Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Armenian) Page 5

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State of California—Health and Human Services Agency
Department of Health Care Services
G. Ò»½ Ùáï ϳ± »ñ»Ë³ÛÇ §Individualized Education Plan¦-Ç (IEP` ³ÛÝ Ñ³ßí»ïíáõÃÛáõÝÁ, áñÇ Ù»ç
County Use Only
áõëáõóÇãÁ ÝßáõÙ ¿ »ñ»Ë³ÛÇ ËݹÇñÝ»ñÁ ¨ ¹ñ³Ýù ϳñ·³íáñ»Éáõ ù³ÛÉ»ñÁ) ûñÇݳÏÁ:
²Ûá
(MC 220) signed
ºÃ» §²Ûá¦, ËݹñáõÙ »Ýù Ïó»É ûñÇݳÏÁ:
àã
H. ºñ»Ë³Ý ѳïáõÏ ËáñÑñ¹³ïíáõÃÛáõÝ Ï³Ù ¹³ë³í³Ý¹áõÙ ëïáÝáõ±Ù ¿:
²Ûá
ºÃ» §²Ûá¦, ËݹñáõÙ »Ýù Éñ³óÝ»É Ñ»ï¨Û³ÉÁ (»Ã» ï»ÕÁ ãµ³í³Ï³Ý³óÝÇ, ϳñáÕ »ù Éñ³óáõóÇã ¿ç»ñ Ïó»É).
àã
ÊáñÑñ¹³ïíáõÃÛáõÝÁ ϳ٠¹³ë³í³Ý¹áõÙÁ ¹åñáóáõ±Ù ïñ³Ù³¹ñíáõÙ ¿£
²Ûá
àã
ÊáñÑñ¹³ïíáõÃÛáõÝÁ ϳ٠¹³ë³í³Ý¹áõÙÁ ¹åñáóÇó ¹áõ±ñë ¿ ïñ³Ù³¹ñíáõÙ:
²Ûá
àã
ºÃ» §²Ûá¦, ËݹñáõÙ »Ýù Éñ³óÝ»É Ñ»ï¨Û³ÉÁ.
ÊáñÑñ¹³ïáõÇ Ï³Ù ¹³ë³í³Ý¹áÕÇ ³ÝáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
öáÕáóÇ Ñ³ëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
²Ûó»ÉáõÃÛáõÝÝ»ñÇ
´áõÅáõÙÁ ëÏë»Éáõ ³Ùë³ÃÇíÁ
´áõÅáõÙÝ ³í³ñï»Éáõ ³Ùë³ÃÇíÁ (»Ã»
ѳ׳˳ϳÝáõÃÛáõÝÁ
³í³ñïí»É ¿)
I.
ºñ»Ë³Ý Çñ ÑÇí³Ý¹áõÃÛáõÝÝ»ñÇ Ï³Ù íݳëí³ÍùÝ»ñÇ Ñ³Ù³ñ ѳïáõÏ µáõÅáõÙ (ýǽÇϳϳÝ, ËáëùÇ ¨ É»½íÇ,
³ß˳ﳵáõÅáõÃÛáõÝ) ϳ٠³ÛÉ Í³é³ÛáõÃÛáõÝÝ»ñ ëï³ó»±É ϳ٠ëï³Ýáõ±Ù ¿: ²Ûëï»Õ Ýß»ù ³ÛÝ µáõÅáõÙÝ»ñÁ,
áñáÝù »ñ»Ë³Ý ëï³ÝáõÙ ¿ ÍÝáÕÇó, ËݳٳϳÉÇó, ËݳÙáÕÇó ϳ٠¹åñáóáõÙ ·ïÝí³Í ųٳݳÏ:
²Ûá
ºÃ» §²Ûá¦, ËݹñáõÙ »Ýù Éñ³óÝ»É Ñ»ï¨Û³ÉÁ µáõÅÙ³Ý Ù³ëÇÝ.
àã
1. ´áõÅáÕ µÅßÏÇ ³ÝáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
öáÕáóÇ Ñ³ëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
(MC 220) signed
´áõÅáõÙÁ Ý߳ݳÏáÕÁ/ϳ½ÙáÕÁ
´áõÅÙ³Ý ï»ë³ÏÁ
²Ûó»ÉáõÃÛáõÝÝ»ñÇ
´áõÅáõÙÁ ëÏë»Éáõ ³Ùë³ÃÇíÁ
´áõÅáõÙÝ ³í³ñï»Éáõ ³Ùë³ÃÇíÁ (»Ã»
ѳ׳˳ϳÝáõÃÛáõÝÁ
³í³ñïí»É ¿)
2. ´áõÅáÕ µÅßÏÇ ³ÝáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
öáÕáóÇ Ñ³ëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
(MC 220) signed
´áõÅáõÙÁ Ý߳ݳÏáÕÁ/ϳ½ÙáÕÁ
´áõÅÙ³Ý ï»ë³ÏÁ
²Ûó»ÉáõÃÛáõÝÝ»ñÇ
´áõÅáõÙÁ ëÏë»Éáõ ³Ùë³ÃÇíÁ
´áõÅáõÙÝ ³í³ñï»Éáõ ³Ùë³ÃÇíÁ (»Ã»
ѳ׳˳ϳÝáõÃÛáõÝÁ
³í³ñïí»É ¿)
MC 223C_ARM_0611
¾ç 5` 9 ¿çÇó

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