Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Tagalog) Page 2

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State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
KARAGDAGANG PAHAYAG NG MGA KATOTOHANAN
PARA SA LAMANG SA BATANG APLIKANTE NG
County Number
Aid Code
Case Number
MEDI-CAL — MGA TAGUBILIN PARA SA MAS
BATA SA EDAD NA 18
BAHAGI 1—PERSONAL NA IMPORMASYON
A. Pangalan ng Bata (pangalan, gitnang pangalan, apelyido)
B. Social Security na Numero
C. Petsa ng Kapanganakan
F. Timbang sa Libra
D. Kasarian
E. Taas
  
Piye__________ Pulgada__________
Lalaki
Babae
G. Sino ang kasama ng bata sa bahay?
Pangalan
Kaugnayan
Numero ng Telepono
Walang
Telepono
Address ng Tirahan (numero, kalye)
Lungsod
Estado
Zip Code
H. Address Pang-koreo (kung iba mula sa Address ng tirahan)
Estado
Zip Code
Address (numero, kalye)
Lungsod
I. Tao na nag-a-apply para sa bata
Pangalan
Kaugnayan
Numero ng Telepono
Walang
Telepono
Numero ng Teleponong Mapag-iiwan ng Mensahe (Message Phone)
Tao na iiwanan ng mensahe
J. Anong wika/diyalekto ang pinakamainam sa pagsasalita at pagbabasa ng tao na nag-a-apply para sa bata?
BAHAGI 2—ANG MGA SAKIT, PINSALA, O MEDIKAL NA KUNDISYON NG BATA
County Use Only
Kailan ito nagsimula?
A. Ano ang mga sakit, pinsala, o medikal na kundisyon ng bata?
(buwan/taon)
Pahina 2 ng 9
MC 223C_TAG_0611

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