CalAIM Community Supports Prior Authorization Request
Date of Request:
*
 /
Month
 /
Day
Year
Date
Community Supports Program:
Recuperative Care (Medical Respite)
Short Term Post Hospitalization Housing
Member Information:
Member's Name:
*
First Name
Last Name
Member's Date of Birth:
*
 /
Month
 /
Day
Year
Date
Member's Medi-Cal Client ID Number:
*
Member's Address (if available):
Member's Primary Phone Number:
Format: (000) 000-0000.
Member's Email (if available):
example@example.com
Language:
English speaking
English not primary language
Member's Preferred Language:
Homeless Status [Check all that apply]:
*
Currently homeless
Chronically homeless
Lives alone and no formal support
Lives in an inappropriate place ie. car, tent
Facing housing insecurity or non-consistent
Current housing may jeopardize health and safety
Eligibility for Either Program [Check all that apply]:
*
Post-hospitalization
At-risk of hospitalization
Still needs to heal from an injury or illness (including behavioral health)
Too ill or frail to recover from an illness or injury (physical or behavioral health) in usual living environment
Needs to achieve or maintain medical stability and prevent hospital admission/readmission (which may require behavioral health interventions)
Condition would be exacerbated by an unstable living environment
Still needs recovery and post-discharge (medical) treatment
Limited or short term assistance with Instrumental Activities of Daily Living and/or ADLs
Needs ongoing monitoring of medical or behavioral health condition (i.e. monitoring vital signs, assessments, wound care, medication monitoring)
Social Determinants of Health (SDOH) ICD-10 Diagnosis Identified within prior 12 months [Check all that apply]:
*
Z55.0 Illiteracy and low-level literacy
Z59.0 Homelessness
Z59.10 Inadequate housing (unspecified)
Z59.3 Problems related to living in residential institution
Z59.4 Lack of adequate food and safe drinking water
Z59.7 Insufficient social insurance and welfare support
Z59.8 Other problems related to housing and economic circumstances
Z59.811 Housing instability, with risk of homelessness
Z60.2 Problems related to living alone
Z59.812 Housing instability, with homelessness in last 12 months
Z60.4 Social exclusion and rejection (physical appearance, illness or behavior)
Z62.819 Personal history of unspecified abuse in childhood
Z63.0 Problems in relationship with spouse or partner
Z63.5 Disruption of family by separation and divorce (marital estrangement)
Z63.6 Dependent relative needing care at home
Z63.72 Alcoholism and drug addiction in family
Z65.1 Imprisonment and other incarceration
Z65.2 Problems related to release from prison
Z65.8 Other specified problems related to psychosocial circumstances (religious or spiritual problem)
Referral Source Information:
Referral By:
*
Hospital
ECM
SNF
Outpatient Clinic
Community Outreach
Referring Organization Name:
*
Referring Individual Name:
Referrer Phone Number:
Format: (000) 000-0000.
Referrer Fax Number:
Format: (000) 000-0000.
Referring Individual Email:
example@example.com
Referring Attending/Provider:
Referring Attending/Provider's NPI (if known):
Referral Information:
Expected Admission Date:
*
 /
Month
 /
Day
Year
Date
Diagnoses/Reason(s) for Admission:
Height:
Weight:
Any Known Allergies:
Any Dietary Restrictions:
Mental/Physical Health Information:
History of Mental Health (MH) Issues:
Yes
No
Main MH history [Check all that apply]:
Anxiety Disorder
Depression
Major depression
Schizophrenia
Bipolar disorder
Paranoid Schizophrenia
Substance use disorder
Psychotic disorders
Other Stimulant abuse
Serious mental disturbance
Psychoactive substance abuse
Serious Mental Illness
Cognitive impairment or dementia
Trauma-related
Altered Mental Status
ADHD
Suicidal Ideation
Insomnia
PTSD
Adjustment Disorder
Other
Clinical Chronic Conditions:
Asthma
Chronic congestive heart failure
Chronic kidney disease
Chronic liver disease
Coronary artery disease
COPD
Diabetes
Hypertension
HIV/Aids
Cancer
Seizures
Other
TB Test or Chest X-Ray Performed:
Yes
No
Any Communicable Disease (If YES, please include documentation):
Yes
No
Colonized (If YES, please include documentation):
Yes
No
Covid-19 Test Performed (If YES, please include documentation):
Yes
No
Covid-19 Test Results:
Positive
Negative
Wound Care:
Does Member Require Wound Care?
Yes
No
What Stage?
1
2
3
4
Location(s) on Body:
Can Member perform wound care independently?
Yes
No
Who will be providing home health services (if known)?
Substance Use:
Alcohol:
Yes
No
Smoking:
Yes
No
Cannabis
Cocaine:
Yes
No
Opioids or Painkillers:
Yes
No
Heroine:
Yes
No
Methamphetamine:
Yes
No
Methadone Clinic needed?
Yes
No
Other
Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL):
Is Member Independent with ADLs?
Yes
No
Please check all ADL issues that apply:
Mobility/walking
Transferring bed/chair
Bathing
Dressing
Eating
Grooming/personal hygiene
Toileting
Mouth care
Climbing stairs
Is Member Independent with IADLs?
Yes
No
Please check all IADL issues that apply:
Shopping
Meal preparation
Housework
Money management
Transportation
Medication management
Communication (ie telephone or computer)
Medical Stability and Care:
Self-Administering medication:
Yes, 100% independently
No, needs reminders
No, needs reminders and assistance
Is Member continent with bladder?
Yes
No
Can self-care be completed independently?
Yes
No
Is Member continent with bowel?
Yes
No
Can self-care be completed independently?
Yes
No
Does Member require colostomy care?
Yes
No
Who is providing the colostomy supply?
Does Member require catheter care?
Yes
No
Can it be completed independently?
Yes
No
Does Member require antibiotics?
Yes
No
Does Member require an IV infusion? (If YES, please provide documentation):
Yes
No
Is the PICC line already in place at discharge?
Yes
No
Alcohol detox needed?
Yes
No
Durable Medical Equipment (DME) Dependent:
Does Member require a Walker?
Yes
No
Does Member require a Cane?
Yes
No
Does Member require Crutches?
Yes
No
Does Member require a Wheelchair?
Yes
No
Please check one of the following:
Manual wheelchair
Electric wheelchair
Does Member require Oxygen?
Yes
No
Please indicate how many liters Member will be discharged with:
Does Member require Wound Vac?
Yes
No
Does Member require a BiPAP?
Yes
No
Does Member require a CPAP?
Yes
No
Does Member require any other DME? [Please list]:
Additional Clinical Information:
Overview of Member's clinical concerns:
Does Member require Medication? (If YES, please provide Rx list):
Yes
No
Does Member require Medication Management and Education?
Yes
No
Does Member require Physical Therapy?
Yes
No
Please Attach Following Information:
Included in Submission:
Facesheet
CXR or PPD (TB)
History & Physical
S.W. Notes
Consultation Notes
Recent PT/OT/Speech
Medication List
Wound Care notes
Psych notes (please include last 2 days of nursing documentation)
Covid-19 Test result (within last 24 hours)
Home Health Provider info
All RXs to be filled
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