Form MC14 A "Qualified Low-Income Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individuals (Qi) Application" - California (Armenian)

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 Armenian. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2021;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form MC14 A by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form MC14 A "Qualified Low-Income Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individuals (Qi) Application" - California (Armenian)

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Department of Health Care Services
State of California–-Health and Human Services Agency
QUALIFIED MEDICARE BENEFICIARY (QMB), SPECIFIED LOW-INCOME MEDICARE
BENEFICIARY (SLMB), AND QUALIFYING INDIVIDUAL (QI) APPLICATION
§ § MEDICARE
MEDICARE¦-Æ Æð²ì²êàô Üä²êî²èàôÆ
¦-Æ Æð²ì²êàô Üä²êî²èàôÆ (QMB)
(QMB)« ò²Ìð ºÎ²Øàôî ²ÜÒ àôܺòàÔ Ö²Ü²âì²Ì
« ò²Ìð ºÎ²Øàôî ²ÜÒ àôܺòàÔ Ö²Ü²âì²Ì
SLMB) ºì Æð²ì²êàô ²ÜÒÆ (
QI) ¸ÆØàôØ
Üä²êî²èàôÆ (
Üä²êî²èàôÆ (SLMB
) ºì Æð²ì²êàô ²ÜÒÆ (QI
) ¸ÆØàôØ
§Social Security¦-Ç Ñ³Ù³ñÁ §Medicare¦-Ç Ñ³Ù³ñÁ ²Ùë³ÃÇíÁ
§Social Security¦-Ç Ñ³Ù³ñÁ §Medicare¦-Ç Ñ³Ù³ñÁ ²Ùë³ÃÇíÁ
²ÝáõÝÁ
²ÝáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
лé³ËáëÇ Ñ³Ù³ñÁ
ÌÝÝ¹Û³Ý ³Ùë³ÃÇíÁ ê»éÁ
ÌÝÝ¹Û³Ý ³Ùë³ÃÇíÁ
ê»éÁ
ÀÝï³Ý»Ï³Ý ¹ñáõÃÛáõÝÁ`
ÀÝï³Ý»Ï³Ý ¹ñáõÃÛáõÝÁ`
³ñ³Ï³Ý
³Ùáõëݳó³Í
³ÙáõëݳÉáõÍí³Í
(
(
)
)
Ç·³Ï³Ý
³é³ÝÓݳó³Í
³ÙáõñÇ
³ÛñÇ
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ø³Õ³ùÁ
ܳѳݷÁ
ܳѳݷÁ
öáëï³ÛÇÝ Çݹ»ùëÁ
öáëï³ÛÇÝ Çݹ»ùëÁ
²Ûë ï»Õ»ÏáõÃÛáõÝÝ»ñÇ Ýå³ï³ÏÝ ¿ û·Ý»É Ò»½ ¹ÇÙ»É Qualified Medicare Beneficiary` (QMB)
(§Medicare¦-Ç áñ³Ïí³Í Ýå³ëï³éáõÇ), Specified Low-Income Medicare Beneficiary` (SLMB)
(§Medicare¦-Ç` ë³ÑÙ³Ýí³Í ó³Íñ »Ï³Ùáõï áõÝ»óáÕ Ýå³ëï³éáõÇ), Qualifying Individual` (QI)
(ϳ٠àñ³Ïí³Í ³ÝѳïÇ) Íñ³·ñ»ñÇ Ñ³Ù³ñ: ܳѳݷÁ Ïí׳ñÇ QMB Íñ³·ñÇÝ Ù³ëݳÏó»Éáõ
Çñ³í³ëáõ ³ÝÓ³Ýó §Medicare¦-Ç §Part A¦-Ç ¨ §Part B¦-Ç ³å³Ñáí³·ÇÝÁ, ã³å³Ñáí³·ñí³Í
Ù³ëÁ ¨ ѳٳ³å³Ñáí³·ñáõÃÛáõÝÁ: ܳѳݷÁ Ïí׳ñÇ SLMB ϳ٠QI Íñ³·ñ»ñÇÝ Ù³ëݳÏó»Éáõ
Çñ³í³ëáõ ³ÝÓ³Ýó §Medicare¦-Ç §Part B¦-Ç ³å³Ñáí³·ÇÝÁ: ¸áõù ϳñáÕ »ù ¹ÇÙ»É QMB, SLMB
ϳ٠QI Íñ³·ñ»ñÇÝ Ù³ëݳÏó»Éáõ ѳٳñ` Éñ³óÝ»Éáí ³Ûë ûñÃÇÏÁ ¨ áõÕ³ñÏ»Éáí ³ÛÝ ëáódzɳϳÝ
ͳé³ÛáõÃÛáõÝÝ»ñÇ Ò»ñ ßñç³Ý³ÛÇÝ ·áñͳϳÉáõÃÛáõÝ:
QMB, SLMB ϳ٠QI Íñ³·ñÇ Çñ³íáõÝù ëï³Ý³Éáõ ѳٳñ ¸áõù å»ïù ¿`
y §Medicare¦-Ç A Ù³ëÇ Çñ³í³ëáõÃÛáõÝ (ÑÇí³Ý¹³Ýáó³ÛÇÝ ³å³Ñáí³·ñáõÃÛáõÝ) áõݻݳù:
y §Medicare¦-Ç B Ù³ëÇ Çñ³í³ëáõÃÛáõÝ (µÅßÏ³Ï³Ý ³å³Ñáí³·ñáõÃÛáõÝ) áõݻݳù:
y ´³í³ñ³ñ»ù »Ï³ÙáõïÇ í»ñ³µ»ñÛ³É Ñ»ï¨Û³É å³Ñ³ÝçÝ»ñÁ.
5 QMB` ½áõï ѳßí³ñÏ»ÉÇ »Ï³ÙáõïÁ å»ïù ¿ §Federal Poverty Level¦-Ç (FPL)
`
100%-Ç ã³÷ ϳ٠¹ñ³ÝÇó ó³Íñ ÉÇÝÇ (³ÝѳïÇ ¹»åùáõÙ` $1,074* ϳ٠å³Ï³ë,
ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $1,452* ϳ٠å³Ï³ë):
5 SLMB` ½áõï ѳßí³ñÏ»ÉÇ »Ï³ÙáõïÁ å»ïù ¿ FPL-Ç 120%-Çó ó³Íñ ÉÇÝÇ (³ÝѳïÇ
`
¹»åùáõÙ` $1,288*-Çó, ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $1,742*-Çó å³Ï³ë):
5 QI` ½áõï ѳßí³ñÏ»ÉÇ »Ï³ÙáõïÁ å»ïù ¿ FPL-Ç 135%-Çó ó³Íñ ÉÇÝÇ (³ÝѳïÇ
`
¹»åùáõÙ` $1,449* -Çó, ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $1,960*-Çó å³Ï³ë):
* ºÃ» ¸áõù ï³ÝÁ Ò»½ Ñ»ï ³åñáÕ »ñ»Ë³ áõÝ»ù, ³Û¹ ·áõÙ³ñÝ»ñÁ ϳñáÕ »Ý ³í»ÉÇ Ù»Í
ÉÇÝ»É: ²ÏÝϳÉíáõÙ ¿, áñ ³Ù»Ý ï³ñÇ ³åñÇÉÇÝ ³Û¹ ·áõÙ³ñÝ»ñÇ ã³÷Á Ïٻͳݳ: ºÃ»
ÑáõÝí³ñÇÝ Ò»½ ѳٳñ §Title II¦-Ç §Social Security¦-Ç ³åñáõëïÇ Ñ³Ù³ñ ³ÝÑñ³Å»ßï
Ýí³½³·áõÛÝ ·áõÙ³ñÇ ×ß·ñïáõÙ ¿ ϳï³ñí»É, ³å³ ³Û¹ ·áõÙ³ñÁ ѳßíÇ ãÇ ³éÝíÇ ÙÇÝã¨
³åñÇÉ ³ÙÇëÁ:
y ²ÝѳïÇ ¹»åùáõÙ` $7,970 -Á, ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $11,960-Á ã·»ñ³½³ÝóáÕ
å³ñï³íáñáõÃÛáõÝÇó ã³½³ïí³Í ë»÷³Ï³ÝáõÃÛáõÝ áõݻݳù:
y ´³í³ñ³ñ»ù áñáß³ÏÇ å³Ñ³ÝçÝ»ñ ¨ å³ÛÙ³ÝÝ»ñ, ûñÇݳÏ` California-Ç µÝ³ÏÇã ÉÇÝ»ù:
βðºìàð ¾
βðºìàð ¾
QMB ¨ SLMB Íñ³·ñ»ñÇó µ³óÇ ¸áõù ϳñáÕ »ù Çñ³í³ëáõ ÉÇÝ»É Ù³ëݳÏó»Éáõ ݳ¨
Medi-Cal Ç ³ÛÉ Íñ³·ñ»ñÇ« ûñÇݳÏ` ëÝݹ³ÙûñùÇ ÏïñáÝÝ»ñÇ Íñ³·ñÇÝ ¨/ϳ٠³Ùë³Ï³Ý
Èð²òì²Ì ºðÂÆÎÀ öàêîàì àôÔ²ðκø Òºð Þðæ²ÜÆ êàòÆ²È²Î²Ü Ì²è²ÚàôÂÚàôÜܺðÆ
Èð²òì²Ì ºðÂÆÎÀ öàêîàì àôÔ²ðκø Òºð Þðæ²ÜÆ êàòÆ²È²Î²Ü Ì²è²ÚàôÂÚàôÜܺðÆ
¶àð̲βÈàôÂÚàôÜ:
¶àð̲βÈàôÂÚàôÜ:
Page 1 of 5
MC 14A ARM (Revised 03/2021)
Department of Health Care Services
State of California–-Health and Human Services Agency
QUALIFIED MEDICARE BENEFICIARY (QMB), SPECIFIED LOW-INCOME MEDICARE
BENEFICIARY (SLMB), AND QUALIFYING INDIVIDUAL (QI) APPLICATION
§ § MEDICARE
MEDICARE¦-Æ Æð²ì²êàô Üä²êî²èàôÆ
¦-Æ Æð²ì²êàô Üä²êî²èàôÆ (QMB)
(QMB)« ò²Ìð ºÎ²Øàôî ²ÜÒ àôܺòàÔ Ö²Ü²âì²Ì
« ò²Ìð ºÎ²Øàôî ²ÜÒ àôܺòàÔ Ö²Ü²âì²Ì
SLMB) ºì Æð²ì²êàô ²ÜÒÆ (
QI) ¸ÆØàôØ
Üä²êî²èàôÆ (
Üä²êî²èàôÆ (SLMB
) ºì Æð²ì²êàô ²ÜÒÆ (QI
) ¸ÆØàôØ
§Social Security¦-Ç Ñ³Ù³ñÁ §Medicare¦-Ç Ñ³Ù³ñÁ ²Ùë³ÃÇíÁ
§Social Security¦-Ç Ñ³Ù³ñÁ §Medicare¦-Ç Ñ³Ù³ñÁ ²Ùë³ÃÇíÁ
²ÝáõÝÁ
²ÝáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
лé³ËáëÇ Ñ³Ù³ñÁ
ÌÝÝ¹Û³Ý ³Ùë³ÃÇíÁ ê»éÁ
ÌÝÝ¹Û³Ý ³Ùë³ÃÇíÁ
ê»éÁ
ÀÝï³Ý»Ï³Ý ¹ñáõÃÛáõÝÁ`
ÀÝï³Ý»Ï³Ý ¹ñáõÃÛáõÝÁ`
³ñ³Ï³Ý
³Ùáõëݳó³Í
³ÙáõëݳÉáõÍí³Í
(
(
)
)
Ç·³Ï³Ý
³é³ÝÓݳó³Í
³ÙáõñÇ
³ÛñÇ
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ø³Õ³ùÁ
ܳѳݷÁ
ܳѳݷÁ
öáëï³ÛÇÝ Çݹ»ùëÁ
öáëï³ÛÇÝ Çݹ»ùëÁ
²Ûë ï»Õ»ÏáõÃÛáõÝÝ»ñÇ Ýå³ï³ÏÝ ¿ û·Ý»É Ò»½ ¹ÇÙ»É Qualified Medicare Beneficiary` (QMB)
(§Medicare¦-Ç áñ³Ïí³Í Ýå³ëï³éáõÇ), Specified Low-Income Medicare Beneficiary` (SLMB)
(§Medicare¦-Ç` ë³ÑÙ³Ýí³Í ó³Íñ »Ï³Ùáõï áõÝ»óáÕ Ýå³ëï³éáõÇ), Qualifying Individual` (QI)
(ϳ٠àñ³Ïí³Í ³ÝѳïÇ) Íñ³·ñ»ñÇ Ñ³Ù³ñ: ܳѳݷÁ Ïí׳ñÇ QMB Íñ³·ñÇÝ Ù³ëݳÏó»Éáõ
Çñ³í³ëáõ ³ÝÓ³Ýó §Medicare¦-Ç §Part A¦-Ç ¨ §Part B¦-Ç ³å³Ñáí³·ÇÝÁ, ã³å³Ñáí³·ñí³Í
Ù³ëÁ ¨ ѳٳ³å³Ñáí³·ñáõÃÛáõÝÁ: ܳѳݷÁ Ïí׳ñÇ SLMB ϳ٠QI Íñ³·ñ»ñÇÝ Ù³ëݳÏó»Éáõ
Çñ³í³ëáõ ³ÝÓ³Ýó §Medicare¦-Ç §Part B¦-Ç ³å³Ñáí³·ÇÝÁ: ¸áõù ϳñáÕ »ù ¹ÇÙ»É QMB, SLMB
ϳ٠QI Íñ³·ñ»ñÇÝ Ù³ëݳÏó»Éáõ ѳٳñ` Éñ³óÝ»Éáí ³Ûë ûñÃÇÏÁ ¨ áõÕ³ñÏ»Éáí ³ÛÝ ëáódzɳϳÝ
ͳé³ÛáõÃÛáõÝÝ»ñÇ Ò»ñ ßñç³Ý³ÛÇÝ ·áñͳϳÉáõÃÛáõÝ:
QMB, SLMB ϳ٠QI Íñ³·ñÇ Çñ³íáõÝù ëï³Ý³Éáõ ѳٳñ ¸áõù å»ïù ¿`
y §Medicare¦-Ç A Ù³ëÇ Çñ³í³ëáõÃÛáõÝ (ÑÇí³Ý¹³Ýáó³ÛÇÝ ³å³Ñáí³·ñáõÃÛáõÝ) áõݻݳù:
y §Medicare¦-Ç B Ù³ëÇ Çñ³í³ëáõÃÛáõÝ (µÅßÏ³Ï³Ý ³å³Ñáí³·ñáõÃÛáõÝ) áõݻݳù:
y ´³í³ñ³ñ»ù »Ï³ÙáõïÇ í»ñ³µ»ñÛ³É Ñ»ï¨Û³É å³Ñ³ÝçÝ»ñÁ.
5 QMB` ½áõï ѳßí³ñÏ»ÉÇ »Ï³ÙáõïÁ å»ïù ¿ §Federal Poverty Level¦-Ç (FPL)
`
100%-Ç ã³÷ ϳ٠¹ñ³ÝÇó ó³Íñ ÉÇÝÇ (³ÝѳïÇ ¹»åùáõÙ` $1,074* ϳ٠å³Ï³ë,
ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $1,452* ϳ٠å³Ï³ë):
5 SLMB` ½áõï ѳßí³ñÏ»ÉÇ »Ï³ÙáõïÁ å»ïù ¿ FPL-Ç 120%-Çó ó³Íñ ÉÇÝÇ (³ÝѳïÇ
`
¹»åùáõÙ` $1,288*-Çó, ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $1,742*-Çó å³Ï³ë):
5 QI` ½áõï ѳßí³ñÏ»ÉÇ »Ï³ÙáõïÁ å»ïù ¿ FPL-Ç 135%-Çó ó³Íñ ÉÇÝÇ (³ÝѳïÇ
`
¹»åùáõÙ` $1,449* -Çó, ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $1,960*-Çó å³Ï³ë):
* ºÃ» ¸áõù ï³ÝÁ Ò»½ Ñ»ï ³åñáÕ »ñ»Ë³ áõÝ»ù, ³Û¹ ·áõÙ³ñÝ»ñÁ ϳñáÕ »Ý ³í»ÉÇ Ù»Í
ÉÇÝ»É: ²ÏÝϳÉíáõÙ ¿, áñ ³Ù»Ý ï³ñÇ ³åñÇÉÇÝ ³Û¹ ·áõÙ³ñÝ»ñÇ ã³÷Á Ïٻͳݳ: ºÃ»
ÑáõÝí³ñÇÝ Ò»½ ѳٳñ §Title II¦-Ç §Social Security¦-Ç ³åñáõëïÇ Ñ³Ù³ñ ³ÝÑñ³Å»ßï
Ýí³½³·áõÛÝ ·áõÙ³ñÇ ×ß·ñïáõÙ ¿ ϳï³ñí»É, ³å³ ³Û¹ ·áõÙ³ñÁ ѳßíÇ ãÇ ³éÝíÇ ÙÇÝã¨
³åñÇÉ ³ÙÇëÁ:
y ²ÝѳïÇ ¹»åùáõÙ` $7,970 -Á, ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $11,960-Á ã·»ñ³½³ÝóáÕ
å³ñï³íáñáõÃÛáõÝÇó ã³½³ïí³Í ë»÷³Ï³ÝáõÃÛáõÝ áõݻݳù:
y ´³í³ñ³ñ»ù áñáß³ÏÇ å³Ñ³ÝçÝ»ñ ¨ å³ÛÙ³ÝÝ»ñ, ûñÇݳÏ` California-Ç µÝ³ÏÇã ÉÇÝ»ù:
βðºìàð ¾
βðºìàð ¾
QMB ¨ SLMB Íñ³·ñ»ñÇó µ³óÇ ¸áõù ϳñáÕ »ù Çñ³í³ëáõ ÉÇÝ»É Ù³ëݳÏó»Éáõ ݳ¨
Medi-Cal Ç ³ÛÉ Íñ³·ñ»ñÇ« ûñÇݳÏ` ëÝݹ³ÙûñùÇ ÏïñáÝÝ»ñÇ Íñ³·ñÇÝ ¨/ϳ٠³Ùë³Ï³Ý
Èð²òì²Ì ºðÂÆÎÀ öàêîàì àôÔ²ðκø Òºð Þðæ²ÜÆ êàòÆ²È²Î²Ü Ì²è²ÚàôÂÚàôÜܺðÆ
Èð²òì²Ì ºðÂÆÎÀ öàêîàì àôÔ²ðκø Òºð Þðæ²ÜÆ êàòÆ²È²Î²Ü Ì²è²ÚàôÂÚàôÜܺðÆ
¶àð̲βÈàôÂÚàôÜ:
¶àð̲βÈàôÂÚàôÜ:
Page 1 of 5
MC 14A ARM (Revised 03/2021)
Department of Health Care Services
State of California–-Health and Human Services Agency
ͳËëÇ Ñ³Ù»Ù³ï ½»Õã ïñ³Ù³¹ñáÕ (ͳËë»ñÇ µ³ÅÝáí) Medi-Cal ÇÝ: Ðݳñ³íáñ
²Ûá
àã
¿« áñ ¸áõù ³Ùë³Ï³Ý ͳËë»ñÇ µ³ÅÝáí Medi-Cal Ç Çñ³í³ëáõÃÛáõÝ ¸áõù áõݻݳù
½³Ý Ý ó ó áõ áõÙ Ù ¿ QMB« SLMB ¨ QI Íñ³·ñ»ñÇ
ݳ¨ ³ÛÝ ¹»åùáõÙ« »Ã» Ò»ñ »Ï³ÙáõïÁ · · » » ñ ñ ³ ³ ½³
ë³Ñٳݳã³÷Á: ºÃ» ¸áõù ó³ÝϳÝáõÙ »ù ¹ÇÙ»É ³Û¹ Íñ³·ñ»ñÇ Ñ³Ù³ñ« Ýß³Ý ¹ñ»ù
§³Ûᦠí³Ý¹³ÏáõÙ« ¨ ßñç³ÝÁ Ò»½ ³ÛÉ Ã»ñÃÇÏÝ»ñ ÏáõÕ³ñÏÇ« áñ ¸áõù Éñ³óÝ»ù:
²Ûá
àã
¸áõù ó³ÝϳÝáõ±Ù »ù ¹ÇÙ»É Ñ»ïÇÝ Ãíáí SLMB ¨ QI Íñ³·ñ»ñÇ »é³ÙëÛ³
³å³Ñáí³·ñáõÃÛ³Ý Ñ³Ù³ñ (QMB-Ç Ñ³Ù³ñ Ñ»ïÇÝ Ãíáí ³å³Ñáí³·ñáõÃÛáõÝ ãϳ):
Âí»ù Ò»ñ ï³ÝÁ µÝ³ÏíáÕ µáÉáñ ³ÝÓ³Ýó (ÏÝáçÁ ϳ٠³ÙáõëÝáõÝ/»ñ»Ë³Ý»ñÇÝ):
Âí»ù Ò»ñ ï³ÝÁ µÝ³ÏíáÕ µáÉáñ ³ÝÓ³Ýó (ÏÝáçÁ ϳ٠³ÙáõëÝáõÝ/»ñ»Ë³Ý»ñÇÝ): ºÃ»
Ò»½ Ñ»ï ³í»ÉÇ ù³Ý »ñ»ù Ñá·Ç ¿ ³åñáõÙ, Ýñ³Ýó ϳñáÕ »ù Ýᯐ ³é³ÝÓÇÝ ¿çÇ íñ³:
§Social Security¦-Ç
§
¦-Ç
ê»éÁ
ê»éÁ
ÌÝݹ۳Ý
ÌÝݹ۳Ý
гñ³µ»ñáõÃÛáõÝÁ
гñ³µ»ñáõÃÛáõÝÁ
²ÝáõÝÁ
²ÝáõÝÁ
ѳٳñÁ
ѳٳñÁ
³ñ³Ï³Ý Ç·³Ï³Ý
³ñ³Ï³Ý Ç·³Ï³Ý
³Ùë³ÃÇíÁ
³Ùë³ÃÇíÁ
Ò»½ Ñ»ï
Ò»½ Ñ»ï
A.
COUNTY USE
вÞì²ðκÈÆ ºÎ²ØàôîÀ
вÞì²ðκÈÆ ºÎ²ØàôîÀ
1.
Üß»ù QMB-Ç/
Applicant’s
Üß»ù
-Ç/SLMB-Ç/
-Ç/QI-Ç Ñ³Ù³ñ ¹ÇÙáÕÇ ëï³ó³Í ²Øê²Î²Ü
-Ç Ñ³Ù³ñ ¹ÇÙáÕÇ ëï³ó³Í ²Øê²Î²Ü
unearned
ãí³ëï³Ï³Í »Ï³ÙáõïÁ:
ãí³ëï³Ï³Í »Ï³ÙáõïÁ:
a. §Social Security¦-Ç í׳ñ³·Çñ
$
income (line f)
b. VA Ýå³ëïÝ»ñ
$
$
c. ´³ÝϳÛÇÝ Ñ³ßÇíÝ»ñÇó ϳ٠³í³Ý¹Ç
$
Spouse’s
íϳ۳·ñ(»ñ)Çó ëï³ó³Í ß³Ñ
d.
$
unearned
λÝë³Ãáß³Ï
e. ²ÛÉ ãí³ëï³Ï³Í »Ï³Ùáõï
$
income (line l)
f. Total âì²êî²Î²Ì ºÎ²Øàôî` ·áõÙ³ñ»ù a.-Çó e.
+
$
ïáÕ»ñÁ
2.
º º Ã Ã » ¸
» ¸á á õ õ ù ³
ù ³Ù Ù á á õ õ ë ë Ý Ý ³ ³ ó ó ³ ³ Í »
Í »ù ¨ Ò
ù ¨ Ò» » ñ Î
ñ ÎÜ Ü à à æ Ï
æ ϳ ³ Ù ²
Ù ²Ø Ø à à ô ô ê ê Ü Ü à à ô Ñ
ô Ñ» » ï ï
» » ù ³
ù ³å å ñ ñ á á õ õ Ù, É
Ù, Éñ ñ ³ ³ ó ó ñ ñ » » ù Ò
ù Ò» » ñ Ï
ñ ÏÝ Ý á á ç Ï
ç ϳ ³ Ù ³
Ù ³Ù Ù á á õ õ ë ë Ý Ý á á õ ë
õ ëï ï ³ ³ ó ó ³ ³ Í Í
Any Income
² ² Ø Ø ê ê ² ² β
Î²Ü ã
Ü ãí í ³ ³ ë ë ï ï ³ ³ Ï Ï ³ ³ Í »
Í »Ï Ï ³ ³ Ù Ù á á õ õ ï ï Á Á : :
deduction
g. §Social Security¦-Ç í׳ñ³·Çñ
$
-
h. VA Ýå³ëïÝ»ñ
$
i. ´³ÝϳÛÇÝ Ñ³ßÇíÝ»ñÇó ϳ٠³í³Ý¹Ç
Net unearned
$
íϳ۳·ñ(»ñ)Çó ëï³ó³Í ß³Ñ
income
j. ²ÛÉ ãí³ëï³Ï³Í »Ï³Ùáõï
$
k. λÝë³Ãáß³Ï
$
l. Total ÎÜàæ Î²Ø ²ØàôêÜàô âì²êî²Î²Ì ºÎ²ØàôîÀ`
Net earned
·áõÙ³ñ»ù g.-Çó k. ïáÕ»ñÁ
$
income (line r)
+
3.
Üß» » ù ù QMB- - Ç/ Ç/SLMB- - Ç/ Ç/QI- - Ç Ñ
Üß
Ç Ñ³ ³ Ù Ù ³ ³ ñ ¹
ñ ¹Ç Ç Ù Ù á á Õ Õ Ç ¨ Ý
Ç ¨ Ýñ ñ ³ Ï
³ ÏÝ Ý á á ç Ï
ç ϳ ³ Ù ³
Ù ³Ù Ù á á õ õ ë ë Ý Ý á á õ õ
ë ë ï ï ³ ³ ó ó ³ ³ Í ²
Í ²Ø Ø ê ê ² ² β
Î²Ü í
Ü í³ ³ ë ë ï ï ³ ³ Ï Ï ³ ³ Í »
Í »Ï Ï ³ ³ Ù Ù á á õ õ ï ï Á Á : :
m.
²ÛÝ ³ÝÓÇ Ñ³Ù³Ë³éÝ »Ï³ÙáõïÁ, áí ó³ÝϳÝáõÙ ¿
Total net income
QMB, SLMB ϳ٠QI ÉÇÝ»É
$
n. ÎÝáç ϳ٠³ÙáõëÝáõ ѳٳ˳éÝ »Ï³ÙáõïÁ
$
o. Total` ·áõÙ³ñ»ù m. ¨ n. ïáÕ»ñÁ
$
p. гݻù $65
$
MFBU size
q. Øݳóáñ¹Á
$
r. ´³Å³Ý»ù 2-Ç
$
Page 2 of 5
MC 14A ARM (Revised 03/2021)
Department of Health Care Services
State of California–-Health and Human Services Agency
4.
À À ݹ
Ý¹Ñ Ñ ³Ý
³Ýá á õ õ ñ ñ » »Ï Ï ³Ù
³Ùá á õ õ ï ï Á Á ` `
COUNTY USE
¶áõÙ³ñ»ù f., I. ¨ r. ïáÕ»ñÁ
$
Compare to
s. гݻù $20 (»Ï³ÙáõïÇó ó³Ýϳó³Í ѳÝáõñ¹)
$
QMB/SLMB/QI
income limit.
5.
$
__________
À À Ü Ü ¸ ¸ Ð Ð ² ² Ü Ü à à ô ô ð Ð
ð в ² Þ Þ ì ì ² ² ð ð κ
ÎºÈ È Æ º
Æ ºÎ²
Î²Ø Ø à à ô ô î î À À
If over income limit,
6. QMB- - Ç, Ç, SLMB- - Ç Ï
Ç Ï³ ³ Ù Ù QI- - Ç Ñ
Ç Ñ³ ³ Ù Ù ³ ³ ñ Ñ
ñ ѳ ³ í í ³ ³ Ý Ý ³ ³ Ï Ï ³ ³ Ý Ç
Ý Çñ ñ ³ ³ í í ³ ³ ë ë á á õ ³
õ ³Ý Ý ÓÇ
ÓÇÝ Ý ù ù . .
is there a spouse
¸ áõù ѳí³Ý³Ï³Ý Çñ³í³ëáõ ³ÝÓ »ù ѳٳñíáõÙ QMB-Ç Ñ³Ù³ñ,
5
and/or children
»Ã» Ò»ñ »Ï³ÙáõïÁ FPL-Ç 100%-Ç ã³÷ ϳ٠¹ñ³ÝÇó ó³Íñ ¿
in the home?
(³ÝѳïÇ ¹»åùáõÙ` $1,074* ϳ٠å³Ï³ë, ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç
Complete the MC
¹»åùáõÙ` $1,452* ϳ٠å³Ï³ë):
176-2 A QMB/
¸ áõù ѳí³Ý³Ï³Ý Çñ³í³ëáõ ³ÝÓ »ù ѳٳñíáõÙ SLMB-Ç Ñ³Ù³ñ,
5
SLMB/QI form.
»Ã» Ò»ñ »Ï³ÙáõïÁ FPL-Ç 120%-Çó ó³Íñ ¿ (³ÝѳïÇ ¹»åùáõÙ`
$1,288*-Çó, ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $1,742*-Çó å³Ï³ë):
5 ¸ áõù ѳí³Ý³Ï³Ý Çñ³í³ëáõ ³ÝÓ »ù ѳٳñíáõÙ QI-Ç Ñ³Ù³ñ, »Ã» Ò»ñ
»Ï³ÙáõïÁ FPL-Ç 135%-Çó ó³Íñ ¿ (³ÝѳïÇ ¹»åùáõÙ` $1,449*-Çó, ÇëÏ
³ÙáõëÝ³Ï³Ý ½áõÛ·Ç ¹»åùáõÙ` $1,960*-Çó å³Ï³ë):
*ºÃ» ¸áõù ï³ÝÁ »ñ»Ë³ áõÝ»ù, ³Û¹ ·áõÙ³ñÝ»ñÁ ϳñáÕ »Ý ³í»ÉÇ Ù»Í
ÉÇÝ»É:
B.
ê êº º ö ö ² ² Î Î ² ² Ü Ü àô àôÂ Â Ú Ú àô àôÜ Ü À À
Æñ ÏÝáç ϳ٠³ÙáõëÝáõ Ñ»ï ã³åñáÕ QMB-Ý, SLMB-Ý Ï³Ù QI-Á ϳñáÕ ¿ $7,970-Ç ã³÷
ϳ٠¹ñ³ÝÇó å³Ï³ë ѳßí³ñÏ»ÉÇ ë»÷³Ï³ÝáõÃÛáõÝ áõݻݳÉ: ²Ùáõëݳó³Í ¨ Çñ ÏÝáç ϳÙ
³ÙáõëÝáõ Ñ»ï ³åñáÕ QMB-Ý, SLMB-Ý Ï³Ù QI-Á ϳñáÕ ¿ $11,960-Ç ã³÷ ϳ٠¹ñ³ÝÇó å³Ï³ë
ѳßí³ñÏ»ÉÇ ë»÷³Ï³ÝáõÃÛáõÝ áõݻݳÉ:
êïáñ¨ µ»ñí³Í »Ý ѳßí³ñÏ»ÉÇ »Ï³ÙáõïÇ ûñÇݳÏÝ»ñ: Î Î ³ ³ ñ ñ ¨ ¨ á á ñ ñ ¿: ¿: îáõÝÁ, áñáõÙ µÝ³ÏíáõÙ »ù ¸áõù ¨/
ϳ٠һñ ÏÇÝÁ/³ÙáõëÇÝÁ, ѳßíÇ ãÇ ãÇ ³éÝíáõÙ: öá˳¹ñÙ³Ý Ñ³Ù³ñ û·ï³·áñÍíáÕ Ù»Ï ³íïáÙ»ù»Ý³Ý
ѳßíÇ ãÇ ³éÝíáõÙ: ºÃ» ¸áõù ¹ÇÙáõÙ »ù ëáóÇ³É³Ï³Ý Í³é³ÛáõÃÛáõÝÝ»ñÇ Ò»ñ ßñç³Ý³ÛÇÝ
·áñͳϳÉáõÃÛáõÝ: áñå»ë QMB, SLMB ϳ٠QI, ³å³ ßñç³ÝÁ ϳñáÕ ¿ ï³ñµ»ñ Ï»ñå í»ñ³µ»ñí»É
³Ûë ûñÃÇÏáõÙ Ýßí³Í ë»÷³Ï³ÝáõÃÛ³ÝÁ: Î³Ý ë»÷³Ï³ÝáõÃÛ³Ý Ý³¨ ³ÛÉ ï»ë³ÏÝ»ñ, áñáÝù Þñç³ÝÇ
ëáóÇ³É³Ï³Ý Í³é³ÛáõÃÛáõÝÝ»ñÇ ·áñͳϳÉáõÃÛáõÝ ÝáõÛÝå»ë ÏáõëáõÙݳëÇñÇ, ûñÇݳÏ` ³í³Ý¹Ç
íϳ۳·ÇñÁ/íϳ۳·ñ»ñÁ: ê»÷³Ï³ÝáõÃÛ³Ý ³Û¹ ï»ë³ÏÝ»ñÁ ϳñáÕ »Ý ѳßíÇ ³ ³ é é Ý Ý í»
í»É É Ï³Ù ã³
ã³é é Ý Ý í í » » É É
ë»÷³Ï³ÝáõÃÛ³Ý ë³Ñٳݳã³÷Á áñáß»ÉÇë:
Èñ³óñ»ù Ò»½, Ò»ñ ÏÝáçÁ/³ÙáõëÝáõÝ Ï³Ù »ñÏáõëǹ å³ïϳÝáÕ Ñ»ï¨Û³É ë»÷³Ï³ÝáõÃÛ³Ý
³ñÅ»ùÁ:
COUNTY USE
1. ÁÝóóÇÏ Ñ³ßÇíÝ»ñ
$
2. ËݳÛáÕ³Ï³Ý Ñ³ßÇí
$
3. ³í³Ý¹Ç íϳ۳·Çñ/íϳ۳·ñ»ñ
$
4. ³ñÅ»ïáÙë»ñ
$
5. å³ñï³ïáÙë»ñ
$
6. »ñÏñáñ¹ Ù»ù»Ý³ (·ÇÝÁ ÙÇÝáõë ãí׳ñí³Í Ù³ëÁ)
$
7. »ñÏñáñ¹ ïáõÝ (·ÇÝÁ ÙÇÝáõë ãí׳ñí³Í Ù³ëÁ)
$
8. ÏÛ³ÝùÇ ³å³Ñáí³·ñ»ñÇ »ï·ÝÙ³Ý ·áõÙ³ñÁ, »Ã»
$
µ µ á á Éá Éáñ ñ ³å³Ñáí³·ñ»ñÇ Ñ³Ù³ï»Õ ³Ýí³Ý³Ï³Ý
³ñÅ»ùÁ ·»ñ³½³ÝóáõÙ ¿ $1,500-Á (ÙÇ Ñ³ßí»ù
ÏÛ³ÝùÇ §Å³ÙÏ»ï³ÛÇݦ ³å³Ñáí³·ñ»ñÁ)
Page 3 of 5
MC 14A ARM (Revised 03/2021)
Department of Health Care Services
State of California–-Health and Human Services Agency
9. ÀݹѳÝáõñ êºö²Î²ÜàôÂÚàôÜÀ` ·áõÙ³ñ»ù 1-Çó
8-ñ¹ ïáÕ»ñÁ
**$
** ²Ûë ÁݹѳÝáõñ ·áõÙ³ñÁ Ù»Ï ³ÝÓÇ Ñ³Ù³ñ ãå»ïù ¿ ·»ñ³½³ÝóÇ
$7,970-Á, ÇëÏ ³ÙáõëÝ³Ï³Ý ½áõÛ·Ç Ñ³Ù³ñ` $11,960-Á:
Èñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñ: Ðݳñ³íáñ ¿, áñ SLMB ¨ QI Íñ³·ñ»ñáí` ¸áõù Çñ³í³ëáõ ÉÇÝ»ù ÙÇÝã¨
Èñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñ:
ÙÇÝã¨
»ñ»ù ³ÙÇë Ñ»ïÇÝ Ãíáí ³å³Ñáí³·ñáõÃÛáõÝ ëï³Ý³Éáõ` §Medicare¦-Ç Ò»ñ §Part B¦-Ç
»ñ»ù ³ÙÇë Ñ»ïÇÝ Ãíáí ³å³Ñáí³·ñáõÃÛáõÝ ëï³Ý³Éáõ`
³å³Ñáí³·ÝÇ Ñ³Ù³ñ:
̲ÜàÂàôÂÚàôÜ: § § Medi-Cal¦ Íñ³·ÇñÁ å»ïù ¿ ÷áñÓÇ §
̲ÜàÂàôÂÚàôÜ:
¦ Íñ³·ÇñÁ å»ïù ¿ ÷áñÓÇ §Medi-Cal¦-Ç áñáß Ù³Ñ³ó³Í ³Ý¹³ÙÝ»ñÇ
¦-Ç áñáß Ù³Ñ³ó³Í ³Ý¹³ÙÝ»ñÇ
·áõÛùÇ Ñ³ßíÇÝ ÷áËѳïáõó»É Çñ ͳËë»ñÁ« ³Û¹ ÃíáõÙ` ϳé³í³ñíáÕ µáõÅëå³ë³ñÏÙ³Ý
·áõÛùÇ Ñ³ßíÇÝ ÷áËѳïáõó»É Çñ ͳËë»ñÁ« ³Û¹ ÃíáõÙ` ϳé³í³ñíáÕ µáõÅëå³ë³ñÏÙ³Ý
³Ùë»í׳ñÝ»ñÁ« Í»ñ³ÝáóÇ« ïݳÛÇÝ ¨ ѳٳÛÝù³ÛÇÝ Í³é³ÛáõÃÛáõÝÝ»ñÇ áõ ¹ñ³Ýó Ñ»ï ϳåí³Í
³Ùë»í׳ñÝ»ñÁ« Í»ñ³ÝáóÇ« ïݳÛÇÝ ¨ ѳٳÛÝù³ÛÇÝ Í³é³ÛáõÃÛáõÝÝ»ñÇ áõ ¹ñ³Ýó Ñ»ï ϳåí³Í
ÑÇí³Ý¹³Ýáó³ÛÇÝ áõ ¹»Õ³ïáÙë³ÛÇÝ ¹»Õ»ñÇ Í³é³ÛáõÃÛáõÝÝ»ñÇ Ñ³Ù³ñ ϳï³ñí³Í í׳ñáõÙÝ»ñÁ«
ÑÇí³Ý¹³Ýáó³ÛÇÝ áõ ¹»Õ³ïáÙë³ÛÇÝ ¹»Õ»ñÇ Í³é³ÛáõÃÛáõÝÝ»ñÇ Ñ³Ù³ñ ϳï³ñí³Í í׳ñáõÙÝ»ñÁ«
¦-Ç Ù³Ñ³ó³Í ³Ý¹³ÙÇÝ` í»ñçÇÝÇë 55-ñ¹ ï³ñ»¹³ñÓÇÝ Ï³Ù
áñáÝù ïñ³Ù³¹ñí»É »Ý §
áñáÝù ïñ³Ù³¹ñí»É »Ý §Medi-Cal¦-Ç Ù³Ñ³ó³Í ³Ý¹³ÙÇÝ` í»ñçÇÝÇë
-ñ¹ ï³ñ»¹³ñÓÇÝ Ï³Ù
¹ñ³ÝÇó Ñ»ïᣠºÃ» Íñ³·ñÇ ³Ý¹³ÙÁ ٳѳݳÉÇë ·áõÛù ϳ٠å³ñïù ãÇ ÃáÕÝáõÙ« ³å³ ݳ ³½³ï
¹ñ³ÝÇó Ñ»ïᣠºÃ» Íñ³·ñÇ ³Ý¹³ÙÁ ٳѳݳÉÇë ·áõÛù ϳ٠å³ñïù ãÇ ÃáÕÝáõÙ« ³å³ ݳ ³½³ï
¿ áñ¨¿ å³ñï³íáñáõÃÛáõÝÇó£ Èñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñÇ Ñ³Ù³ñ ϳñáÕ »ù ³Ûó»É»É §¶áõÛùÇ
¿ áñ¨¿ å³ñï³íáñáõÃÛáõÝÇó£ Èñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñÇ Ñ³Ù³ñ ϳñáÕ »ù ³Ûó»É»É §¶áõÛùÇ
ѳßíÇÝ ÷áËѳïáõóáõÙ¦ ϳÛùÁ` http://dhcs.ca.gov/er
ѳëó»áí« Ï³Ù ½³Ý·³Ñ³ñ»É (916) 650-0590
http://dhcs.ca.gov/er ѳëó»áí« Ï³Ù ½³Ý·³Ñ³ñ»É
(916) 650-0590£ £
ѳßíÇÝ ÷áËѳïáõóáõÙ¦ ϳÛùÁ`
ê³Ï³ÛÝ QMB/ / SLMB/ / QI Íñ³·ñ»ñáõÙ Áݹ·ñÏí³Í ³ÝÓÇÝù (ϳ°Ù §
ê³Ï³ÛÝ
Íñ³·ñ»ñáõÙ Áݹ·ñÏí³Í ³ÝÓÇÝù (ϳ°Ù §Medi-Cal¦-Ç Ñ»ï ÙdzëÇÝ, ϳ°Ù
¦-Ç Ñ»ï ÙdzëÇÝ, ϳ°Ù
³é³Ýó ¹ñ³) »Ýóϳ ã»Ý ·áõÛùÇ Ñ³ßíÇÝ §
³é³Ýó ¹ñ³) »Ýóϳ ã»Ý ·áõÛùÇ Ñ³ßíÇÝ §Medicare¦-Ç ³å³Ñáí³·ÝÇ, ã³å³Ñáí³·ñí³Í Ù³ëÇ
¦-Ç ³å³Ñáí³·ÝÇ, ã³å³Ñáí³·ñí³Í Ù³ëÇ
ϳ٠ѳٳí׳ñáõÙÝ»ñÇ Ñ³Ù³ñ ϳï³ñí³Í ͳËë»ñÇ ÷áËѳïáõóÙ³Ý:
ϳ٠ѳٳí׳ñáõÙÝ»ñÇ Ñ³Ù³ñ ϳï³ñí³Í ͳËë»ñÇ ÷áËѳïáõóÙ³Ý:
Ç ¨ State of California- - Ç Ç
Î Î » » Õ Õ Í ï
Í ïí í Û Û ³ ³ É É Ý Ý » » ñ ï
ñ ïñ ñ ³ ³ Ù Ù ³ ³ ¹ ¹ ñ ñ » » É É á á õ Ñ
õ ѳ ³ Ù Ù ³ ³ ñ ²
ñ ²Ù Ù » » ñ ñ Ç Ç Ï Ï ³ ³ Û Û Ç Ø
Ç ØÇ Ç ³ ³ ó ó Û Û ³ ³ É Ü
É Ü³ ³ Ñ Ñ ³ ³ Ý Ý · · Ý Ý » » ñ ñ Ç ¨
û û ñ ñ » » Ý Ý ù ù Ý Ý » » ñ ñ Ç Ñ
Ç Ñ³ ³ Ù Ù ³ ³ Ó Ó ³ ³ Û Û Ý å
Ý å³ ³ ï ï ³ ³ ë ë Ë Ë ³ ³ Ý Ý ³ ³ ï ï í í á á õ õ Ã Ã Û Û ³ ³ Ý »
Ý »Ý Ý Ã Ã ³ ³ ñ ñ Ï Ï í í » » É É á á õ ë
õ ëå å ³ ³ é é Ý Ý ³ ³ É É Ç Ç ù ù Ç ï
Ç ï³ ³ Ï Ï ` »
` »ë ë
Ñ Ñ ³ ³ Û Û ï ï ³ ³ ñ ñ ³ ³ ñ ñ á á õ õ Ù »
Ù »Ù, á
Ù, áñ ³
ñ ³Û Û ë Ã
ë û » ñ ñ Ã Ã Ç Ç Ï Ï Ç í
Ç íñ ñ ³ Ç
³ ÇÙ ï
Ù ïñ ñ ³ ³ Ù Ù ³ ³ ¹ ¹ ñ ñ ³ ³ Í ï
Í ï» » Õ Õ » » Ï Ï á á õ õ Ã Ã Û Û á á õ õ Ý Ý Ý Ý » » ñ ñ Á ×
Á ×ß ß Ù Ù ³ ³ ñ ñ ï ï ³ ³ ó ó Ç, ë
Ç, ëï ï á á õ õ Û Û · ¨
· ¨
³Ù
³Ùµ µ á á Õ Õ ç ç ³Ï
³Ï³Ý
³Ý » »Ý Ý : :
¸ÇÙáñ¹Ç ëïáñ³·ñáõÃÛáõÝÁ (ϳ٠Ýß³ÝÁ)
²Ùë³ÃÇíÁ
County Use
 QMB approved
 SLMB approved
 QI approved
 QMB/SLMB/QI-denied
Eligibility Worker’s signature
Date
Page 4 of 5
MC 14A ARM (Revised 03/2021)
Department of Health Care Services
State of California–-Health and Human Services Agency
DHCS
DHCS-Æ Ð²Úî²ð²ðàôÂÚàôÜÀ îºÔºÎàôÂÚàôÜܺðÆ ¶²ÔîÜÆàôÂÚ²Ü ä²Ðä²ÜزÜ
-Æ Ð²Úî²ð²ðàôÂÚàôÜÀ îºÔºÎàôÂÚàôÜܺðÆ ¶²ÔîÜÆàôÂÚ²Ü ä²Ðä²ÜزÜ
زêÆÜ
زêÆÜ
²Ûë ûñÃÇÏÁ §Department of Health Care Services¦-Ç (DHCS)-Ç ÙÇçáóáí Ýå³ëïÝ»ñ
ëï³Ý³Éáõ ѳٳñ ¿: ¸ÇÙáõÙÇ Ù»ç Ò»ñ ÏáÕÙÇó ïñ³Ù³¹ñíáÕ ³ÝÓÝ³Ï³Ý ¨ µÅßϳϳÝ
ï»Õ»ÏáõÃÛáõÝÝ»ñÁ ·³ÕïÝÇ »Ý: DHCS-Á ¹ñ³Ýó û·ÝáõÃÛ³Ùµ å»ïù ¿ å³ñ½Ç Ò»ñ
¨ ³Ûë ûñÃÇÏÇ Ù»ç Ýßí³Í ³ÛÉ ³ÝÓ³Ýó ÇÝùÝáõÃÛáõÝÁ ¨ ϳé³í³ñÇ Ù»ñ Íñ³·ñ»ñÁ:
Ø»Ýù Ò»ñ Ù³ëÇÝ ï»Õ»ÏáõÃÛáõÝÝ»ñÝ ³ÛÉ Ý³Ñ³Ý·³ÛÇÝ, ¹³ßݳÛÇÝ ¨ ï»Õ³Ï³Ý
ϳ½Ù³Ï»ñåáõÃÛáõÝÝ»ñÇ, ϳå³É³éáõÝ»ñÇ ¨ ³éáÕç³å³Ñ³Ï³Ý Íñ³·ñ»ñÇ
Ïïñ³Ù³¹ñ»Ýù ÙÇÙdzÛÝ Íñ³·ñ»ñÝ Çñ³Ï³Ý³óÝ»Éáõ Ýå³ï³Ïáí, ÇÝãå»ë ݳ¨
Ïïñ³Ù³¹ñ»Ýù ³ÛÉ Ý³Ñ³Ý·³ÛÇÝ ¨ ¹³ßݳÛÇÝ Ï³½Ù³Ï»ñåáõÃÛáõÝÝ»ñÇ` ûñ»Ýùáí
ÃáõÛɳïñí³Í ϳñ·áí:
¸áõù å»ïù ¿ å³ï³ë˳ݻù ³Ûë ûñÃÇÏÇ Ù»ç ïñí³Í µáÉáñ ѳñó»ñÇÝ,
µ³ó³éáõÃÛ³Ùµ ³ÛÝ Ñ³ñó»ñÇ, áñáÝó ¹ÇÙ³ó Ýßí³Í ¿ §Ï³ÙÁÝïñ³Ï³Ý¦: ºÃ»
Ò»ñ ûñÃÇÏÇ Ù»ç Ù»½ ³ÝÑñ³Å»ßï áñ¨¿ ï»Õ»ÏáõÃÛáõÝ å³Ï³ë ÉÇÝÇ, Ù»Ýù Ò»½
Ñ»ï ϳå Ïѳëï³ï»Ýù ³ÛÝ ëï³Ý³Éáõ ѳٳñ: ºÃ» ¸áõù ãïñ³Ù³¹ñ»ù ³Û¹
ï»Õ»ÏáõÃÛáõÝÝ»ñÁ, Ù»Ýù ã»Ýù ϳñáճݳ áñáßáõ٠ϳ۳óÝ»É Ò»ñ Ýå³ëïÝ»ñÇ
ϳå³ÏóáõÃÛ³Ùµ: Ðݳñ³íáñ ¿, áñ ¸áõù ëïÇåí³Í ÉÇÝ»ù Ýáñ ¹ÇÙáõÙ áõÕ³ñÏ»É,
³Ûɳå»ë ͳé³ÛáõÃÛáõÝÝ»ñÁ ÏÙ»ñÅí»Ý:
Ø»Í Ù³ë³Ùµ ¸áõù Çñ³íáõÝù áõÝ»ù ï»ëÝ»Éáõ Ò»ñ Ù³ëÇÝ ³ÛÝ ³ÝÓݳϳÝ
ï»Õ»ÏáõÃÛáõÝÝ»ñÁ, áñáÝù å³ÑíáõÙ »Ý ¹³ßݳÛÇÝ ¨ ݳѳݷ³ÛÇÝ
ϳ½Ù³Ï»ñåáõÃÛáõÝÝ»ñáõÙ: ò³ÝÏáõÃÛ³Ý ¹»åùáõÙ` ¸áõù ϳñáÕ »ù ¹ñ³Ýù ï»ëÝ»É
³ÛÉÁÝïñ³Ýù³ÛÇÝ Ó¨³ã³÷áí (ûñÇݳÏ` Ëáßáñ³ï³é): Èñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñÇ
ѳٳñ ¹ÇÙ»ù DHCS-Ç Information Protection Unit`
P.O. Box 997413, MS 4721
Sacramento, CA
95899-7413
Phone: 1-866-866-0602
TTY: 1-877-735-2929
лï¨Û³É ݳѳݷ³ÛÇÝ ûñ»ÝùÝ»ñÁ Ù»½ Çñ³íáõÝù »Ý ï³ÉÇë ѳí³ù»É ¨ å³Ñ»É
ï»Õ»ÏáõÃÛáõÝÝ»ñÁ. CA Welfare and Institutions Code § 14011 and Article 3, Chapters 5
and 7, Parts 2 and 3, Division 9: Ø»Ýù å»ïù ¿ Ò»½ ï³Ýù Ñ»ï¨Û³ÉÁ. Privacy Statement
under CA Civil Code § 1798.17:
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MC 14A ARM (Revised 03/2021)
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