Financial Assistance Application - Hmong

Valley Children’s Hospital
9300 Valley Children’s Place
Madera, CA 93636
Patient Accounting Department PCX 102
Daim Ntawv Thov Nyiaj Txiag Pab
Thov muab daim ntawv no ua kom tag nrho thiab xa rov qab tuaj nrog cov ntaub ntawv uas tau hais kom nqa tuaj nrog
li 15 hnub, xa tuaj rau qhov chaw nyob tau sau rau saum toj no. Xav tau kev pab ua daim ntawv thov no kom tiav losyog
muaj lus nug ntxiv thov hu rau 559-353-7009.
Thov muab cov ntaub ntawv raws li nram no tuaj nrog (cim tag nrho cov kom muaj):
1._____Qhia tseeb txog koj qhov chaw nyob (daim qhi faisfab, Cable losyog xovtooj)
2._____Qhia tsevneeg seb muaj tsawg leej (koj daim copy se (tax return) tsis ntev no)
3._____Cov tw check lub hli dhau los losyog sau ib daim ntawv qhia nyiaj uas muaj
koos pasnis lub npe rau saum daim hau ntawv thiab xee los ntawm koj tus nai
4._____Ntawv qhia nyiaj hauv bank tsis ntev los no
5._____Notice of Action from Government sponsored insurance program
6._____Lwm yam ntaub ntawv uas yuav tsum muaj thiaj paub ua koj cov ntawv thov nyiaj pab
Lus Paub Txog Tus Neegmob
Neegmob Npe: ____________________________________________________
Neegmob tus Najnpawb Ntaub Ntawv____________________________________
____________________________________
Tus Neeg Thov/Tus Neeg Lav
Txheeb Ze rau Neegmob: _____________________________________
Npe:_____________________________________________________
Chaw Nyob: _______________________________________________ Xovtooj Ntawm Tes:_________________
Nroog/Lav: ________________________________________________ Xovtooj Hauv Tsev:__________________
Tus Neeg Nrog Thov/Tus Neeg Lav
Txheeb Ze rau Neegmob:______________________________________
Npe: ____________________________________________________ Xovtooj Ntawm Tes__________________
Tsevneeg: Teev tag nrho cov neeg uas tos koj pab nkaus xwb (tsis xam koj thiab Tus Neeg Nrog Thov)
Npe
Hnub Nyug
Txheeb Ze
____________________________________ ___________________________________________
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Nplooj 1 ntawm 3
Neegmob Npe: ________________________________________________________
Neegmob tus Najnpawb Ntaub Ntawv_______________________________________
Lus Paub Txog Kev Ua Hauj Lwm
Tus Neeg Thov/Tus Neeg Lav
Tus Tswv Hauj Lwm:__________________________________________ Luag Hauj Lwm: __________________
Tus Neeg Hu Cuag:__________________________________________ Xovtooj: ________________________
Yog Koj Ua Koj Li Hauj Lwm,
Npe Hauj Lwm: ________________________________________ Xovtooj: ________________________
Tus Neeg Nrog Thov/Tus Neeg Lav:
Tus Tswv Hauj Lwm:__________________________________________ Luag Hauj Lwm:___________________
Tus Neeg Hu Cuag: _________________________________________ Xovtooj:_________________________
Yog Koj Ua Koj Li Hauj Lwm,
Npe Hauj Lwm: ________________________________________ Xovtooj:_________________________
Nyiaj Hli Tam Sim No:
Tus Neeg Thov/Tus Neeg Lav
Tus Neeg NrogThov/Tus Neeg Lav
_____________________
_____________________
Nyiaj Txiag los ntawm Kev Ua Lag Luam
(Yog Koj Ua Koj Li Hauj Lwm)
Nyiaj txiag los lwm qhov los
_____________________
_____________________
Paj laum
__________________________________________
Los ntawm vaj tse liaj teb losyog khoom ntiag tug
__________________________________________
Nyiaj Laus
__________________________________________
Tau txais nyiaj pab Txij Nkawm/Nqi Menyuam
__________________________________________
Nyiaj tau los ua ntej txiav se
Ntxiv
Lwm yam nyiaj txiag (qhia seb yog dab tsi)
__________________________________________
__________________________________
Rho tawm
Tau them nyiaj rau Txij Nkawm/Menyuam
_____________________
_____________________
Tawm yog
Nyiaj Hli Tam Sim No
_____________________
_____________________
Tag nrho nyiaj txiag rau lub hli tam sim no yog (ntxiv tus thov/tus lav + Tus Nrog Thov/Tus Lav)
_________________________________________
Siv Tawm:
Rho Nyiaj Hnab Tshos Them Nqi Khomob 12 lub hlis dhau los no: _________________________________________
(Rho Nyiaj Hnab Tshos los them nqi txawm hais tias los ntawm tus thov Applicant losyog tus nrog thov Co-Applicant sawv
cev rau tus neegmob ntawm 12 lub hlis uas ua ntu zus los)
Nplooj 2 ntawm 3
Neegmob Npe: ________________________________________________________
Neegmob tus Najnpawb Ntaub Ntawv_______________________________________
Kuv lees paub tias cov saum no muaj tseeb thiab raug. Kuv to taub tias cov xwm txheej sau rau hauv daim ntawv thov pab
uas tau muab xa tuaj mus no yuav tau taug seb puas tseeb los ntawm tsev khomob Valley Children’s Hospital thiab tshawb
xyuas dua ntxiv los ntawm cov koom haum hauv Teb Chaws Federal thiab/losyog State Enforcement Agencies. Tus tau xee
npe nram no pom zoo tias yeej qhia qhov muaj tseeb rau cov lus paub yam tsim nyog kom muaj. Tej zaum xav tau lus paub
ntxiv thiab.
____________________________________________________
______________________________
Tus Neeg Thov/Tus Neeg Lav Xee Npe Hnub Tim
____________________________________________________
______________________________
Tus Neeg Nrog Thov/Tus Neeg Lav Xee Npe
Hnub Tim
Valley Children’s Hospitalqhov nyiaj txiag pab no tsis kam them rau cov neeg ua hauj lwm txheej siab professional services
uas tuaj muab kev khomob rau cov neegmob hauv tsev khomob no xws li cov kws khomob los sis lwm cov neeg khomob
koom nrog tab sis tsis txwv rau kev pab ntawm thaij fais fab, tshuaj tsaug zog, kuaj kabmob losyog tsev khomob cov kws
khomob.
Nplooj 3 ntawm 3