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

Form MC604 MDV HMO is a California Department of Health Care Services form also known as the "Doctor's Verification For Home And Community Based Services Under Spousal Impoverishment Provisions". The latest edition of the form was released in August 1, 2017 and is available for digital filing.

Download an up-to-date Form MC604 MDV HMO in PDF-format down below or look it up on the California Department of Health Care Services Forms website.

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

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(COUNTY LETTERHEAD)
Hnub:
TUS NEEG MOB COV NTAUB NTAWV (Lub Zos Yuav Tsum Sau Tshooj No Kom Tiav)
TUS NEEG MOB LUB NPE:
TUS NEEG MOB HNUG YUG:
CLIENT INDEX NUMBER (CIN):
Nyob Zoo Dr.
Thov sau rau hauv qab no kom tiav muab nws xa rov qab mus rau lub zos kom txog
ntsig txog
tus neeg mob muaj npe saum toj saud yog li ntawd peb thiaj tuaj yeem txiav txim txog nws qhov muaj cai tau txais kev
pab rau ntawm Medi-Cal. Thov siv lub hnab ntawv uas twb them tus nqi xa ntawv no xa rov qab mus. Tej zaum koj yuav
muab cov ntaub ntawv no fej hauv xov tooj mus lossis muab xa hauv email raws li qhov chaw nyob hauv qab no. Koj tus
neeg mob twb tso cai cia muab cov ntaub ntawv no tshaj tawm rau peb lawm. Thov saib daim ntawv tso cai ntawm tus
neeg mob uas muab tso nrog ua ke tuaj nov.
Tus Neeg Ua Haujlwm Hauv Lub Zos Kos Npe:
Hnub:
Tus Neeg Ua Haujlwm Hauv Lub Zos Lub Npe:
Nab Npawb Xovtooj:
Nab Npawb Fej Ntawv:
Tus Neeg Ua Haujlwm Hauv Lub Zos Tus Email:
Tus Kws Kho mob Daim Ntawv Ua Pov Thawj txog Qhov Kev Saib Xyuas Rau Hauv Tsev thiab Hauv Lub Zos Raws Li Cov
Cai Ntawm Tus Txij Nkawm Tsis Muaj Nyiaj Txaus Them
(Doctor’s Verification for Home and Community Based Services Under Spousal Impoverishment Provisions)
TUS KWS KHO MOB COV NTAUB NTAWV
TUS KWS KHO MOB LUB NPE:
HNUB:
XOV TOOJ:
EMAIL:
Saib raws li kuv qhov tshuaj ntsuam xyuas, kuv tus neeg mob,
, zoo li yuav tsum
raug saib xyuas rau hauv lub tsev tu neeg mob yam tsawg kawg yog 30 hnub ua ke, tshwj tsis yog nws raug saib xyuas
hauv tsev thiab raug pab txhawb kom nws nyob tau nyab xeeb rau hauv tsev. Thaum xub thawj kuv tus neeg mob yeej
xav kom raug saib xyuas rau hauv lub tsev tu neeg mob rau ntawm
, thiab nws yeej tseem xav
tau kev saib xyuas mus ntxiv suav txij hnub ntawd los txog tam sim no.
Kuv lees raws li cov kev cai lij choj ntawm Teb Chaw Meskas thiab Lub Xeev California tias cov ntaub ntawv sau tseg rau
hauv Tus Kws Kho mob Daim Ntawv Pov Thawj no yeej muaj tseeb thiab raug lawm.
TUS KWS KHO MOB KOS NPE:
MC 604 MDV HMO (08/17)
(COUNTY LETTERHEAD)
Hnub:
TUS NEEG MOB COV NTAUB NTAWV (Lub Zos Yuav Tsum Sau Tshooj No Kom Tiav)
TUS NEEG MOB LUB NPE:
TUS NEEG MOB HNUG YUG:
CLIENT INDEX NUMBER (CIN):
Nyob Zoo Dr.
Thov sau rau hauv qab no kom tiav muab nws xa rov qab mus rau lub zos kom txog
ntsig txog
tus neeg mob muaj npe saum toj saud yog li ntawd peb thiaj tuaj yeem txiav txim txog nws qhov muaj cai tau txais kev
pab rau ntawm Medi-Cal. Thov siv lub hnab ntawv uas twb them tus nqi xa ntawv no xa rov qab mus. Tej zaum koj yuav
muab cov ntaub ntawv no fej hauv xov tooj mus lossis muab xa hauv email raws li qhov chaw nyob hauv qab no. Koj tus
neeg mob twb tso cai cia muab cov ntaub ntawv no tshaj tawm rau peb lawm. Thov saib daim ntawv tso cai ntawm tus
neeg mob uas muab tso nrog ua ke tuaj nov.
Tus Neeg Ua Haujlwm Hauv Lub Zos Kos Npe:
Hnub:
Tus Neeg Ua Haujlwm Hauv Lub Zos Lub Npe:
Nab Npawb Xovtooj:
Nab Npawb Fej Ntawv:
Tus Neeg Ua Haujlwm Hauv Lub Zos Tus Email:
Tus Kws Kho mob Daim Ntawv Ua Pov Thawj txog Qhov Kev Saib Xyuas Rau Hauv Tsev thiab Hauv Lub Zos Raws Li Cov
Cai Ntawm Tus Txij Nkawm Tsis Muaj Nyiaj Txaus Them
(Doctor’s Verification for Home and Community Based Services Under Spousal Impoverishment Provisions)
TUS KWS KHO MOB COV NTAUB NTAWV
TUS KWS KHO MOB LUB NPE:
HNUB:
XOV TOOJ:
EMAIL:
Saib raws li kuv qhov tshuaj ntsuam xyuas, kuv tus neeg mob,
, zoo li yuav tsum
raug saib xyuas rau hauv lub tsev tu neeg mob yam tsawg kawg yog 30 hnub ua ke, tshwj tsis yog nws raug saib xyuas
hauv tsev thiab raug pab txhawb kom nws nyob tau nyab xeeb rau hauv tsev. Thaum xub thawj kuv tus neeg mob yeej
xav kom raug saib xyuas rau hauv lub tsev tu neeg mob rau ntawm
, thiab nws yeej tseem xav
tau kev saib xyuas mus ntxiv suav txij hnub ntawd los txog tam sim no.
Kuv lees raws li cov kev cai lij choj ntawm Teb Chaw Meskas thiab Lub Xeev California tias cov ntaub ntawv sau tseg rau
hauv Tus Kws Kho mob Daim Ntawv Pov Thawj no yeej muaj tseeb thiab raug lawm.
TUS KWS KHO MOB KOS NPE:
MC 604 MDV HMO (08/17)
(COUNTY LETTERHEAD)
Hnub:
Tus Neeg Mob Daim Ntawv Tso Cai
Kuv,
tso cai rau tus kws kho mob
muab cov ntaub ntawv kho mob nyob ntawm daim ntawv foos no tshaj tawm rau Lub Zos
txhawm rau lub hom phiaj los npaj saib xyuas kuv qhov muaj cai tau txais kev pab rau ntawm Medi-Cal.
Kuv tso cai cia muab kuv tus kheej ntiag tug cov ntaub ntawv kev noj qab haus huv siv lossis tshaj tawm rau lub
hom phiaj uas tau sau tseg rau saum toj saud.
Kuv muaj cai thim tau kuv daim ntawv tso cai muab kuv cov ntaub ntawv tshaj tawm. Yog kuv kos npe rau daim
ntawv tso cai pom zoo cia muab cov ntaub ntawv siv lossis tshaj tawm, kuv tuaj yeem thim daim ntawv tso cai
no tau txhua lub sijhawm. Yuav tsum sau ntawv mus thim thiab yuav tsis cuam tshuam txog cov ntaub ntawv uas
twb yeej muab siv lossis tshaj tawm ua ntej lawm.
Kuv muaj cai tau txais ib daim ntawv theej ntawm daim ntawv tso cai no.
Kev kos npe rau daim ntawv tso cai no tsuas yog kev yeem dawb xwb thiab kev kho mob, kev them nqi, lossis siv
rau kuv qhov muaj cai tau txais cov txiaj ntsig, tej zaum kuv yuav tsis muaj cai tau txais kev pab yog kuv tsis kos
npe rau daim ntawv tso cai no.
Kuv kuj nkag siab tias ib tug neeg uas teev tseg cov ntaub ntawv thiab muab tshaj tawm yuav tsum ua raws li
daim ntawv tso cai no, tsis pub muab cov ntaub ntawv kho mob siv lossis tshaj tawm ntxiv, tshwj tsis kuv tau tso
cai ntxiv lossis tshwj tsis yog lwm txoj cai lij choj pub muab siv lossis tshaj tawm tau.
KOS NPE:
HNUB:
Yog tus neeg mob tsis kos npe leej twg thiaj yuav yog tus los tshaj tawm, qhia tus neeg raug tso cai los kos npe:
£ Niam Txiv ntawm Tus Menyuam
£ Tus Neeg Saib Xyuas Menyuam
£ Tus Txij Nkawm
£ Tus Neeg Sawv Cev Raug Cai
Piav qhia txog qhov kev txheeb ze rau tus neeg mob thiab yog vim li cas tus neeg mob thiaj li tsis tuaj yeem kos npe tau:
TUS NEEG UA POV THAWJ: Kuv paub tus neeg kos npe rau daim ntawv no lossis kuv pom zoo rau tus neeg no:
(Yuav tsum kos “X”, qauv tes, lossis kos npe)
Tus neeg ua pov thawj kos npe:
Hnub:
Chaw Nyob:
Nroog/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 HMO (08/17)
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