No Share of Cost Assessment Form
Date of Assessment:
*
-
Month
-
Day
Year
Date
Client Information:
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Date of Birth:
*
-
Month
-
Day
Year
Date
Power of Attorney Name:Type a question
Client Address:
Current Living Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Information:
Who Referred You to Us
Financial Information:
Social Security Income:
Pension Income:
Rental Income:
Savings Account Balance:
Annuity Monthly Payments:
Medi-Cal Application Status:
Has the Client Applied for Medi-Cal?
Yes
No
Client's Goal to Eliminate Medi-Cal Share-of-Cost:
What's Your Goal?
In-Home Supportive Services (IHSS): In need of a caregiver to assist with Activities ofDaily Living (ADL)
Access to DHCS Assisted Living Waiver Facility or Hospital Partnership
Hospitalization Details:
Date Admitted from Hospital:
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Month
-
Day
Year
Date
Date Discharged from Hospital:
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Month
-
Day
Year
Date
Medical Diagnosis:
Additional Notes:
Submit
Should be Empty: