Fillable MEDI-CAL- MEDI-CAL NOTICE OF ACTION (Department of Health Care Services)

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MEDI-CAL- MEDI-CAL NOTICE OF ACTION (Department of Health Care Services)

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State of California – Health and Human Services Agency Department of Health Care Services
MEDI-CAL NOTICE OF ACTION ┌ ┐
RESTRICTED BENEFITS APPROVAL
WITH SHARE OF COST:
REFERRED TO THE COUNTY
OR LOCAL-SPONSORED
HEALTH INSURANCE PROGRAM └ ┘
┌ ┐
└ ┘
MC 4035 (04/08) – Armenian
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³å³Ñáí³·ñáõÃÛ³Ý _____________________ Íñ³·ñÇÝ, áñÝ ³å³ÑáíáõÙ ¿ ³éáÕç³å³Ñ³Ï³Ý ËݳÙù
(Insert name of program)
³ÛÝ »ñ»Ë³Ý»ñÇ Ñ³Ù³ñ, áíù»ñ Çñ³í³ëáõ ã»Ý ÉdzñÅ»ù Medi-Cal-Ç Ï³Ù Healthy Families Íñ³·ñÇÝ: Ò»ñ
ѳٳӳÛÝáõÃÛ³Ùμª Ù»Ýù Ò»ñ »ñ»Ë³ÛÇ ¹ÇÙáõÙÁ ÏáõÕ³ñÏ»Ýù ³Û¹ Íñ³·ñÇÝ:
ºÃ» ѳٳӳÛÝ »ù, áñ Ù»Ýù Ò»ñ »ñ»Ë³ÛÇ Medi-Cal-Ç ¹ÇÙáõÙÝ áõÕ³ñÏ»Ýù í»ñáÑÇßÛ³É Íñ³·ñÇÝ, ³å³ Ýñ³Ýù
Ïí»ñ³Ý³Û»Ý Ò»ñ »ñ»Ë³ÛÇ ïíÛ³ÉÝ»ñÁª Ýñ³ Çñ³í³ëáõÃÛáõÝÁ áñáß»Éáõ Ýå³ï³Ïáí: ºÃ» Ù»½ ѳٳӳÛÝáõÃÛáõÝ ï³ù,
³å³ ¸áõù ϳñÇù ã»ù áõݻݳ Ýáñ ¹ÇÙáõÙݳӨ Éñ³óÝ»Éáõª í»ñáÑÇßÛ³É Íñ³·ñÇÝ ¹ÇÙ»Éáõ ѳٳñ, ¨ Íñ³·ñÇ
Ý»ñϳ۳óáõóÇãÁ Ò»½ Ñ»ï ϳåÇ Ù»ç ÏÙïÝÇ, »Ã» áñ¨¿ ѳí»ÉÛ³É ï»Õ»ÏáõÃÛ³Ý Ï³ñÇù ÉÇÝǪ Ò»ñ »ñ»Ë³ÛÇÝ Íñ³·ñáõÙ
Áݹ·ñÏ»Éáõ ѳݳñ:
βð¨à°ð ¾.
ºÃ» ó³ÝϳÝáõÙ »ù ѳٳӳÛÝáõÃÛáõÝ ï³É, áñ Ù»Ýù áõÕ³ñÏ»Ýù Ò»ñ »ñ»Ë³ÛÇ ïíÛ³ÉÝ»ñÁ, ³å³ Ýß»ù
ëïáñ»í í³Ý¹³ÏáõÙ, ëïáñ³·ñ»ù ¹ÇÙáõÙݳӨÁ ¨ Ýß»ù ³Ùë³ÃÇíÁ, ³å³ ³ÛÝ áõÕ³ñÏ»ù Ù³ñ½Ç (county) í»ñ¨áõÙ
Ýßí³Í ѳëó»áí: ¸áõù ϳñáÕ »ù ݳ¨ Ñ»é³Ó³ÛÝ»É Medi-Cal-Ç Ò»ñ ³ß˳ï³ÏóÇÝ ¨ Ýñ³Ý ѳÛïÝ»É, áñ ó³ÝϳÝáõÙ »ù
ѳٳӳÛÝáõÃÛáõÝ ï³É:
ºÃ» ã»ù ó³ÝϳÝáõ٠ѳٳӳÛÝáõÃÛáõÝ ï³É, ³å³ ØÆ áõÕ³ñÏ»ù ³Ûë ¹ÇÙáõÙݳӨÁ: ºÃ» ¹ÇÙáõÙݳӨÁ ãáõÕ³ñÏ»ù,
Ý߳ݳÏáõÙ ¿, áñ ѳٳӳÛÝáõÃÛáõÝ âºø ï³ÉÇë: Ò»ñ »ñ»Ë³ÛÇ Medi-Cal-Ç ¹ÇÙáõÙݳӨÁ ãÇ áõÕ³ñÏíÇ ¨ Ò»ñ »ñ»Ë³Ý ãÇ
ëï³Ý³ ³éáÕç³å³Ñ³Ï³Ý ³å³Ñáí³·ñáõÃÛáõÝ Ù³ñ½Ç (county) ³ÛÉ Íñ³·ñ»ñÇ ÙÇçáóáí, ÙÇÝ㨠áñ ¸áõù ã¹ÇÙ»ù:
□ ºë ѳٳӳÛÝáõÃÛáõÝ »Ù ï³ÉÇë ÇÙ »ñ»Ë³ÛÇ Medi-Cal-Ç ¹ÇÙáõÙÝ³Ó¨Ý áõÕ³ñÏ»É ____________________________
Íñ³·ñÇÝ:
(Insert name of program)
êïáñ³·ñáõÃÛáõÝ.____________________________________ ²Ùë³ÃÇí._________лé³ËáëÇ Ñ³Ù³ñ._____________
(ÐÇÝ· ûñí³ ÁÝóóùáõÙ Ò»ñ ³ß˳ï³ÏóÇÝ áõÕ³ñÏ»ù ³Ûë ¹ÇÙáõݳӨÁ ϳ٠һñ å³ï³ë˳ÝÁ ѳÛïÝ»ù Ñ»é³Ëáëáíª
û·ï³·áñÍ»Éáí í»ñ¨áõÙ Ýßí³Í ѳëó»Ý ϳ٠ѻé³ËáëÇ Ñ³Ù³ñÁ)
ºÃ» áñ¨¿ ѳñó ϳ٠ѳí»ÉÛ³É ï»Õ»ÏáõÃÛ³Ý Ï³ñÇù áõÝ»ù, ËݹñáõÙ »Ýù ѳÕáñ¹³Ïóí»É Medi-Cal-Ç Ò»ñ ³ß˳ï³ÏóÇ
Ñ»ï, áñÇ ³ÝáõÝÁ Ýßí³Í ¿ ³Ûë ï»Õ»Ï³·ñÇ í»ñ¨Ç ³ç ³ÝÏÛáõÝáõÙ: _____________________ Íñ³·ñÇ í»ñ³μ»ñÛ³É
(Insert program phone number)
Éñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñÇ Ñ³Ù³ñ ËݹñáõÙ »Ýù Ñ»é³Ó³ÛÝ»É _____________________ Ñ»é³Ëáë³Ñ³Ù³ñáí:
(Insert name of program)
MEDI-CAL-Ç
ѳٳӳÛݳ·Çñ
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MEDI-CAL- MEDI-CAL NOTICE OF ACTION (Department of Health Care Services)

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Completed 23 November 2020

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