Fillable MEDI-CAL kdasbMeBjkaryl'Bm MEDI-CAL NOTICE OF ACTION (Department of Health Care Services)

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MEDI-CAL kdasbMeBjkaryl'Bm MEDI-CAL NOTICE OF ACTION (Department of Health Care Services)

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State of California – Health and Human Services Agency Department of Health Care Services
MEDI-CAL NOTICE OF ACTION ┌ ┐
RESTRICTED BENEFITS APPROVAL
WITH SHARE OF COST:
REFERRED TO THE COUNTY
OR LOCAL-SPONSORED
HEALTH INSURANCE PROGRAM └ ┘
┌ ┐
└ ┘
MC 4035 (04/08) – Cambodian
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elxsMNMuerOg :
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elxTUrs&Bæ«nG~keFÃIkar :
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kUnrbs'G~kEdlmankt'enAxagelI GacnwgmansiTìiTTYlkarraÔb'rgsuxPaB eday²tKit«f ÉmandM«Lefak tamry:kmμviFI _____________________;
(Insert name of program)
Edlp¶l'karEfTaMsuxPaBsMrab'ekμg@ EdlBMumansiTìiTTYl Medi-Cal É Healthy Families eBjelj . ebIG~kp¶l'[eyIgnUvkaryl'¨Bm
eyIgnwgbJØèn¨kdasdak'Bak´sMu«nkUnrbs'G~k eTAkmμviFIenH .
ebIG~kyl'¨Bm[eyIgbJØèn¨kdasdak'Bak´sMu Medi-Cal «nkUnrbs'G~k eTAkmμviFIEdlEfÂgenAxagelI eKnwgBinit´emIlB&támansaeLIgvij E¨kgelakUn
rbs'G~kmansiTìiTTYl . ebIG~kyl'¨Bm G~knwgminVc'bMeBj¨kdasdak'Bak´sMufμI edImºIdak'Bak´sMukmμviFIEdlEfÂgenAxagelIeLIy ehIyG~ktMNag
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ebIG~kcg'p¶l'karyl'¨Bm [bJØènB&táman«nkUnrbs'G~keTA[eK G~k¨tUvEtKUs¨bGb'enAxage¨kam ¨BmTaMg¨tUvcuHhtÄelxa nigcuHEx«f©q~aM
enAelI¨kdasbMeBjenH ehIyepÆIva¨tLb'eTAexanFIvij tamGasyd½anenAxagelI . G~kk*GacnwgTUrs&BæeTAG~keFÃIkarxag Medi-Cal rbs'G~kEdr
edImºI¨Vb'Kat'[dwgfaG~kcg'p¶l'karyl'¨Bm .
ebIG~kmincg'p¶l'karyl'¨BmeT G~kminVc'epÆI¨kdasbMeBjenHmkvijeLIy . ebIG~kminepÆI¨kdasbMeBjenHmkvijeT mann&yfakaryl'¨Bmmin Vn
p¶l'eLIy . ¨kdasdak'Bak´sMu Medi-Cal «nkUnrbs'G~k nwgminVnepÆIeTA[eKeLIy ehIykUnrbs'G~knwgminTTYlkarraÔb'rgEfTaMsuxPaB tamkmμviFI
ep§g@eTotrbs'exanFIeT luH¨taEtG~kdak'Bak´sMu .
xƬMp¶l'karyl'¨Bm [bJØèn¨kdasdak'Bak´sMu Medi-Cal «nkUnrbs'xƬM eTA[ ______________________________
(Insert name of program)
htÄelxa : ___________________________________ Ex«f©q~aM : ____________ elxTUrs&Bæ : __________________
(epÆI¨kdasbMeBjenHmkvij ÉTUrs&BæmkCMrabkartbeqÂIyrbs'G~k eTAG~keFÃIkarrbs'G~k k~¬gry:eBl¨VM«f© tamGasyd½an ÉelxTUrs&BæEdlmankt'enAxagelI)
ebIG~kmansMNYrGÃI ÉebI¨tUvkarB&támanbEnÄm sUmTak'TgeTAG~keFÃIkar Medi-Cal rbs'G~k Edlmankt'enAEbÔkxagelI xags¶aM«d «nesck¶ICUndMNwgenH .
sUmTUrs&BæeTA _______________________________ ebIG~kcg'VnB&támanbEnÄm s¶IGMBI _______________________________ .
(Insert program phone number) (Insert name of program)
MEDI-CAL
¨kdasbMeBjkaryl'¨Bm
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MEDI-CAL kdasbMeBjkaryl'Bm MEDI-CAL NOTICE OF ACTION (Department of Health Care Services)

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Completed 23 November 2020

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