Form MC604 MDV MIE "Doctor's Verification for Home and Community Based Services Under Spousal Impoverishment Provisions" - California (Mien)

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California.

The document is provided in Mien. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form MC604 MDV MIE by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form MC604 MDV MIE "Doctor's Verification for Home and Community Based Services Under Spousal Impoverishment Provisions" - California (Mien)

Download PDF

Fill PDF online

Rate (4.8 / 5) 78 votes
(COUNTY LETTERHEAD)
Hnoi:
BUTV BAEGC MIENH NYEI WAAC-FIENX (Bun kaauv div fiev ziangx naaiv kang nzangc)
BUTV-BAENGC MIENH
BUTV-BAENGC MIENH
NYEI MBUOZ:
NYEI CUOTV-SEIX HNOI:
CLIENT INDEX NUMBER (CIN):
Hnamv camv domh ndie-sai
Oix zuqc tov heuc tengx fiev ziangx liuz aengx caux fungx naaiv zeiv waac-fienx fiev yiem njiec ga’ndiev uov fungx
daaux nqaang nzuonx mingh bun taux ninh mbuo kaau div naaiv
gorngv taux meih nyei
butv-baengc mienh fiev mbuoz yiem gu’nguaaic uov liuz yie mbuo cingx daaih haih tengx zaah paaiv mangc ninh
nyei puix-zipv liouh tengx Medi-Cal. Oix zuqc dapv fienx mbuoqc fungx gan zipv fienx dorngx daaih. Meih se fungx
nzuonx gan fax a’fai email mbiuv yiem ga’ndiev uov yaac duqv. Meih nyei baengc mienh yaac buatc longx bungz
cuotv naaiv deix waac-fienx daaih bun yie mbuo duqv hiuv. Doqc mangc fungx daaih ninh mbuo baengc mienh buatc
longx nyei sou-gorn.
Kaau div zoux gong mienh mbuoz-liuc:
Hnoi:
Kaau div zoux gong mienh mbuoz:
Fonh nam mber:
Fax nam mber:
Kaau div gong mienh Email:
Domh ndie-sai zaah mangc liouh tengx goux mangc yiem biauv aengx caux domh zuangx dorngx
bun auv-nqoz doic tengx goux mangc kaauv haic
(Doctor’s Verification for Home and Community Based Services Under Spousal Impoverishment Provisions)
DOMH NDIE-SAI DOUC NYEI WAAC-FIENX
DOMH NDIE-SAI MBUOZ
HNOI:
NZANGC-WUONH:
FONH:
EMAIL:
Ei gan yie nyei zaah dimv mangc liuz buatc yie nyei baengc mienh,
, oix zuqc
qiemx longc tengx fioux goux mangc nyei jaa-sic mv gauv zoqc jiex 30 hnoi nyei ziangh hoc zuov taux ninh duqv
zipv longc tengx goux mangc yiem biauv aengx caux zipv tengx goux dongh oix zuqc bun ninh yiem njiec kuv-yiem
dingh torqv dorngx dauh. Yie nyei baengc mienh nor oix zuqc jiex gorn qiemx zuqc longc naaiv deix tengx fioux
goux mangc nyei jaa-sic yiem naaiv norm
, aengx caux nzipc jienv longc naaiv deix gong-
bou zuov taux buangv hnoi-nyieqc.
Yie laengx bun njiec zuiz gan naaiv meiv guoqv deic bung doh leiz aengx caux naaiv California saengv zangc se
gorngv yie gorngv waac jaav gu’baeqc nduov gorngv taux naaiv deix waac-fienx fiev njiec daaih se benx ninh mbuo
domh ndie-sai paaiv daaih nyei waac nor zien maaih aengx caux zuqc nzengc.
DOMH NDIE-SAI NJIEC MBUOZ-LIUC:
MC 604 MDV MIE (08/17)
(COUNTY LETTERHEAD)
Hnoi:
BUTV BAEGC MIENH NYEI WAAC-FIENX (Bun kaauv div fiev ziangx naaiv kang nzangc)
BUTV-BAENGC MIENH
BUTV-BAENGC MIENH
NYEI MBUOZ:
NYEI CUOTV-SEIX HNOI:
CLIENT INDEX NUMBER (CIN):
Hnamv camv domh ndie-sai
Oix zuqc tov heuc tengx fiev ziangx liuz aengx caux fungx naaiv zeiv waac-fienx fiev yiem njiec ga’ndiev uov fungx
daaux nqaang nzuonx mingh bun taux ninh mbuo kaau div naaiv
gorngv taux meih nyei
butv-baengc mienh fiev mbuoz yiem gu’nguaaic uov liuz yie mbuo cingx daaih haih tengx zaah paaiv mangc ninh
nyei puix-zipv liouh tengx Medi-Cal. Oix zuqc dapv fienx mbuoqc fungx gan zipv fienx dorngx daaih. Meih se fungx
nzuonx gan fax a’fai email mbiuv yiem ga’ndiev uov yaac duqv. Meih nyei baengc mienh yaac buatc longx bungz
cuotv naaiv deix waac-fienx daaih bun yie mbuo duqv hiuv. Doqc mangc fungx daaih ninh mbuo baengc mienh buatc
longx nyei sou-gorn.
Kaau div zoux gong mienh mbuoz-liuc:
Hnoi:
Kaau div zoux gong mienh mbuoz:
Fonh nam mber:
Fax nam mber:
Kaau div gong mienh Email:
Domh ndie-sai zaah mangc liouh tengx goux mangc yiem biauv aengx caux domh zuangx dorngx
bun auv-nqoz doic tengx goux mangc kaauv haic
(Doctor’s Verification for Home and Community Based Services Under Spousal Impoverishment Provisions)
DOMH NDIE-SAI DOUC NYEI WAAC-FIENX
DOMH NDIE-SAI MBUOZ
HNOI:
NZANGC-WUONH:
FONH:
EMAIL:
Ei gan yie nyei zaah dimv mangc liuz buatc yie nyei baengc mienh,
, oix zuqc
qiemx longc tengx fioux goux mangc nyei jaa-sic mv gauv zoqc jiex 30 hnoi nyei ziangh hoc zuov taux ninh duqv
zipv longc tengx goux mangc yiem biauv aengx caux zipv tengx goux dongh oix zuqc bun ninh yiem njiec kuv-yiem
dingh torqv dorngx dauh. Yie nyei baengc mienh nor oix zuqc jiex gorn qiemx zuqc longc naaiv deix tengx fioux
goux mangc nyei jaa-sic yiem naaiv norm
, aengx caux nzipc jienv longc naaiv deix gong-
bou zuov taux buangv hnoi-nyieqc.
Yie laengx bun njiec zuiz gan naaiv meiv guoqv deic bung doh leiz aengx caux naaiv California saengv zangc se
gorngv yie gorngv waac jaav gu’baeqc nduov gorngv taux naaiv deix waac-fienx fiev njiec daaih se benx ninh mbuo
domh ndie-sai paaiv daaih nyei waac nor zien maaih aengx caux zuqc nzengc.
DOMH NDIE-SAI NJIEC MBUOZ-LIUC:
MC 604 MDV MIE (08/17)
(COUNTY LETTERHEAD)
Hnoi:
Butv baengc mienh nyei buatc longc waac
Yie,
buatc longc bun domh ndie-sai
bungx cuotv zunh tong naaiv deix zorc baengc waac-fienx yiem njiec naaiv zeiv sou-form bun taux ninh mbuo
kaau div gorn zangc liouh funx benx fih mbenc bun yie duqv zipv longc tengx taux Medi-Cal.
Yie buatc longx bun longc a’fai bongx tong yaangh gorngv taux baengc zingh waac-fienx duqv paaiv njiec
ga’ganh nyei dimv mangc baengc zingh liouh funx yiem gu’nguaaic uov.
Yie maaih ze’buonc gaux torv siou nzuonx dongh yie buatc longx bun bungx cuotv naaiv deix waac-fienx uov. Se
gorngv yie duqv njiec mbuoz bun longc a’fai bun bungx tong yaangh cuotv naaiv deix waac-fienx nor, yie yaac
haih siou nzuonx haaix zanc yaac duqv. Zorqv siou nzuonx naaiv deix waa-fienx nor oix zuqc fiev sou-nzangc
fungx mingh aengx caux yaac mv maaih haaix diuc sic dauh ging-dongx taux waac-fienx dongh duqv longc liuz
a’fai bungx tong yaangh cuotv liuz uov.
Yie maaih ze’buonc zipv longc ienx cuotv nyei sou-daan gorngv taux naaiv deix buatc longx nyei waac dauh.
Yie njiec mbuoz yiem naaiv zeiv sou-gorn se longx hnyouv cuotv daaih aengx caux zorc baengc zingh, cuotv
nyaanh a’fai yie maaih ze’buonc zipv longc nyei fu’loqc nyaanh se yiem njiec naaiv norm gong-bou gorn se
buangv hnyouv cuotv daaih.
Yie bieqc hnyouv camv faaux gorngv haaix dauh mienh faaux sou-nzangc aengx caux bungx waa-fiengx tong
yaangh cuotv zuangx uov yaac mv haih aapv heuc buatc longx bun bungx naiav deix waac yaac mv haih longc
mingh a’fai bungx tong yaangh gorngv zorc baengc waac-fienx se gorngv mv zuov taux zorqv waac-fienx yiem
yie fai ninh bungx cuotv ei gan doh leiz paaiv njiec nyei buonc hnangv.
NJIEC MBUOZ:
HNOI:
Se gorngv baengc mienh haaix dauh dongh benx naaiv zeiv bungx tong waac-fienx ziouv mv duqv njiec mbuoz nor,
fiev paaiv-mengh waac njiec mbuoz nyei gorn zangc:
£ Dae maa
£ Goux mangc mienh
£ Auv-nqoz doic
£ Div gong-gorn zangc
Porv mengh caux baengc mienh hnangv haaix nor cien aengx caux porv cing gorngv wueic laaix haaix diuc ninh
mbuo baengc mienh mb haih njiec mbuoz duqv:
YIEM HLEM MIENH: Yie hiuv duqv naaiv dauh mienh njiec mbuo yiem naiav zeiv sou-form a’fai yiem longx hnyouv
naaiv dauh mienh nyei waac-fienx: (se gorngv njiec mbuoz benx “X”, maaih puix-zipv gaux a’fai mv dapv waac-fienx
nyei waac-nyiouz)
Yiem hlen mienh mbuoz:
Hnoi:
Dorngx yiem njiec cie-jauv:
Mungv/Zip Code:
This general and special authorization to disclose information has been developed to comply with the provisions regarding
disclosure of medical and other information under: The Health Insurance Portability and Accountability Act, Section 262(a), 42
U.S.C, Section 1320d-1320d-8 (45 CFR Part 164); 42 U.S.C., Section 290dd-2 (42 CFR Part 2); 38 U.S.C., Section 7332; 20 U.S.C.,
Section 1232g (34 CFR Parts 99 and 300); and state law, including Civil Code, Section 56.10(b), Welfare and Institutions Code,
Section 10850 and 14100.2 and Civil Code, Sections 1798-1798.78.
MC 604 MDV MIE (08/17)
Page of 2