CS Member Summary

This form gathers essential information about the member to determine eligibility for the CalAIM Community Supports program.

Member Information

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Age

Medi-Cal Number

This is a 9 character number starting with '9' and ending with a letter.

Confirm Medi-Cal Number

Medical Record Number (MRN)

For Health Net use the same Medi-Cal number. For Kaiser this is not the Medi-Cal number but a distinct number oftentimes starting with some zeros.

Confirm Medical Record Number (MRN)

Preferred Language

e.g., English, Spanish

County

Your Information (Person Filling Out Form)

First Name

Last Name

Your Phone

(xxx) xxx-xxxx

Your Email

Relationship to Member (e.g., Family Member, Social Worker)

Agency (e.g., Bob's Referral Agency, Hospital Name, etc.)

If not applicable, leave blank.

Primary Contact Person

First Name

Last Name

Relationship to Member

Phone

(xxx) xxx-xxxx

Preferred Language

Secondary Contact Person (Optional)

First Name

Last Name

Relationship to Member

Phone

(xxx) xxx-xxxx

Preferred Language

Legal Representative

A legal representative (e.g., with Power of Attorney) is distinct from a contact person. If the legal representative is also the primary or secondary contact, please enter their information again here to confirm their legal role.

Does member have capacity to make their own decisions?

Yes

Does member have a legal representative? (e.g., power of attorney)

Yes

Unknown

Representative's Contact Info

Is the Legal Representative also the Primary Contact Person?

If the member does not have a legal representative, you can leave these fields blank.

First Name

Last Name

Relationship to Member

Phone

(xxx) xxx-xxxx

Location Information

Member's Current Location

Home

Hospital

Skilled Nursing

Unhoused

Sub-Acute

Assisted Living

Other

Current Address

Street Address

City

State

ZIP Code

County

Customary Residence (where is the member's normal long term address)

Same as current location

Street Address

City

State

ZIP Code

County

Health Plan & Pathway

Health Plan (Managed Care Plan)

Kaiser Permanente

Health Net

Other

If Other, what is existing health plan?

Will member be switching Health Plan by end of month?

Yes

N/A

Pathway Selection

SNF Transition

SNF Diversion

SNF Transition Eligibility Requirements

Enables a current SNF resident to transfer to a RCFE or ARF.

Has resided in a SNF for at least 60 consecutive days (which can include a combination of Medicare and Medi-Cal days and back and forth from SNF-hospital-SNF); and
Is willing to live in RCFE as an alternative to a SNF; and
Is able to safely reside in RCFE with appropriate and cost-effective supports and services.

SNF Diversion Eligibility Requirements

Transition a member who, without this support, would need to reside in a SNF and instead transitions him/her to RCFE or ARF.

Interested in remaining in the community; and
Is able to safely reside in RCFE with appropriate and cost-effective supports and services; and
Must be currently at medically necessary SNF level of care: e.g., require substantial help with activities of daily living (help with dressing, bathing, incontinence, etc.) or at risk of premature institutionalization; and meet the criteria to receive those services in RCFE or ARF.

Reason for SNF Diversion (if applicable)

All criteria for the selected pathway (SNF Diversion/Transition) have been met.

ISP & Facility Information

Individual Service Plan (ISP) Contact

First Name

Last Name

Relationship to Member

Facility Name

Phone

(xxx) xxx-xxxx

ISP Assessment Location

Same as current location

Type of Location

Home

SNF

RCFE

Hospital

Sub-Acute

Unhoused

Other

Street Address

City

State

ZIP Code

County

Assisted Living Waiver (ALW) Status

Is the member currently on the ALW waitlist?

Yes

Unknown

RCFE Selection

Has a preferred assisted living facility (RCFE) been chosen?

Yes

Preferred Facility Details

If a facility has not been chosen, you can leave these fields blank.

Facility Name

Facility Address

Administrator Name

Administrator Phone

(xxx) xxx-xxxx

Administrator Email