Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Hmong)

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

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

Form Details:

  • Released on August 1, 2018;
  • The latest edition provided by the California Department of Managed Health Care;
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Download a printable version of Form DMHC20-224 by clicking the link below or browse more documents and templates provided by the California Department of Managed Health Care.

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Download Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Hmong)

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State of California
Health and Human Services Agency
Department of Managed Health Care
IMR APPLICATION/COMPLAINT FORM – Hmong Clarify
DMHC 20-224
New: 04/06 Rev: 08/18
DAIM NTAWV TSO NPE THOV KOM ROV XYUAS KEV KHO MOB UAS
NCAJ Nrab (IMR)/Daim Foos Tsis Txaus Siab
XOV XWM TSEEM CEEB
Koj tuaj yeem xa koj Daim Ntawv Tso Npe Thov IMR/Daim Foos Tsis Txaus Siab hauv oos lais
ntawm: www.HealthHelp.ca.gov
 QHOV UA PUB DAWB: Tej txheej txheem Kev Tsis Txaus Siab ntawm IMR/Tus Neeg Siv Kev
Pab Cuam yog ua pub dawb.
 QHOV UA SAI: IMRs ib txwm raug txiav txim tsis dhau li 45 hnub, lossis yog hais tias qhov kev
mob nkeeg maj ceev ces tsis dhau li 7 hnub.
 QHOV UA TIAV LAWM: Kwv yees li ntawm 60 feem pua ntawm cov neeg mob tau txais kev pab
cuam uas raug thov los ntawm IMR.
 THAUM KAWG: Cov phwj xwm npaj kho mob yuav tsum ua raws li kev txiav txim ntawm IMR
thiab muab kev pab cuam tam sid.
X
X
Q
T
T
N
M
OV
WM
HIA
XOG
US
EEG
OB
Lub Npe
Tsiaj Ntawv Cim Lub Npe Nrab
Lub Xeem
Pojniam lossis Txiv Neej:  Txiv Neej  Poj Niam
Tus Neeg Mob li Hnub Yug
(mm/dd/yyyy)
Lwm Yam
Leej Niam Leej Txi lossis Tus Neeg Saib Xyuas Lub Npe yog hais tias Sau rau Tus Menyuam Uas Tsis Tau
Puv Hnub Nyoog
Chaw Nyob Txoj Kev
Lub Nroog
Lub Xeev
Zauv Cim Xa Ntawv
Tus Xov Tooj Tseem Ceeb #
Tus Xov Tooj Thib Ob #
Chaw Nyob Email
Koj puas nyiam kom muab qhov kev sib txuas lus/sau ntawv sib teb xa mus rau tus email no?
Yiam
Tsis
Nyiam
Lub Npe Phiajxwm Npaj Kho Mob
Tus Neeg Mob li Naj Npawb Tub Koom Xeeb #
Lub Npe Pawg Neeg Kho Mob
(yog hais tias nyob hauv ib pawg neeg kho mob)
Tus Tswv Haujlwm
Page 1 of 4
#100HM
State of California
Health and Human Services Agency
Department of Managed Health Care
IMR APPLICATION/COMPLAINT FORM – Hmong Clarify
DMHC 20-224
New: 04/06 Rev: 08/18
DAIM NTAWV TSO NPE THOV KOM ROV XYUAS KEV KHO MOB UAS
NCAJ Nrab (IMR)/Daim Foos Tsis Txaus Siab
XOV XWM TSEEM CEEB
Koj tuaj yeem xa koj Daim Ntawv Tso Npe Thov IMR/Daim Foos Tsis Txaus Siab hauv oos lais
ntawm: www.HealthHelp.ca.gov
 QHOV UA PUB DAWB: Tej txheej txheem Kev Tsis Txaus Siab ntawm IMR/Tus Neeg Siv Kev
Pab Cuam yog ua pub dawb.
 QHOV UA SAI: IMRs ib txwm raug txiav txim tsis dhau li 45 hnub, lossis yog hais tias qhov kev
mob nkeeg maj ceev ces tsis dhau li 7 hnub.
 QHOV UA TIAV LAWM: Kwv yees li ntawm 60 feem pua ntawm cov neeg mob tau txais kev pab
cuam uas raug thov los ntawm IMR.
 THAUM KAWG: Cov phwj xwm npaj kho mob yuav tsum ua raws li kev txiav txim ntawm IMR
thiab muab kev pab cuam tam sid.
X
X
Q
T
T
N
M
OV
WM
HIA
XOG
US
EEG
OB
Lub Npe
Tsiaj Ntawv Cim Lub Npe Nrab
Lub Xeem
Pojniam lossis Txiv Neej:  Txiv Neej  Poj Niam
Tus Neeg Mob li Hnub Yug
(mm/dd/yyyy)
Lwm Yam
Leej Niam Leej Txi lossis Tus Neeg Saib Xyuas Lub Npe yog hais tias Sau rau Tus Menyuam Uas Tsis Tau
Puv Hnub Nyoog
Chaw Nyob Txoj Kev
Lub Nroog
Lub Xeev
Zauv Cim Xa Ntawv
Tus Xov Tooj Tseem Ceeb #
Tus Xov Tooj Thib Ob #
Chaw Nyob Email
Koj puas nyiam kom muab qhov kev sib txuas lus/sau ntawv sib teb xa mus rau tus email no?
Yiam
Tsis
Nyiam
Lub Npe Phiajxwm Npaj Kho Mob
Tus Neeg Mob li Naj Npawb Tub Koom Xeeb #
Lub Npe Pawg Neeg Kho Mob
(yog hais tias nyob hauv ib pawg neeg kho mob)
Tus Tswv Haujlwm
Page 1 of 4
#100HM
 Xav  Tsis Xav
Koj puas xav tau ib tug neeg twg los pab koj ua koj daim ntawv tsis txaus siab?
Yog hais tias xav, ces thov caw sau kom tiav “Daim Foos Tus Neeg
Pab Uas Raug Tso Cai Rau (Authorized Assistant Form).”
 Muaj  Tsis Muaj
Koj puas muaj Medi-Cal?
Yog hais tias muaj, es koj puas tau sau ib Daim Ntawv Thov txog Ib
 Sau Lawm  Tsis Tau Sau
Rooj Lus Kho Ob Tog Raws Kev Ncaj Ncees Qib Xeev dhau los?
Koj puas muaj Medicare lossis Tau Txiaj Ntsig Los Ntawm Medicare
 Muaj  Tsis Muaj
(Medicare Advantage)?
Koj puas tau sau ib daim ntawv tsis txaus siab lossis daim ntawv tsis zoo
 Sau Lawm  Tsis Tau Sau
siab txog koj li phiajxwm npaj kho mob dhau los?
Koj puas xav tau nyiaj them nqi rau ib qho kev pab cuam uas koj twb tau
 Yog  Tsis Yog
txais lawm?
Yog hais tias yog, ces sau hnub tim ntawm kev pab cuam, thiab
tus neeg muab kev pab cuam nkag:
(Sau rau lwm daim ntawv thiab tsuam lwm cov ntaub ntawv nrog, yog hais tias tsim
K
T
M
M
N
OJ LI
EEB
EEM
OB
KEEG
nyog.)
Koj puas xav kom koj lub chaw pab them nqi kho mob them rau cov nqi kev pab
Xav Tsis Xav
cuaam yav tom ntej?
Koj li zwj ceeb kho mob lossis koj tus kws kho mob qhia tias yog mob
dab tsi? (thov caw qhia kiag rau) _____________________________________________________________
(Cov) kev kho mob/(cov) kev pab cuam thiab/lossis (cov) tshuaj kho mob uas koj tab tom thov yog dab tsi?
(thov caw qhia kiag rau)
Koj li phiajxwm kho mob puas tau tsis kam muab, ncua qeeb lossis hloov koj
 Yog  Tsis Yog
qhov kev kho mob?
Yog hais tias yog, thov kos rau qhov laj thawj tau muab: (kos rau ib qho)
 Tsis Yog Kev Kho Mob Uas Tseem Ceeb
 Kev Sim lossis Kev Soj Xyuas
 Tsis Yog ib qho Mob Ceev/Maj
 Tsis Yog Qhov Kev Pab Uas Tau Txais Kev Pab
 Lwm Yam
Them
(thov caw piav qhia rau hauv qab no)
Sau lub npe thiab tus naj npawb xov tooj ntawm koj tus kws kho mob tseem ceeb thiab lwm cov neeg muab
kev saib xyuas mob tus uas tau mus ntsib, tau kho, lossis tau muab lus sab laj rau koj ntsig txog qhov zwj ceeb
no.
Koj puas tau mus ntsib ib tus neeg muab kev saib xyuas mob uas tsis koom
Page 2 of 4
#100HM
 Tau Mus  Tsis Tau Mus
nrog ntsig txog koj li zwj ceeb?
Yog hais tias tau mus, ces thov caw sau cov ntawv teev kho mob nkag rau daim foos no.
Piav luv luv txog tej teeb meem uas koj tab tom muaj hauv koj li phiajxwm kho mob. Piv txwv li, piav qhia seb
qhov teeb meem yog ib qho kev kho mob uas tsis lees paub, ib qho kev tsub nqi uas tsis tau them, muaj teeb
meem kev tau txais kev teem caij lossis kev kho mob lossis tsis yog, lossis seb koj li kev duav txog kev kho
mob raug tso tseg los ntawm lub phiajxwm kho mob.
KEV NTHUAV QHIA TXOG KEV KHO MOB
Kuv thov kom Lub Rooj Tsav Xwm Saib Xyuas Kev Saib Xyuas Fab Kev Mob Nkeeg Uas Raug Tswj Xyuas
(Lub Rooj Tsav Xwm) los txiav txim ntsig txog kuv qhov teeb meem nrog kuv li phiajxwm kho mob. Kuv thov
kom Lub Rooj Tsav Xwm los xyuas dua txog kuv Daim Ntawv Tso Npe Thov Kom Rov Xyuas Kev Kho Mob
Uas Ncaj Nrab (IMR)/Daim Foos Tsis Txaus Siab txhawm rau txiav txim seb kuv tej lus tsis txaus siab uas zoo
tsim nyog rau lossis tsis tsim nyog rau IMR lossis Lub Rooj Tsav Xwm tej txheej txheem ua haujlwm fab Lus
Tsis Txaus Siab. Kuv tso cai rau kuv cov neeg muab kev saib xyuas kho mob thiab kuv li phiajxwm kho mob
yav dhau los thiab niaj hnub no los nthuav qhia txog kuv cov ntawv teev kev kho mob thiab tej xov xwm
txhawm rau rov xyuas dua txog qhov teeb meem no. Cov ntawv teev tseg no kuj yuav xam muaj kev kho mob,
kev mob puas siab puas ntsws, kev siv tshuaj txhaum cai, mob HIV, cov ntawv tshaj qhia uas muaj duab tsom
qhia kab mob, thiab lwm cov ntaub ntawv teev tseg ntsig txog kuv li case. Cov ntaub ntawv teev tseg no tej
zaum kuj yuav xam muaj cov ntaub ntawv teev tseg uas tsis yog kev kho mob nrog thiab lwm yam xov xwm
uas ntsig txog kuv li case. Kuv tso cai rau Lub Rooj Tsav Xwm los xyuas dua txog cov ntaub ntawv teev tseg
no thiab tej xov xwm es xa nws mus rau kuv li phiajxwm. Kuv li kev tso cai yuav xaus thaum puv ib xyoos txij li
hnub sau tseg hauv qab no, tshwj yog hais tias raug tso cai los ntawm kev cai li choj. Piv txwv li tsab cai lij choj
yuav tso cai rau Lub Rooj Tsav Xwm siv kuv tej xov xwm kiag hauv Lub Rooj Tsav Xwm txuas mus ntxiv. Kuv
tuaj yeem xaus kuv li kev tso cai sai dua ntawd yog hais tias kuv xav ua. Tag nrho txhua tej xov xwm uas kuv
tau muab nyob rau daim ntawv no yog muaj tseeb tiag.
Tus Neeg Mob lossis Niam Txiv Lub Npe (Sau)_________________________________________________
Tus Neeg Mob lossis Niam Txiv Kos Npe )________________________________ Hnub Tim______________
Thov caw saib daim ntawv lus qhia hais txog xov xwm qhia txog kev xa ntawv lossis xa fax.
HAIS TXOG XOV XWM TEEV SUAV (STATISTICAL)
Koj raug hais kom muab tej xov xwm nram qab no yam txaus siab hlo. Kev muab tej xov xwm no yuav pab rau
Lub Rooj Tsav Xwm taw qhia txog ib tug qauv ntawm cov teeb meem. Tsab Cai Kev Noj Qab Nyob Zoo thiab
Kev Nyab Xeeb tshooj 1374.30 yuav tso cai rau Lub Rooj Tsav Xwm los muaj tej xov xwm no txhawm rau lub
hom phiaj tshawb nrhiav thiab teev suav (statistical). Kev muab tej xov xwm no yog ua lossis tsis ua los tau
thiab yuav tsis tswm sim tsis zoo rov rau IMR lossis tej lus txiav txim txog kev tsis txaus siab hauv ib txoj hau
kev twg.
Page 3 of 4
#100HM
Thawj Hom Lus Tham Uas Koj Hais:
Koj puas nyiam kom muab qhov kev sib txuas lus/sib teb no tham nyob rau hauv
koj thawj hom lus?
Yiam
Tsis Nyiam
Haiv Neeg/Haiv Neeg Me:
Page 4 of 4
#100HM
State of California
Health and Human Services Agency
Department of Managed Health Care
AUTHORIZED ASSISTANT FORM – Hmong Clarify
DMHC 20-160
New: 04/06 Rev: 08/18
DAIM FOOS TUS NEEG PAB UAS RAUG TSO CAI RAU
Yog hais tias koj xav muab kev tso cai rau lwm tus neeg los pab koj sau koj daim ntawv Rov Xyuas Kev
Kho Mob Kom Ncaj Nrab (IMR) lossis daim ntawv tsis txaus siab, cess au kom tiav Tshooj A thiab B
hauv qab no.
(Ob tog yuav tsum kos npe rau daim ntawv)
Yog hais tias koj yog ib tug leej niam leej txi lossis neeg saib xyuas raws kev cai uas tab tom sau
daim IMR lossis daim ntawv tsis txaus siab rau ib tug menyuam uas hnub nyoog qis dua 18 xyoo,
ces koj tsis tas sau daim foos no.
Yog hais tias koj tab tom sau daim ntawv IMR/Daim Ntawv Tsis Txaus Siab rau ib tug neeg mob tus
uas tsis tuaj yeem sau daim foos no vim yog tus neeg mob tsis muaj peev xwm lossis tsis muaj tswv
yim, thiab koj ho tau kev tso cai raws li kev cai lij choj los sau rau tus neeg mob no, ces thov caw sau
kom tiav Part B nkaus xwb. Kuj tseem tsuam ib daim luam qauv lus muab cai ntsig txog cov kev txiav
txim fab kev saib xyuas mob nkeeg lossis lwm cov ntaub ntawv uas hais tias koj tuaj yeem txiav txim
sawv cev rau tus neeg mob.
TSHOOJ A:
UA TIAV LOS NTAWM
TUS NEEG MOB
Kuv tso cai rau tus neeg uas muaj npe nyob hauv Tshooj B los pab kuv sau kuv daim IMR lossis daim
ntawv tsis txaus siab nrog Rooj Tsav Xwm Saib Xyuas Kev Saib Xyuas Mob Nkeeg Uas Tau Tswj
Xyuas (Lub Rooj Tsav Xwm). Kuv tso cai rau cov neeg ua haujlwm ntawm Lub Rooj Tsav Xwm thiab
IMR los nthuav qhia tej xov xwm ntsig txog kuv li zwj ceeb kho mob thiab kev saib xyuas mob hauv tus
neeg uas muaj npe hauv qab no. Tej xov xwm no kuj yuav xam muaj kev kho mob puas siab puas
ntsws, kho mob lossis kuaj mob HIV, kev cim dej cawv lossis cim tshuaj, lossis lwm yam xov xwm saib
xyuas kev mob nkeeg.
Kuv nkag siab tias tsuas muaj tej xov xwm uas ntsig txog kuv li IMR lossis tej lus tsis txaus siab thiaj li
yuav raug nthuav qhia rau pom.
Kuv li kev pom zoo ntawm qhov kev pab no yog txaus siab ua pub dawb thiab kuv muaj cai los xaus
nws tseg. Yog hais tias kuv xav xaus nws tseg, ces kuv yuav tsum sau ntawv qhia tias kuv xav ua li
ntawd.
Tus Neeg Mob Lub Npe (Sau)___________________________________________
Tus Neeg Mob Kos Npe
Hnub Tim
TSHOOJ B:
UA TIAV LOS NTAWM
TUS NEEG UAS TAB TOM PAB TUS NEEG MOB
Lub Npe ntawm Tus Neeg Tab Tom Pab (sau)
Tus Qauv Tes Kos Npe ntawm Tus Neeg Tab Tom Pab
Chaw Nyob
Lub Nroog
Lub Xeev
Zauv Cim Xa Ntawv
Kev Txheeb Ze rau Tus Neeg Mob
Tus Xov Tooj Tseem Ceeb #
Tus Xov Tooj Thiv Ob #
Chaw Nyob Email
Kuv li lus tso cai hais txog cov kev txiav txim fab kev saib xyuas mob nkeeg lossis lwm cov ntaub
ntawv raug cai raug tshuam tuaj nrog.
Page 1 of 1
#100HM