦﻣ ﺔﻴﺤﺼﻟا ﺔﻳﺎﻋﺮﻟا ﺔﻴﻄﻐﺗ ﻰﻠﻋ ﻞﺼﺤﻳ ﻦﻟ ﻚﻠﻔﻃ ﻚﻟﺬﺑو ،ﻚﻠﻔﻄﺑ ﺔﺻﺎﺨﻟا .
□ ﺎﻧأأ ﺐﻠﻃ ﺔﻤﻴﺴﻗ لﺎﺳرإ ﻰﻠﻋ ﻖﻓاوMedi-Calﻰﻟإ ﻲﻠﻔﻄﻟ ____________________.
(Insert name of program)
ﻊﻴﻗﻮﺘﻟا :________________________ ________ﺦﻳرﺎﺘﻟا : ______________ﻒﺗﺎﻬﻟا ﻢﻗر:_________________
)ﻩﻼﻋأ نوﺪﻤﻟا ﻒﺗﺎﻬﻟا ﻢﻗر وأ ناﻮﻨﻌﻠﻟ ،ﻚﻔﻠﻣ ﻦﻋ لوﺆﺴﻤﻟا ﻒﻇﻮﻤﻟا ﻰﻟإ ،مﺎﻳأ ﺔﺴﻤﺧ لﻼﺧ ﻚﺘﺑﺎﺟﺈﺑ ﺎﻴﻔﺗﺎه ﻞﺼﺗإ وأ ﺔﻤﻴﺴﻘﻟا ﻩﺬه ﻞﺳرأ(
لﺎﺼﺗﻹا ﻮﺟرأ ،ﺔﻴﻓﺎﺿإ تﺎﻣﻮﻠﻌﻤﻟ ﺔﺟﺎﺤﺑ ﺖﻨآ وأ ﺔﻠﺌﺳأ ﺔﻳأ ﻚﻳﺪﻟ ﺖﻧﺎآ اذإﻮﻤﺑﻇ ﻒMedi-Calةﺮآﺬﻤﻟا ﻩﺬه ﻰﻠﻋأ ﻲﻓ ﻦﻴﻤﻴﻟا ﺔﻳواﺰﻟا ﻲﻓ ﻞﺠﺴﻤﻟا .
ﻢﻗﺮﻟﺎﺑ لﺎﺼﺗﻹا ﻮﺟرأ
_________________ﻦﻋ ﺔﻴﻓﺎﺿإ تﺎﻣﻮﻠﻌﻣ ﻰﻠﻋ لﻮﺼﺤﻠﻟ _____________________.
(Insert program phone number ) (Insert name of program)
ﺮآﺬﻤﻟا ﺦﻳرﺎ
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ﻒﻠﻤﻟا ﻢﻗ
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ﻒﻇﻮﻤﻟا ﻢﺳإ:
ﻒﻇﻮﻤﻟا ﻢﻗ
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ﻒﻇﻮﻤﻟا نﻮﻔﻠﺗ ﻢﻗ
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ﻞﻤﻌﻟا تﺎﻋﺎ
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ـﻟ ةﺮآﺬ
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