Home- And Community-Based Services (Hcbs) Waiver Application - California Department Of Health Care Services

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State of California-Health and Human Services Agency
Department of Health Services
SANDRA SHEWRY
ARNOLD SCHWARZENEGGER
Director
Governor
Home- and Community-Based Services (HCBS) Waiver Application
⇒ Para recibir esta información en español, por favór llámenos a uno de los números siguientes: (916) 552-9105.
To apply for one of the Medi-Cal HCBS Waivers administered by the In-Home Operations (IHO)
Section, please complete this two-page application.
______________________________
_________________
Applicant’s Name:
Home Phone: (____)
_______________________
_______
Date of Birth:
Age:
Married:
Yes
No
________________________
___________________
_________
Mailing Address:_
City:
, CA ZIP:
__________________________
Street Address:
City:
__________, CA ZIP: _________
(If different from Mailing Address)
Health Care Insurance:
________________________________________
Medi-Cal?
Yes
No If yes, Medi-Cal Number
Located on the applicant’s Medi-Cal Beneficiary Identification Card (BIC)
Medicare?
Yes
No If yes,
Part A
Part B
Part A & B
Part D
___________________________________
Other Medical Insurance?
Yes
No If yes, identify
_______________________________________
List current medical diagnoses (main illness or injury):
_______________________________________________________________________________
_______________________________________________________________________________
Check the boxes that identify your current medical needs. Use the blank spaces below to write-in your specific
medical needs that are not listed. You may provide additional comments on the back of the application.
______
Ventilator - Hours Used Per Day (hrs/day)
Tracheostomy
______
Continuous Positive Airway Pressure (CPAP) Device – hrs/day
Tracheal Suctioning
_______
Bi-Level Positive Airway Pressure (BiPAP) Device – hrs/day
Oral Suctioning
______
Respiratory Treatments - number per day
Nasal Suctioning
Room Air Mist
Continuous Use of Oxygen
Oxygen as needed
Oral (by mouth) Medications
Oral (by mouth) Feedings
Urinary Incontinence
Gastric Tube (GT) Medications
Gastric Tube (GT) Feedings
Bladder Catheterizations
Intravenous (IV) Medications
Intravenous (IV) Nutrition
Bowel Incontinence
Chronic Pain Treatment
Pressure Sores/Open Wounds
Routine Bowel Care
Contractures
Skin or Wound Treatments
Urostomy/Colostomy
Some ability to move arms or legs. Needs some help with care needs. Briefly explain on back.
No movement of arms or legs. Needs total help with care needs. Briefly explain on back.
Special equipment needs. (ex: wheelchair, lift system, ramp) Briefly explain on back.
_________________________________________________________________________
Other
1501 Capitol Avenue, MS 4502; P.O. Box 997419; Sacramento, CA 95899-7419
(916) 552-9105
Internet Address:
3/07
1

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