Gold Country Community Directory Form
Thank you for sharing your information to help build a Connected Community of Care for Medi-Cal members with complex needs in Amador, Calaveras, Inyo, Mariposa, Mono and Tuolumne counties.
Name
*
First Name
Last Name
Title
*
Organization Name
*
Best Phone Number to Reach You
*
Format: (000) 000-0000.
Email Address
*
Website
Organization's Referral Coordinator
First Name
Last Name
Referral Coordinator's Email Address
Best Phone Number to Reach Referral Coordinator
Format: (000) 000-0000.
Organization Information
My organization is:
*
A contracted Enhanced Care Management (ECM) provider
A contracted Community Supports provider
Contracted to provide both ECM and Community Supports
Not contracted as an ECM or Community Supports provider
Interested in becoming a contracted ECM and/or Community Supports provider
Other
If your organization is a contracted provider, which Medi-Cal managed care plans are you contracted with? (Please choose all that apply.)
Anthem Blue Cross
Central California Alliance for Health (Mariposa County only)
Health Net
Kaiser Permanente
Other
If your organization is not a contracted provider, would you like your organization to be listed in the directory as a Community Partner?
Yes
No
Other
Counties we serve (Please select all that apply):
Amador
Calaveras
Inyo
Mariposa
Mono
Tuolumne
Other
Populations of Focus my organization serves: (Please check all that apply.) (Visit this website for more information: https://bit.ly/3UarRR0)
Individuals and Families Experiencing Homelessness
Individuals At Risk for Avoidable Hospital or EDUtilization
Individuals with Serious Mental Health and/or SUDNeeds
Individuals Transitioning from Incarceration
Adults Living in the Community and At Risk for Long-Term Care Institutionalization
Adult Nursing Facility Residents Transitioning to theCommunity
Children and Youth Enrolled in California Children's Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS Condition
Children and Youth Involved in Child Welfare
Birth Equity
Community Supports services my organization offers: (Please check all that apply.) (Visit this website for more information: https://bit.ly/49579Gq)
Housing Transition Navigation Services
Housing Deposits
Housing Tenancy and Sustaining Services
Short-Term Post-Hospitalization Housing
Recuperative Care (Medical Respite)
Respite Services
Day Habilitation Services
Nursing Facility Transition/Diversion to Assisted Living Facilities
Community Transition Services/Nursing Facility Transition to a Home
Personal Care and Homemaker Services
Environmental Accessibility Adaptations (Home Modifications)
Medically Supportive Food/Medically Tailored Meals
Sobering Centers
Asthma Remediation
Services Offered
*
Have you completed the DHCS form to register for the Gold Country CalAIM PATH Collaborative? (Here's the link: https://pcgus.jotform.com/222306493964865)
*
Yes
No
No, but I will today
I don't know.
Would your organization be willing to be a resource for other Gold Country PATH Collaborative members?
Yes
No
If yes, please check the ways you are willing to assist others in the Gold Country PATH Collaborative.
Becoming a provider
Applying for CalAIM funding
Answering referral and/or billing questions
Sharing information about managed care plans (MCPs)
Building engagement with Medi-Cal members
Sharing my story, e.g. a Provider Spotlight in a Collaborative meeting
Other
I consent to having the above information included in the Gold Country Community of Care Directory that will be shared with Gold Country CalAIM Collaborative participants.
*
Yes
No
Signature
Save and Continue Later
Submit
Should be Empty: