Declaration of Eligibility

This form is for a Physician/AP to establish presumptive eligibility and must be signed by the member's Primary Care Provider (PCP) or a provider with an established relationship with the member.

To be completed by the Primary Care Provider (PCP) or other physician/practitioner (practitioner).

I, , in the professional capacity as a , affirm that Member is currently receiving a medically necessary Skilled Nursing Facility Level of Care (SNF LOC) or meets the minimum criteria for receiving SNF LOC services and, in lieu of entering a facility, is choosing to remain in the community and continue receiving medically necessary SNF LOC services in an assisted living facility for the following reason(s):

Medical Record Number (MRN)

For Health Net use the Medi-Cal number (starts with 9). For Kaiser use their specific MRN.

1. Please provide a short narrative on why you believe the member is at risk for premature institutionalization and his/her need for the CS:

Provider's Title

Provider's NPI #

Provider's Phone

Provider's Email

Provider's Organization

Provider's Signature (Full Name)

Signature Date