Referral Packet

Responsible Party

First Name *

Last Name *

Phone *

Relationship to Client/Member *

Client/Member Information

First Name *

Last Name *

Phone *

Date of Birth *

Gender *MaleFemale

Married *YesNo

9-Digit Medi-Cal Number *0 / 9

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

In which county does the applicant currently reside? *

Care Coordination Agency (CCA) Name

Where is the applicant currently residing? *

Who has the legal authority to make the applicant's health care decisions? *ApplicantOther

Was the legal representative notified of this request for the ALW waitlist? *YesNo

Is there Adult Protective Services / Long-Term Care Ombudsman Involvement? *If yes, please attach supporting documentation near the end of this form.YesNo

For home health agency, how many hours per week? *

For home health agency, what type of services received? *Attendant CareCertified Home Health Aide (CHHA)Nursing (RN)Nursing (LVN)

For IHSS, how many hours authorized per month? *

Authorization to Release Personal/Health Information

List individuals that are exceptions (optional):

Consent for Telehealth

Consent to Receive Services and Certification

I consent to the following programs and services (please select at least one): *Assisted Living Waiver Program (ALWP)Enhanced Care Management (ECM) ServicesCommunity Support (CS) ServicesCommunity Health Worker (CHW) Services

Assisted Living Waiver - Amenity Form

The Medi-Cal Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medi-Cal beneficiaries to live in the community and avoid institutionalization.

Each beneficiary of the ALW program is eligible and offered, at enrollment, the following benefits per Appendix C: Participant Services C-1/C-3 Service Specification):

Private or semi-private room with full bathroom (shared by not more than two beneficiaries). The choice of roommate is independent of the ALW.
Kitchenette, equipped with a refrigerator, a microwave (or cooking appliance) and adequate storage space for utensils and supplies.

You may waive your rights to the following (optional):A private roomA refrigeratorA microwave

Assisted Living Waiver - Freedom of Choice Form

This HCBS Waiver is intended to provide Medi-Cal beneficiaries with a choice to reside in an assisted living setting as an alternative to care in a nursing facility.

Whether accepting or declining these services, the Department is required to obtain written confirmation of your choice.

Your acceptance of refusal of ALW services is based on the following:

You have the right to choose an HCBS Waiver service provider who has been identified under the waiver as an able provider of the service(s) requested; and,
You are aware of your role and responsibility, and that of the providers, in the waiver program.

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