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

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MEDI-CAL MAU NG THUAN 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) – Vietnamese
Ngaøy Thoâng Baùo:
Soá Hoà Sô:
Teân Nhaân Vieân:
Maõ Soá Nhaân Vieân:
Ñieän Thoaïi Nhaân Vieân:
Giô Laøm Vieäc:
Thoâng Baùo Cho:
Con quyù vò coù teân ôû treân coù theå hoäi ñuû ñieàu kieän ñöôïc ñaøi thoï baûo hieåm söùc khoûe mieãn phí hoaëc
giaù treû qua _____________________; moät chöông trình cung caáp chaêm soùc söùc khoûe cho treû em
(Insert name of program)
khoâng hoäi ñuû ñieàu kieän höôûng Medi-Cal hoaëc Healthy Families troïn veïn. Neáu quyù vò öng thuaän cho
pheùp chuùng toâi, chuùng toâi seõ chuyeån ñôn cuûa con quyù vò ñeán chöông trình naøy.
Neáu quyù vò öng thuaän ñeå chuùng toâi göûi ñôn Medi-Cal cuûa con quyù vò ñeán chöông trình noùi treân, hoï seõ
duyeät chi tieát ñeå xem con quyù vò coù hoäi ñuû ñieàu kieän khoâng. Neáu quyù vò öng thuaän, quyù vò seõ khoâng phaûi
ñieàn moät ñôn môùi ñeå xin chöông trình noùi treân, vaø moät ngöôøi ñaïi dieän chöông trình seõ lieân laïc cho quyù vò
bieát caàn phaûi ñöa theâm nhöõng chi tieát naøo ñeå ghi danh cho con quyù vò.
QUAN TROÏNG Neáu quyù vò chòu öng thuaän cho göûi chi tieát cuûa con mình ñi, quyù vò phaûi ñaùnh daáu
vaøo oâ beân döôùi, kyù teân vaø ghi ngaøy treân maãu naøy, vaø göûi veà ñòa chæ quaän ôû treân. Quyù vò cuõng coù theå
goïi cho nhaân vieân Medi-Cal cuûa mình ñeå cho hoï bieát raèng quyù vò chòu öng thuaän.
Neáu quyù vò khoâng chòu öng thuaän, ÑÖØNG göûi laïi maãu naøy. Neáu quyù vò khoâng göûi laïi maãu naøy, quyù vò
KHOÂNG chòu öng thuaän. Ñôn Medi-Cal cuûa con quyù vò seõ khoâng ñöôïc göûi ñi vaø con quyù vò seõ khoâng
ñöôïc ñaøi thoï baûo hieåm chaêm soùc söùc khoûe qua caùc chöông trình khaùc cuûa quaän tröø khi quyù vò noäp
ñôn xin.
□ Toâi öng thuaän cho chuyeån maãu ñôn Medi-Cal cuûa con toâi ñeán _____________________
(Insert name of program)
Kyù Teân:________________________________ Ngaøy:____________Ñieän Thoaïi:__________________
(Göûi laïi maãu naøy hoaëc ñieän thoaïi cho nhaân vieân bieát yù quyù vò, trong voøng naêm ngaøy, taïi ñòa chæ hoaëc soá ñieän thoaïi lieät keâ ôû treân)
Neáu quyù vò coù baát cöù thaéc maéc naøo hoaëc caàn theâm chi tieát, xin lieân laïc vôùi nhaân vieân Medi-Cal cuûa
quyù vò ñöôïc lieät keâ ôû goùc phaûi phía treân cuûa thoâng baùo naøy. Xin goïi _________________ neáu quyù vò
(Insert program phone number)
muoán bieát theâm chi tieát veà _____________________.
(Insert name of program)
MAÃU ÖNG THUAÄN
MEDI-CAL
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MEDI-CAL MAU NG THUAN MEDI-CAL NOTICE OF ACTION (Department of Health Care Services)

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Completed 23 November 2020

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