Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Tagalog) Page 4

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State of California—Health and Human Services Agency
Department of Health Care Services
2. Pangalan ng Ahensya
Numero ng Telepono ng Ahensya
County Use Only
(MC 220) signed
Address (numero, kalye)
Lungsod
Estado
Zip Code
Pangalan ng Counselor, Caseworker (namamahala sa kaso), Therapist, atbp.
Numero ng Telepono
Uri ng pagsusuri o pagtatasa, kung mayroon man (halimbawa, paningin, pandinig, pananalita, pisikal, sikolohikal)
Petsa ng Pagsusuri o Pagtatasa
Numero ng ID o Numero ng Claim ng Bata
C. Ang bata ba ay dumadalo/dumalo sa anumang uri ng preschool, day care, at/o programa pagkatapos ng pasukan sa
paaralan (after school)?
Oo
Kung Oo, mangyari lamang na kumpletuhin ang sumusunod na impormasyon:
(MC 220) signed
Hindi
Pangalan ng Programa
Numero ng Telepono
Address (numero, kalye)
Lungsod
Estado
Zip Code
Makipag-Ugnayan Kay
Mga Petsa na Dumalo
D. Ang bata ba ay pumapasok/pumasok sa paaralan?
Kung Oo, mangyari lamang na kumpletuhin ang sumusunod na impormasyon:
Oo
Kung Hindi, lumaktaw sa Seksyon H
Hindi
1. Pangalan ng Paaralan
Numero ng Telepono
(MC 220) signed
Address (numero, kalye)
Lungsod
Estado
Zip Code
Pangalan ng Guro
2. Pangalan ng Paaralan
Numero ng Telepono
(MC 220) signed
Address (numero, kalye)
Lungsod
Estado
Zip Code
Pangalan ng Guro
E. Ang paaralan ba ay maaaring magsagawa ng mga espesyal na tulong para sa bata (halimbawa:
mga angkop na muwebles, mga rampa para sa wheelchair, karagdagang tulong, o pansin)?
Oo
Kung Oo, anong uri ng tulong?
Hindi
F. Ang bata ba ay nasa programa ng espesyal na edukasyon?
Oo
Kung Oo, anong uri ng programa ng espesyal na edukasyon?
Hindi
MC 223C_TAG_0611
Pahina 4 ng 9

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