Divine Agape Health Care Agency Referral Form

Member Information

Please complete members information
Medi-Cal ID*
Insurance Name
Example: Gold Coast Health Plan
Member Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Member preferred contact
Language Preference*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referral Source Information

Please complete your organization’s or person’s information
Referring Organization Name
Facility or Business (optional)
Full Name*

First NameLast Name
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Direct Phone Number*
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Email*
example@example.com
Preferred Contact Method*
Relation to member

SelfParent / GuardianPrimary Care Provider (PCP)ECMOther service providerGCHP StaffCommunity Based OrganizationCSOther
Has the member been informed that a referral was being submitted?*

Department of Health Care Services (DHCS) Summary

Updated: April 2025 | Effective: July 1, 2025
Personal Care and Homemaker Services (PCHS)

What is PCHS?

PCHS helps members remain safely at home by providing assistance with:
- Personal Care: Bathing, dressing, toileting, mobility, and eating
- Homemaker Tasks: Meal preparation, shopping, light housekeeping, laundry, and money management
- Other Support: Transportation to medical appointments and supervision for memory-related conditions
When Can Members Get PCHS?

While waiting for In-Home Supportive Services (IHSS) approval
If member need additional help beyond members approved IHSS hours
If member don’t qualify for IHSS but need help to avoid nursing home placement (up to 60 days)

Is the Member Eligible?

Member may qualify if:
- Member are at risk of hospitalization or nursing home placement
- Member have difficulty performing daily activities independently
- Member lack sufficient support from family or friends
- Member have applied for or been approved for IHSS
Important Things to Know
- IHSS is the primary program for in-home help. PCHS can only provide extra hours if IHSS is not enough
- Member cannot receive PCHS and HCBA Waiver services at the same time
- If member's needs change, member's IHSS hours must be reassessed (member can keep PCHS while waiting)
- Member must apply for IHSS if member might qualify
Respite Services

What is Respite?

Respite gives member family caregiver a break by providing temporary, non-medical care so they can rest and avoid burnout
What Does Respite Include?
- Short Breaks: A few hours for errands or rest
- Longer Breaks: Day or overnight care when your caregiver is away
- Basic Help: Supervision, companionship, daily routines, and safety
Where Can Member Receive Respite?

Out-of-Home: Approved care facilities or community programs

At Home: A Hone Care Aide comes to member's home

Why is Respite Important?

It helps caregivers stay healthy and prevents unnecessary nursing home placement

Is the Member Eligible?

Member may qualify if:

Member live at home and rely on a family or unpaid caregiver
Member need supervision or help throughout the day
Without member's caregiver, member might need nursing home care
(Includes children with special health needs, foster care members, and individuals with complex medical or behavioral conditions)

Service Limits

Maximum: 336 hours per year (combined in-home and out-of-home)
Exception: Additional hours may be approved if your caregiver is hospitalized or unable to provide care
Important: No more than 24 hours of combined in-home services per day
Not Allowed: Video or phone-based respite services

Supporting Documents

Providing supporting documents can help members get reviewed for services more quickly. Documents may be discharge letters, care summary, care plans, and other relevant information about the member.
Type of document
Example: Discharge Summary, IHSS Application
Supporting Document

Please upload (one or multiple)
Cancelof

Disclaimer and Acknowledgment

The information provided above has been obtained to the best of my ability. The member has been informed and acknowledges that Divine Agape Health Care Agency will contact and notify GCHP and the client regarding the requested services. While criteria are established by DHCS, services may or may not be approved by the Mange Care Plan (MCP). The client must meet the criteria set forth by MCP, which include:
- Individuals at risk for hospitalization or institutionalization in a nursing facility; OR
- Individuals with functional deficits and no other adequate support system; OR
- Individuals approved for In-Home Supportive Services (IHSS). These services cannot replace IHSS but may be provided in addition to IHSS. Members must be referred to the IHSS program when they meet referral criteria.
This referral is made in compliance with GCHP and DHCS Close Loop Referral requirements.
Today's Date*

MonthDayYear
Date
Full Name & Role*
Example: Sally Blacksmith, Care Coordinator
Signature*

Powered by Jotform SignClear
Please verify that you are human*
Should be Empty:

Member Information

Referral Source Information

Services Overview

Supporting Documents