Fillable MEDI-CAL THOV NTAUB NTAWV (REQUEST FOR INFORMATION) (Department of Health Care Services)

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MEDI-CAL THOV NTAUB NTAWV (REQUEST FOR INFORMATION) (Department of Health Care Services)

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State of California—Health and Human Services Agency Department of Health Care Services
Medi-Cal Program
MEDI-CAL THOV NTAUB NTAWV (REQUEST FOR INFORMATION)
MC 355 HMO (Rev.07/18)
Hnub Tshaj Qhia:
Tus Case Number:
Lub Npe Tus Ua Hauj Lwm:
Tus Zauv ID Ua Hauj Lwm:
Tus Zauv Xa Ntawv Ntawm
Tus Ua Hauj Lwm:
Tus Xov Tooj Ua Hauj Lwm:
Cov Teev Ua Hauj Lwm:
Ceeb Toom Rau:
CEEB TOOM: NYEEM NPLOOJ NO UA NTEJ
Peb xav tau ib co ntaub ntawv ntxiv los ntawm koj peb thiaj li ua tiav txoj kev soj ntsuam seb koj puas
tsim nyog rau Medi-Cal. Ua ntej peb hais kom koj muab ntaub ntawv ntxiv, peb tau saib peb cov
ntaub ntawv thiab tag nrho lwm cov ntaub ntawv uas muaj rau peb. Qhov peb tshawb fawb tsis muaj
tag nrho cov ntaub ntawv uas xav tau. Peb tseem xav tau cov ntaub ntawv uas muaj lub thawv kos
nyob rau hauv cov nplooj nram qab no.
Peb yuav tsum tau cov ntaub ntawv no tsis pub dhau lub tsis li tej zaum koj
yuav tsis tau Medi-Cal cov kev pab!
• Siv daim ntawv no los muab cov ntaub ntawv lossis cov lus qhia uas xav tau.
• Koj tsis tas yuav xa daim ntawv no rov qab tuaj rau peb.
• Koj yuav muab tau cov ntaub ntawv rau peb los ntawm qhov xa hauv kev xa ntawv tuaj, fax, hu
xov tooj, tuaj tim ntsej tim muag, lossis hauv online. Hu rau koj lub nroog (county) es xyuas
seb yuav xa koj cov ntaub ntawv hauv online tuaj li cas.
• Tau muab ib lub hnab ntawv uas muaj qhov chaw xa rov qab tuaj thiab twb lo nqi xa tas rau
lawm rau koj xa cov ntaub ntawv lossis cov lus qhia rov tuaj.
• Thov sau tus zauv cim ntaub ntawv (case number) uas nyob rau saum toj ntawm nplooj no rau
hauv cov ntaub ntawv uas koj xa tuaj rau peb.
• Yog tias koj muaj lus nug, xav tau cov lus qhia ntxiv, lossis muab tsis tau cov lus qhia uas thov
txog ntawd thov hu rau peb ntawm tus xov tooj uas nyob saum toj ntawm nplooj no.
TSEEM CEEB! THOV NYEEM TAG NRHO COV NPLOOJ HAUV
DAIM
NTAWV NO
Pab peb txuas lus nrog koj!
MC 355 HMO (Rev.07/18)
Hu rau koj tus neeg ua haujlwm saib xyuas kev tsim nyog yog tias koj
hloov chaw nyob lossis xov tooj lawm.
(Cov kev yuav nug tau tus neeg ua haujlwm muaj nyob rau saum toj hauv nplooj no)
MEDI-CAL THOV NTAUB NTAWV (REQUEST FOR INFORMATION)
LUS CIM: PEB TSUAS XAV TAU COV NTAUB NTAWV UAS MUAJ LUB THAWV KOS XWB.
Nyiaj tau
Cov ntaub ntawv qhia txog koj cov nyiaj tau yuav pab peb txiav txim seb koj puas tsim nyog rau
Medi-Cal dawb lossis them tsawg zog lossis kev pab los ntawm Covered California, uas yog xeev
txoj kev pab them nqi kho mob.
Ib daim qauv ntawm daim tw tshev tshiab tshaj lossis daim ntawv qhia los ntawm koj qhov
chaw ua haujlwm uas qhia txog koj txoj haujlwm (seb koj tau pes tsawg ua ntej txiav se tawm,
them koj heev npaum li cas, koj ua haujlwm pes tsawg teev) rau txhua txoj haujlwm koj ua (yog
tias koj muaj ntau tshaj ib txoj haujlwm) rau:
Yog tias koj tsis tau tw tshev thiab muab tsis tau ib daim ntawv qhia los ntawm koj qhov (cov)
chaw ua haujlwm, koj ua tau ib qho nram qab no:
•
Muab ib daim qauv ntawm koj cov ntawv ua se tshiab tshaj rau:
• Hu rau koj tus neeg ua haujlwm kom teb thiab kos npe rau daim ntawv ua pov thawj uas
yeej paub tias yuav raug nplua yog tias dag thiab koj sau hnub tim rau uas qhia seb koj
tau nyiaj pes tsawg ua ntej txiav se, them koj heev npaum li cas, thiab seb koj ua
haujlwm pes tsawg teev.
Yog tias koj ua haujlwm rau koj tus kheej, muab ib daim qauv ntawm daim Schedule C ntawm
cov ntawv ua se tshiab tshaj, lossis daim ntawv qhia txog cov peev thiab nuj nqis rau peb lub
hlis tas los rau cov hli:
Pov thawj txog nyiaj poob haujlwm lossis nyiaj xiam oob khab—ib daim qauv ntawm cov tw
uas tau them nyiaj lossis ib tsab ntawv uas qhia tias koj tau pes tsawg ua ntej rho nyiaj tawm
rau:
Pov thawj txog Cov Nyiaj Qub Tub Rog (kev pab thiab lub sij hawm twg, nyiaj xiam oob khab
lossis so tsis ua haujlwm lawm)—ib daim qauv ntawm cov tw uas tau them nyiaj lossis ib daim
ntawv qhia tias tau nyiaj pes tsawg rau:
Pov thawj txog cov nyiaj laus
social security—ib daim qauv ntawm cov tw uas tau them lossis
ib tsab ntawv uas qhia seb tau nyiaj pes tsawg rau:
Pov thawj txog cov nyiaj rau yav laus (
retirement) lossis nyiaj pension uas tau txais—ib daim
qauv ntawm cov nyiaj tau lossis daim tw tshev rau:
Cov lus qhia txog seb koj ua se li cas (filing status) thiab/lossis seb lwm cov neeg hauv tsev
neeg ua se li cas rau:
Teb daim ntawv nrog nov hu ua
“Daim Ntawv Thov Cov Lus Qhia Txog Se Rau Cov Neeg
Hauv Tsev Neeg” (Request for Tax Household Information) (RFTHI) rau:
MC 355 HMO (Rev.07/18)
Lwm yam:
Cov kev rho tawm (Deductions)
Ib daim qauv ntawm cov tshev lossis tw uas tau them nyiaj rau kev zov me nyuam, nyiaj yug
me nyuam, nyiaj yug txij nkawm, lossis kev tuav pov hwm uas tau them rau:
Lwm yam:
Cov Lus Qhia txog Tus (Cov) Neeg Thov Medi-Cal
Ib daim qauv ntawm koj daim ntawv tsav tsheb hauv California lossis ib daim ID muaj duab
rau:
Tus Naj Npawb Xaus Saus:
Ib daim qauv ntawm cov ntaub ntawv lossis daim khaj hla teb chaws (luam tag nrho ob sab
ntawm cov khaj lossis cov ntaub ntawv) rau:
Yog tias koj yog ib tug neeg hla teb chaws thiab tsis muaj ib tug zauv pua cev (social security
number) lossis muab tsis tau cov ntaub ntawv hla teb chaws tuaj rau peb, tej zaum koj yeej
tseem yuav tsim nyog rau kev pab thaum muaj xwm ceev thiab kev pab rau thaum cev xeeb
tub. Thov hu rau koj tus neeg ua haujlwm es qhia rau peb txog cov kev hloov hauv qhov koj
hla teb chaws/kev ua xam xaj lossis yog tias koj tsis muaj ib tug zauv pua cev (social security
number) lossis cov ntaub ntawv txog qhov hla teb chaws, kom peb thiaj li ua tiav peb txoj kev
soj ntsuam.
Me Nyuam Uas Nyob Hauv Niam Qhuav Txiv Qhuav Kev Saib Xyuas Yav Tas Los
Ib daim qauv ntawm cov ntaub ntawv rau: uas qhia tias koj tau nyob
hauv niam qhuav txiv qhuav kev saib xyuas hnub koj muaj 18 xyoo. Peb nug cov ntaub ntawv
no vim tias peb muab tsis tau pov thawj tias koj nyob hauv niam qhuav txiv qhuav kev saib
xyuas thaum muaj hnub nyoog 18 xyoo lossis laus dua ntawd.
Cov lus qhia uas peb tau xyuas qhia tias:
Chaw nyob
Pov thawj txog koj qhov chaw nyob tam sim no (daim tw xauj tsev, daim nqi hluav taws xob, lwm
yam zoo li no)
Khoom Ntawm Ntiag Tug lossis Vaj Tsev
Ib daim qauv ntawm tag nrho cov tsheb lossis ntawv ua tswv rau cov tsheb (yog tias koj muaj
ntau tshaj ib lub tsheb) rau:
Ib daim qauv ntawm koj daim ntawv qhia nyiaj tshiab tshaj tim tuam txhab tso nyiaj (as khauj
sau tshev, as khauj tseg nyiaj, lwm yam zoo li no) rau:
Ib daim qauv ntawm phau ntawv yuav kev tuav pov hwm txoj sia, cov nyiaj tso ua lag luam
stocks, nyiaj tso ua lag luam bonds, daim ntawv qhia nyiaj rau tus as khauj tso nyiaj laus
(retirement) rau
:
MC 355 HMO (Rev.07/18)
Ntaub ntawv txog lwm yam uas nyob hauv lossis nyob tawm sab nraum Teb Chaws Mis Kas
(United States) (cov tsev dua li ntawm lub koj nyob, av, lwm yam zoo li no) rau
:
Pov thawj tias koj tau muab khoom muag, pauv lossis muab pub dawb lossis tau kaw as khauj
lawm rau:
Kev xiam oob khab/Tsis muaj peev xwm ua (Incapacity)
Daim ntawv qhia txog nyiaj laus
social security rau ib qho kev tsis taus rau:
Lwm yam pov thawj tias koj muaj ib qho kev tsis taus ntawm cev, saum hlwb, lossis kev xav
ntawm siab uas yuav kav mus
12 lub hlis lossis ntev dua ntawd rau:
Yog koj xav tias koj lossis ib tug neeg hauv tsev neeg uas tau Medi-Cal muaj kev tsis taus thov
hu rau koj tus neeg ua haujlwm.
Lwm cov ntaub ntawv uas peb xav tau
:
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MEDI-CAL THOV NTAUB NTAWV (REQUEST FOR INFORMATION) (Department of Health Care Services)

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Completed 30 July 2020

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