Divine Agape Health Care Agency Referral Form

  • Personal Care & Homemaker Services

  • Personal Care and Homemaker Services (PCHS) support individuals who need help with:
    Activities of Daily Living (bathing, dressing, toileting, ambulation, feeding) and Instrumental Activities of Daily Living (meal preparation, grocery shopping, money management).
    These services closely align with those offered by the In-Home Supportive Services (IHSS) program and may include:

    • Housekeeping (cleaning, laundry)
    • Meal preparation
    • Shopping assistance
    • Personal care (bathing, grooming, bowel/bladder care, paramedical services)
    • Accompaniment to medical appointments
    • Supervision for individuals with cognitive or mental impairments

    Program overview

    PCHS helps individuals remain safely in their homes and may be authorized in the following scenarios:

    • During the IHSS application process: Including any waiting period after a referral. PCHS may be approved before IHSS services begin.
    • Supplemental support: When IHSS hours are insufficient or exhausted.
    • IHSS-ineligible individuals: To prevent short-term skilled nursing facility stays (up to 60 days).

    Note: For short-term PCHS, members are not required to apply for IHSS. However, authorization requests must document the risk of institutionalization without PCHS.

    Eligibility

    Individuals may qualify for PCHS if they:

    • Are at risk of hospitalization or institutionalization in a nursing facility.
    • Have functional impairment and lack adequate support.
    • Are approved for IHSS.

    Coordination with IHSS and Home and Community-Based Alternatives (HCBA) Waiver

    IHSS as primary support: PCHS supplements IHSS when authorized hours are insufficient.

    • HCBA waiver coordination: Waiver Personal Care Services (WPCS) under HCBA must be managed separately to avoid duplication.
    • Eligibility restrictions: Individuals receiving WPCS through HCBA are not eligible for PCHS. However, those on the HCBA waitlist may receive PCHS until waiver approval.

    Restrictions

    • PCHS cannot replace IHSS referrals. Eligible members must be referred to IHSS
    • If a member's condition changes, they must be reassesssed for IHSS. PCHS may continue during the reassessment period.

    Authorization:

    • Initial authorization: Based on assessed need; maximum duration is 60 days.
    • Authorization extension: 
      • IHSS denial: One-time 60-day authorization; no extensions.
      • Other needs: Submit reassessment and request every 30 days until IHSS is approved, a caregiver is identified or alternative care is arranged.

  • Referring Provider Information

  • Format: (000) 000-0000.
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  • Member Information

    Please complete members information
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Service Request

  • Referral Source Information

    Please complete your organization’s or person’s information
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • IHSS Status

  • Services Overview

  • Format: (000) 000-0000.

  • Current support & caregiver situation

  • Functional needs & ADL/IADL assessment

  • Additional Notes

  • 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.
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  • 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 may contact and notify the Manage Care Plan 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.
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