Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Tagalog) Page 8

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State of California—Health and Human Services Agency
Department of Health Care Services
BAHAGI 7—MGA PAGSUSURI
County Use Only
Ang bata ba ay sumailalim, o sasailalim, sa anumang mga medikal na pagsusuri para sa sakit, pinsala, o medikal
na kundisyon?
(MC 220) signed
Oo
Kung Oo, ipagbigay-alam sa amin ang sumusunod:
Hindi
Kailan isinagawa/isasagawa
Saan isinagawa/isasagawa
Sino ang nagpadala sa bata
Uri ng Pagsusuri
ang pagsusuri?
ang pagsusuri?
para sa pagsusuri na ito?
(buwan,taon)
(pangalan ng pasilidad)
EKG
(Pagsusuri sa Puso)
Treadmill
(Pagsusuri sa pamamagitan
ng Ehersisyo)
Cardiac
Catheterization
Biopsy
(Name of Body Part)
Speech/Language
Hearing Test
Vision Test
IQ Test
EEG
(Pagsusuri sa Brain Wave)
HIV Test
Blood Test
(Not HIV)
Breathing Test
X-Ray
(Name of Body Part)
MRI/CAT Scan
(Name of Body Part)
Kung ang bata ay sumailalim sa iba pang mga pagsusuri, ilista ang mga ito sa Bahagi 9—Mga Puna
BAHAGI 8—KASAYSAYAN NG TRABAHO
(MC 220) signed
Ang bata ba ay nagtrabaho kahit minsan?
Oo
Kung Oo, kumpletuhin ang sumusunod:
Hindi
Mga Petsa na Nagtrabaho
Pangalan ng Employer
Address (numero, kalye)
Lungsod
Estado
Zip Code
Numero ng Telepono
Pangalan ng Supervisor
Pahina 8 ng 9
MC 223C_TAG_0611

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