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

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State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
ºÃ» Ò»½ Éñ³óáõóÇã ï»Õ ¿ ѳñϳíáñ, ËݹñáõÙ »Ýù û·ï³·áñÍ»É 9-ñ¹` §ÜßáõÙÝ»ñ¦, µ³ÅÇÝÁ (¿ç 9): ÊݹñáõÙ
»Ýù ãÙáé³Ý³É 6-ñ¹ ¿çáõÙ Ò»ñ Ýß³Í ÑÇí³Ý¹³Ýáó(Ý»ñ)Ç/ÏÉÇÝÇϳ(Ý»ñ)Ç Ñ³Ù³ñ § î»Õ»ÏáõÃÛáõÝÝ»ñÇ
µ³ó³Ñ³ÛïÙ³Ý ³ñïáÝáõÃÛáõÝ ¦ (MC 220) ëïáñ³·ñ»É:
B. ì»ñçÇÝ 12 ³Ùëí³ ÁÝóóùáõÙ »ñ»Ë³Ý A µ³ÅÝáõÙ ãÝßí³Í áñ¨¿ µÅßÏÇ/Ù³ëݳ·»ïÇ ³Ûó»É»±É ¿:
(MC 220) signed
1. ´ÅßÏÇ Ï³Ù Ù³ëݳ·»ïÇ ³ÝáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
öáÕáóÇ Ñ³ëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
²é³çÇÝ ³Ûó»ÉáõÃÛ³Ý ³Ùë³ÃÇíÁ
ì»ñçÇÝ ³Ûó»ÉáõÃÛ³Ý ³Ùë³ÃÇíÁ
гçáñ¹ ųٳ¹ñáõÃÛ³Ý ³Ùë³ÃÇíÁ
²Ûó»ÉáõÃÛáõÝÝ»ñÇ å³ï׳é(Ý»ñ)Á
ƱÝã µáõÅáõÙ ¿ ëï³ó»É »ñ»Ë³Ý
(MC 220) signed
2. ´ÅßÏÇ Ï³Ù Ù³ëݳ·»ïÇ ³ÝáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
öáÕáóÇ Ñ³ëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ
Çݹ»ùëÁ
²é³çÇÝ ³Ûó»ÉáõÃÛ³Ý ³Ùë³ÃÇíÁ
ì»ñçÇÝ ³Ûó»ÉáõÃÛ³Ý ³Ùë³ÃÇíÁ
гçáñ¹ ųٳ¹ñáõÃÛ³Ý ³Ùë³ÃÇíÁ
²Ûó»ÉáõÃÛáõÝÝ»ñÇ å³ï׳é(Ý»ñ)Á
ƱÝã µáõÅáõÙ ¿ ëï³ó»É »ñ»Ë³Ý
Ø²Ê 6ª ¸ºÔºÐÀ
County Use Only
Ü»ñϳÛáõÙë »ñ»Ë³Ý Çñ ÑÇí³Ý¹áõÃÛáõÝÝ»ñÇ, íݳëí³ÍùÝ»ñÇ Ï³Ù ³éáÕç³Ï³Ý ËݹÇñÝ»ñÇ Ñ³Ù³ñ Çñ»Ý Ý߳ݳÏí³Í
áñ¨¿ ¹»Õ ÁݹáõÝáõ±Ù ¿:
²Ûá
ºÃ» §²Ûá¦, Ýß»ù Ñ»ï¨Û³ÉÁ.
àã
ÎáÕÙݳÏÇ ³½¹»óáõÃÛáõÝÝ»ñÁ,
Ü߳ݳÏí³Í ¹»ÕÁ
´ÅßÏÇ ³ÝáõÝÁ
¸»ÕÝ ÁݹáõÝ»Éáõ å³ï׳éÁ
»Ã» »Õ»É »Ý ϳ٠ϳÝ
ºÃ» »ñ»Ë³Ý Çñ»Ý Ý߳ݳÏí³Í ³ÛÉ ¹»Õ»ñ ¿É ¿ ÁݹáõÝáõÙ, Ãí»ù ¹ñ³Ýù 9-ñ¹` §ÜßáõÙÝ»ñ¦, µ³ÅÝáõÙ:
MC 223C_ARM_0611
¾ç 7` 9 ¿çÇó

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