Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Tagalog) Page 6

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State of California—Health and Human Services Agency
Department of Health Care Services
BAHAGI 5—MEDIKAL NA IMPORMASYON
County Use Only
A. Ang bata ba ay nadala sa klinika o ospital para sa anumang sakit, pinsala o medikal na kundisyon sa nakaraang
12 buwan?
Oo
Kung Hindi, pumunta sa Bahagi 6. Kung Oo, mangyari lamang sagutin nang ganap ang sumusunod:
Hindi
1. Pangalan ng Ospital/Klinika
Mga Petsa
Uri ng (mga) Pagbisita
Petsa ng
Petsa ng
Pamamalagi ng Inpatient
pagdating
pag-alis
(nanatili ng kahit man lamang
magdamagan)
Pagbisita ng Outpatient
(pinauwi sa araw na iyon mismo)
Pagbisita sa Emergency Room
(MC 220) signed
Address (numero, kalye)
Lungsod
Estado
Zip Code
Numero ng Telepono
Numero ng File sa Ospital/Klinika
Mga Dahilan sa Pagbisita
Anong paggagamot ang nakuha ng bata?
Anong (mga) uri ng doktor karaniwang nagpatingin ang bata sa ospital na ito?
2. Pangalan ng Ospital/Klinika
Mga Petsa
Uri ng (mga) Pagbisita
(MC 220) signed
Petsa ng pag-alis
Petsa ng pagdating
Pamamalagi ng Inpatient
(nanatili ng kahit man lamang
magdamagan)
Pagbisita ng Outpatient
(pinauwi sa araw na iyon mismo)
Pagbisita sa Emergency Room
Address (numero, kalye)
Lungsod
Estado
Zip Code
Numero ng Telepono
Numero ng File sa Ospital/Klinika
Mga Dahilan sa Pagbisita
Anong paggagamot ang nakuha ng bata?
Anong (mga) uri ng doktor karaniwang nagpatingin ang bata sa ospital na ito?
Pahina 6 ng 9
MC 223C_TAG_0611

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