Referral - North

Referral Form for MediCal Transformation Program (CalAIM)

Please complete the following form to refer individuals or yourself for Community Supports services under the MediCal Transformation Program (CalAIM). This form ensures we have the necessary information to provide the best care and support possible.

Referral Source Information

Please select if you are not an organization and are submitting a referral for yourself.

Referring Organization

First Name

Last Name

Position/Title

Phone

Member Information

First Name

Middle Name

Last Name

Preferred Name

Date of Birth

Gender

Pronouns

Other Pronouns (please specify)

Language

Address

City

State

Postal Code

Phone Number

Managed Care Plan

Managed Care Plan Member ID

ICD-10 Codes (Diagnosis Codes)

Has the member identified someone they would like to have as their caregiver?

Please note: Having a caregiver identified is not required to receive services

Yes

Consent Type

The member understands that Community Support services are meant to supplement, not replace, IHSS or other state, local, or federally funded programs.

Yes

Member’s Main Contact (if not self)

First Name

Last Name

Phone

Language

Relationship to Member

Criteria for Community Supports

Personal Care and Homemaker Services (PCHS)
Services to assist eligible members with activities of daily living.

IHSS Status

IHSS Case Number

Date Applied

IHSS Hours

Frequency

Waitlist Date

Reevaluation Date

Supporting Clinical
Documents

IHSS
Letter

Respite Services (RS)
Services to provide temporary relief for caregivers of eligible members.

Primary Caregiver Name

Reason for Respite Request

Please specify the reason for respite

Before Leaving This Page

Wait until you see the "Thank You" message. Do not leave this page before that. Once your referral is successfully submitted, you will receive an emailed receipt.

Referral Form for MediCal Transformation Program (CalAIM)

Referral Source Information

Member Information

Member’s Main Contact (if not self)

Criteria for Community Supports

Additional Care and Support Needs