Home- And Community-Based Services (Hcbs) Waiver Application - California Department Of Health Care Services Page 2
ADVERTISEMENT
1
2HCBS Waiver Application
,
continued
If this application is being submitted for the applicant:
1. Was he/she or the legal representative notified of this application for the HCBS Waiver?
Yes
No
2. Who has the legal authority to make the applicant’s health care decisions?
_________________________ ________________
____
_________
Applicant
Other:
(
)
Name
Relationship
Telephone Number
3. Where is the applicant currently residing?
_________________________________________
At home
Hospital
Nursing facility:
Facility Name and City
________________________________
Other:
Please specify
Please identify all of your current providers of service:
_____________________________
____________
Home Health Agency – Name:
Hours per week:
Type of services received:
Attendant Care
Certified Home Health Aide (CHHA)
___
___
Nursing: RN
LVN
___________________________
In-Home Supportive Services (IHSS) - Hours Authorized Per Month:
•
To obtain IHSS eligibility information, please contact the applicant’s county Department of Social Services office and
ask for the IHSS Intake Department.
California Children Services (CCS) - Please describe the service(s) and frequency received:
_________________________________________
_____________________
Service:
Frequency:
_________________________________________
_____________________
Service:
Frequency:
___________________________
______________________
Regional Center
Service Coordinator:
Center Name
Name
________________________________
Adult or Pediatric Day Health Care:
Days per week: _______
Center Name
________
_________
Attends school outside of the home? If yes, # days/week?
# hours/day?
Does the school provide medical care services at school? (Ex; nursing care, therapy)
Yes
No
Multipurpose Senior Services Program (MSSP)
•
MSSP is an HCBS waiver benefit for Medi-Cal beneficiaries over the age of 65 that provides general services and
nursing support. For further information on this program, please call 1-800-510-2020, or go
to
Hospice
•
Hospice is a Medicare/Medi-Cal benefit for beneficiaries with a terminal diagnosis. For further information
on this
.
benefit, contact the applicant’s physician
Medical Case Management (MCM)
•
MCM offers short-term medical care services for beneficiaries without other sources of health insurance. For further
information, please call (916) 552-9100.
Please return the completed application to IHO at the address listed below. Should you (the applicant) relocate,
have a significant change in your/his/her health care needs, or change your/his/her Medi-Cal insurance status,
please contact IHO at (916) 552-9105.
_____________________________________________
(____) ________________ _________
Print name and title of person completing the application
Contact Telephone
Date
Enclosures
1501 Capitol Avenue, MS 4502; P.O. Box 997419; Sacramento, CA 95899-7419
(916) 552-9105
Internet Address:
3/07
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Odm 10172 - Home And Community-based Services (hcbs) Settings Evaluation Tool - Ohio Department Of Medicaid
Medical
Nhtd/sri Form 3 Home And Community Based Services Medicaid Waiver Nursing Home Transition And Diversion (nhtd)
Legal
Form Dma-3087 - Service Request For Home And Community-based Services Physician Attestation - North Carolina
Legal
Form Pm 101 - Application For Registration As School Audiometrist - California Department Of Health Care Services
Legal
Ahca Medserv-3008 Form - Medical Certification For Nursing Facility/home- And Community-based Services Form
Medical
Additional Family Members Requesting Medi-cal - California Department Of Health Care Services
Medical
Real And Personal Property - Supplement To Medi-cal Mail-in Application Form - Department Of Health Care Services
Legal
Related Categories
Parent category: Legal