Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Tagalog) Page 7

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State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
Kung kailangan mo ng dagdag na espasyo na pagsusulatan, mangyari lamang gamitin ang Bahagi 9—
Mga Puna (pahina 9). Mangyari lamang tandaan na pirmahan ang Awtorisasyon ng Pagpapalabas ng
Impormasyon (MC 220) para sa (mga) ospital/(mga) klinika na iyong inilista sa pahina 6.
B. Ang bata ba ay natingnan sa loob ng nakaraang 12 buwan ng anumang doktor/therapist, na di nakalista sa
Seksyon A?
(MC 220) signed
1. Pangalan ng Doktor o Therapist
Numero ng Telepono
Address (numero, kalye)
Lungsod
Estado
Zip Code
Petsa ng Unang Pagbisita
Petsa ng Huling Pagbisita
Petsa ng Susunod na Appointment
(Mga) Dahilan sa Pagbisita
Anong paggagamot ang nakuha ng bata?
(MC 220) signed
2. Pangalan ng Doktor o Therapist
Numero ng Telepono
Address (numero, kalye)
Lungsod
Estado
Zip Code
Petsa ng Unang Pagbisita
Petsa ng Huling Pagbisita
Petsa ng Susunod na Appointment
(Mga) Dahilan sa Pagbisita
Anong paggagamot ang nakuha ng bata?
BAHAGI 6—MGA MEDIKASYON
County Use Only
Ang bata ba ay kasalukuyang umiinom/kumukuha ng anumang nireresetang gamot para sa sakit, pinsala, o
medikal na kundisyon?
Oo
Kung Oo, ipagbigay-alam sa amin ang sumusunod:
Hindi
Nireresetang Gamot
Pangalan ng Doktor
Mga Dahilan sa Medikasyon
Side Effects, kung mayroon man
Kung ang bata ay may mga karagdagang nireresetang gamot, ilista ang mga ito sa Bahagi 9—Mga Puna
MC 223C_TAG_0611
Pahina 7 ng 9

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