Department of Health Care Services
State of California—Health and Human Services Agency
COUNTY USE ONLY
DEPARTMENT OF
Case name
Case number
DEVELOPMENTAL SERVICES
WAIVER REFERRAL
Worker name
Worker number
CALIFORNIA REGIONAL CENTER—Please complete this portion and forward to the appropriate County Waiver Contact Person.
Name of applicant
Address (number, street)
City
State
ZIP code
Social Security number
Date of birth
Telephone
(
)
Parent/Guardian (if applicable)
Address of parent/guardian (if different)
City
State
ZIP code
STATUS
Ì
New Medi-Cal applicant.
Ì
Currently receives Medi-Cal with a share of cost. Reevaluate under special institutional deeming rules.
LIVING ARRANGEMENT
Ì
The applicant is currently in an institution. Please determine Medi-Cal eligibility based on his/her anticipated return to the home.
Anticipated date of discharge ____________________.
Ì
The applicant is currently living in the home.
Ì
Other: __________________________________________________________________________
This is to certify that the individual named above has met the admission criteria for an intermediate care facility for the developmentally
disabled as defined in the California Health and Safety Code, Chapter 2, Section 1250.
Signature of Regional Center contact person
®
Printed name of Regional Center contact person
Title
Telephone
(
)
Regional Center address (number, street)
City
State
ZIP code
NOTE TO COUNTY: The eligibility determination waives parental and spousal income and resources even if the
applicant lives in the home. See Section 19D of the Medi-Cal Eligibility Procedures Manual. If the
applicant/beneficiary is entitled to zero share of cost Medi-Cal under regular eligibility rules, no waiver is required.
Please send a copy of the Notice of Action to the Regional Center when the determination is completed.
White: County copy
Yellow: Regional Center Copy
DHCS 7096 (05/07)