Fillable NAAIV MEDI-CAL TOV LORX LONGC WAAC-FIENX (MEDI-CAL REQUEST (Department of Health Care Services)

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NAAIV MEDI-CAL TOV LORX LONGC WAAC-FIENX (MEDI-CAL REQUEST (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
NAAIV MEDI-CAL TOV LORX LONGC WAAC-FIENX (MEDI-CAL
REQUEST FOR INFORMATION)
MC 355 MIE (Rev.07/18)
Box tong fienx hnoi-nyieqc:
Sic dauh nam-mber:
Dengv gong mienh nyei mbuoz:
Dengv gong mienh ID nam-mber:
Dengv gong mienh Fax nam-mber:
Dengv gong mienh nyei fonh nam-mber:
Ze’weic nyei zoux gong ziangh oc:
Box tong fienx liouh:
JIEN SIN MUANGX LONGX: DOQC MANGX NAAIV PIN SOU NDAANGC
Yie mbuo qiemx zuqc longc meih nyei waac-fienx daaih jaa tipv liouh tengx yie mbuo paan pei mangc
nzoih meih nyei puix-zipv gauz longc Medi-Cal jauv-louc. Jaa-ndaangc yie mbuo tov naaic meih lorx
naaiv deix waac-fienx, yie mbuo yaac duqv lorx mangc yiem yie mbuo nyei sou-gorn mi’aqc aengx
caux yietc zungv da’nyeic diuc sou-gorn siou yiem njiec yie mbuo wuov. Yie mbuo dimv lorx mangc
liuz yietc zungv sou-gorn yaac maiv maaih qiemx longc nyei waac-fienx. Yie mbuo corc qiemx longc
naaiv deix waac-fienx dongh yiem njiec wuov deix nzangc-kou bun heuc dimv mangc yiem njiec
nqa’ndiev deix sou-pin wuov oc.
Yie mbuo ix zuqc duqv zipv siou naaiv deix waac-fienx yiem naaiv hnoi a’fai
meih yaac haih zuqc laaih zitc taux meih nyei Medi-Cal fu’loqc nyaanh aqv oc!
• Dorh naaiv zeiv sou-guv mingh tengx siou nzoih qiemx longc nyei zeiv-daan a’fai waac-fienx.
• Meih maiv zuqc fungx naaiv zeiv sou-guv nzuonx bun yie mbuo oc.
• Meih zuqc dorh waac-fienx fungx daaih bun yie mbuo fungx gan dapv fienx dorngx, gan fax,
fonh, daaih cunv yiem buoz zangc, a’fai bieqc online. Lorx buangh taux meih nyei nquenc
zangc ze’weic gorn lorx mangc gorngv hnangv fungx waac-fienx bieqc gan online.
• Dapv bieqc fienx-mbuoqc henh fungx daaih bun meih wuov liouh meih fungx daaih dungh tov
daaih nyei sou-gorn a’fai waac-fienx oc.
• Tov daaix luic fiev njiec sic dauh mengh hoc dungh duqv fiev njiec yiem yietc zungv zeiv-dauh
meih fungx daaih bun yie mbuo wuov.
• Beiv taux meih maaih waac qiemx oix naaic nor, qiemx lorx waac-fienx jaa faaux, a’fai maiv
haih lorx maiv duqv dungh tov daaih nyei waac-fienx nor tov daaix luic lorx buangh taux yie
mbuo yiem naaiv deix fonh nam-mber fiev yiem naaiv pin zeiv-dauh wuov oc.
MC 355 MIE (Rev.07/18)
JIENV KUV JAUV-LOUC! TOV DAAIX LUIC DOQC MANGC YIETC ZUNGV
SOU-PIN
YIEM NAAIV ZEIV SOU-GUV DAAN NZOIH ZUNH NZENGC
Liouh bun yie mbuo nzipc jienv lorx duqv buatc meih oc!
Douc waac lorx taux ninh mbuo maaih ze’buonc gauz benx zoux gong mienh duqv hiuv beiv
taux haaix zanc meih duqv tiuv yienc deic zepv dorngx dauh a’fai douc waac nam-mber.
(Ninh zoux gong mienh lorx doic nyei waac-fienx se duqv fiev yiem gu’nguaaic zeiv-dauh
wuov oc)
NAAIV MEDI-CAL TOV LORX LONGC WAAC-FIENX (MEDI-CAL REQUEST FOR INFORMATION)
MBIUV JANGX: YIE MBUO KUNGX QIEMX LONGC WAAC-FIENX DUNGH MBIUV YIEM
NZANGC-KOU WUOV HNANGV OC.
Zornc nyaanh
Meih nyei zornc nyaanh waac-fienx se haih tengx yie mbuo dorh hlaau ndorqc liuz paaiv bun-dunz
waac beiv taux gorngv meih maaih puix-zipv gauz baeqc henh longc a’fai tengx cuotv zaanc jaaz
tengx Medi-Cal a’fai ninh mbuo beu weih yiem Covered California, ninh mbuo saengv zangc tiuv
yienc heng-wangc fu’loqc nyaanh jauv-louc.
Dorh siang-cuotv nyaanh zeiv-dauh a’fai cingv gong ziouv sou-daan gorngv taux meih zoux
gong jauv-louc (duqv nyaanh hlaax buangv junh ndangc maeqv nzouv-zinh mbu’ziez, duqv
nyaanh saa maqc ndongc haaix, meih zoux gong mbu’ziez norm ziangh hoc) yiem
norm-norm gong (se gorngv meih zoux gauh camv jiex yietc norm gong) liouh:
Se gorngv meih maiv zipv siou duqv maaih cuotv nyaanh zeiv-dauh aengx caux maiv haih
zorqv duqv sou-daan yiem caux meih nyei cingv gong ziouv mienh nor, meih zoux yietc diuc
nga’ndiev deix kou-gong yaac duqv oc:
•
Dorh meih nyei siang cuotv nzouv-zinh fungx nzuonx sou-daan yienx cuotv daaih
bun liouh:
• Lorx buangh taux meih nyei zoux gong mienh tengx fiev ziangx ngaengc waac sou-daan
liuz njiec jienv mbuoz dungh duqv gorngv gu’baeqc waac-jaav nor laengx bun njiec zuiz
aengx caux meih zuqc fiev njiec hnoi-nyieqc gorngv duqv nyaanh hlaax yietc zungv
buangv junh mbuoqc ziez ndaangc maeqv cuotv nzouv-zinh, zipv nyaanh saa maqc
ndongc haaix aengx caux zoux gong mbuoqc ziez norm ziangh hoc.
Se gorngv zoux ga’ganh nyei saeng-eiz nor, dorh naaiv zeiv kou-gong daan Schedule C mingh
yienx cuotv jiex daaih siang cuotv nzouv-zinh nzuonx sou-daan, a’fai leic dauh aengx caux
ndortv buonv sou-daan yiem njiec 3 hlaax nyieqc jiex daaih wuov liouh:
Dorh ndortv gong a’fai benx wuaaic fangx mienh nyaanh daaih bun zaah mangc— yienx cuotv
naaiv deix cuotv nyaanh zeiv-dauh a’fai sou-fienx dongh hinc buatc meih duqv nyaanh hlaax
mbuoqc ziez ndaangc maeqv nzouv-zinh cuotv wuov liouh:
MC 355 MIE (Rev.07/18)
Longc beu sengh sou zaah mangc zoux loh baeng-maanh nyaanh (tengx nyaanh aengx caux
bieqc nyei ziangh hoc, wuaaic fangx a’fai mienh goz jaapc zaangv buangv mi’aqc)- dorh mingh yienx
cuotv naaiv deix cuotv nyaanh zeiv-dauh a’fai sou-fienx yienx cuotv liouh:
Longc beu sengh sou zaah mangc taux zipv longc
social security nyaanh—dorh cuotv nyaanh
zeiv-dauh mingh yienx cuotv a’fai sou-fienx yienx cuotv liouh:
Longc beu sengh sou zaah mangc zipv longc wuix jaapc zaangv buangv nyei mienh a’fai
mienh goz nyaanh
—dorh sou-daan nyaanh a’fai nyaanh qekv zeiv-dauh mingh yienx cuotv
daaih liouh:
Waac-fienx gorngv taux meih njiec sou-nzangc cuotv nzouv-zinh jauv-louc caux/fai huov jaa
da’nyeic dauh hmuangv-doic njiec sou-nzangc cuotv nzouv-zinh jauv-louc liouh:
Dorh naaiv zeiv juangc dapv daaih sou-guv daan mingh fiev nzoih liuz mbuoz-gorn
“Tov lorx
huov-jaa cuotv nzouv-zinh waac-fienx (RFTHI)” “(Request for Tax Household Information
(RFTHI)” liouh:
Da’nyeic diuc:
Maeqv bun nzouv-zinh
Yienx cuotv nyaanh qekv a’fai cuotv nyaanh bun goux mangc fu’jueiv
, tengx goux wuix
fu’jueiv, wuix aauv-leih nyaanh, a’fai heng-wangc beu weih sou-daan cuotv nyaanh liouh bun:
Da’nyeic diuc:
Lorx ga’ganh lengc jeiv waac-fienx dongh tov longc Medi-Cal
Yienx cuotv meih nyei
California saengv zangc niouv cie sou a’fai ID fangx-daan liouh:
Naaiv diuc Social Security nam-mber liouh:
Yienx cuotv bieqc deic-bung sou-gorn a’fai fangx-daan (dorh mingh yienx cuotv yi bung fangx
nzengc a’fai yi maengx sou-gorn) liouh:
Beiv taux gorngv meih biauz bieqc deic-bung mienh aengx caux maiv gaengh duqv social
security nam-mber a’fai maiv maaih sou-gorn daaih bun yie mbuo nor, meih corc se maaih
ze’buonczipv longc jiepv sih jauv-louc aengx caux maaih gu’nguaaz yiem sin nzie-weih gong.
Tov daaix luic douc waac mingh lorx buangh meih nyei zoux gong mienh mbuox tong fienx bun
yie mbuo hiuv gorngv meih maaih haaix diuc tiuv yienc siang taux meih bieqc deic-bung/bengx
guoqv zangc baeqc fingz jauv-louc a’fai beiv taux meih maiv gaengh duqv zipv social security
nam-mber a’fai bieqc deic-bung sou-gorn,liuz yie mbuo cingx haih tengx paan pei mangc duqv
nzoih oc.
MC 355 MIE (Rev.07/18)
Zinh ndaangc lunx wuov zuqc wuix jiex
Yienx cuotv haaic diuc sou-gorn liouh: hinc buatc gorngv meih
duqv yiem njiec ninh mbuo wuix nyanc hopv dorngx dungh buangv 18 hnyangx wuov. Yie mbuo
tov naaic lorx naaiv diuc waac-fienx se wueic laaix yie mbuo lorx liuz maiv buatc maaih sou-gorn daaih
zaah ndorqc mangc gorngv meih duqv bieqc yiem jiex wuix goux nyei dorngx dauh dungh maaih
hnyangx-jeiv buangv 18 hnyangx a’fai gauh goz.
Yie mbuo duqv zaah lorx mangc nyei waac-fienx buatc gorngv:
Deic zepv dorngx yiem
Sou-gorn zaah cing ih zanc meih yiem nyei deic zepv dorngx dauh (cuotv biauv-jaaz,
wuom-douz jaaz, da’diuc jaaz.)
Ga’ganh lengc jeiv a’fai zinh zoih jaa-dorngx
Yienx cuotv yietc zungv cie-sou fai sou-gorn
(beiv taux meih maaih cie gauh camv jiex yietc
pouz) liouh:
Yienx cuotv meih nyei nyaanh lamz siang-sou-daan
(nyaanh qekv, siou nyaanh sou-daan gorn.)
liouh:
Yienx cuotv beu weih maengc doh leiz sou-daan
, zoux huoz-muotc saeng-eiz, nyaanh, mienh
goz nyaanh sou-daan liouh:
Sou-gorn gorngv taux maaih da’nyeic diuc zinh zoih jaa-dorngx yiem njiec a’fai nzuqc maengx
ziqc meiv guoc deic-bung (United States) (ganh norm biauv maiv zeix yiem wuov norm,
ndau-deic, da’nyeic diuc)
liouh:
Sou-gorn zaah cing gorngv meih duqv maaic cuotv
, zoux saeng-eiz a’fai dorh zinh zoih
jaa-dorngx fungx mienh a’fai guon sou-gorn mi’aqc liouh bun:
Wuaaic fangx/Zoux gong mv duqv
Dorh naaiv
Social security zoux sou-fienx bun wuaaic fangx mienh liouh bun:
Da’nyeic diuc sou-gorn zaah mangc gorngv meih beih zangc wuaaic fangx
, benx corngh zingh
baengc, a’fai benx hnyouv huaang baengc oix zuqc tor ziangh hoc zorc lauh taux 12 hlaax
nyieqc a’fai tor ziangh hoc gauh ndaauv liouh bun:
Beiv taux meih hnamv haix ga’ganh a’fai huov jaa hmuangv-doic haaix dauh mienh zipv longc
Medi-Cal tengx liuz zoux zuqc wuaaic nzengc mi’aqc nor tov daaix luic oix zuqc gaanv lorx
buangh taux meih nyei zoux gong dengv sic dauh mienh oc.
Da’nyeic diuc waac-fienx yie mbuo qiemx longc
:
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NAAIV MEDI-CAL TOV LORX LONGC WAAC-FIENX (MEDI-CAL REQUEST (Department of Health Care Services)

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Completed 30 July 2020

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