REFERRAL PRIORITY & SERVICES
PRIORITY LEVEL
*
URGENT - RESPOND WITHIN 24 BUSINESS HOURS
EXPEDITED - RESPOND WITHIN 72 BUSINESS HOURS
ROUTINE - RESPOND WITHIN 5-7 BUSINESS DAYS
TYPE OF SERVICES
*
PCHS (PERSONAL CARE & HOMEMAKER)
RESPITE SERVICES
DATE OF REFERRAL
*
-
Month
-
Day
Year
Date
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REFERRAL SOURCE INFORMATION
REFERRING ORGANIZATION
Please Select
Health Plan
Hospital / Acute Care
Physician / Clinic
Behavioral Health Provider
Post-Acute Facility
Home-Based Care Provider
Community-Based Organization (CBO)
County / Government Agency (includes IHSS)
Care Management / ECM Provider
Housing / Social Services
Justice System
Education / Youth Services
Self / Family Referral
NPI OF REFERRING PROVIDER
REFERRED BY
*
Full name
TITLE / ROLE
REFERRAL CONTACT INFORMATION
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
PREFERRED CONTACT
*
PHONE
EMAIL
GENERAL INFORMATION
RELATION TO MEMBER
*
SELF
PARENT / GUARDIAN
FAMILY / FRIEND
PCP
ECM PROVIDER
GCHP STAFF
Other
CONFIRMATION SIGNATURE
*
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MEMBER INFORMATION
CURRENT HEALTH PLAN
*
Please Select
GOLD COAST HEALTH PLAN
OTHER
MEDI-CAL ID
*
Member Full Name
*
First Name
Last Name
DATE OF BIRTH
*
-
Month
-
Day
Year
Date
PREFERRED LANGUAGE
*
CONTACT INFORMATION
PHONE NUMBER
*
Please enter a valid phone number.
Format: (000) 000-0000.
PREFERRED CONTACT
*
PHONE CALL
TEXT
INTERPRETER NEEDED?
*
YES
NO
GENERAL INFORMATION
MEMBER INFORMED OF REFERRAL?
*
Please Select
YES
NO
HAS AUTHORIZE REP OR INFORMAL CAREGIVER
*
Please Select
YES
NO
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IHSS STATUS & PCHS NEED
IHSS STATUS
*
Referral has been made — awaiting determination
Awaiting Health Certificate
IHSS active — No IHSS provider assigned
IHSS active — Insufficient hours (Maxed IHSS hours) — PCHS supplementsremaining unmet ADL/IADL need
IHSS active — Insufficient hours (Pending IHSS county reassessment) —PCHS bridges while reassessment is in progress
IHSS active — Insufficient hours (Short-Term Functional Need / Recovery)— PCHS bridges during temporary decline or recovery
IHSS ineligible — Must document need for SNF-level care when PCHS isavailable as an alternative
Unknown
EST. BRDIGE DURATION
*
60 DAYS
3 MONTHS
6 MONTHS
CLINICAL SNAPSHOT
PRIMARY DIAGNOSIS (ICD-10)
*
List One
FUNCTIONAL NEEDS
*
ADL (Activities of Daily Living)
IADL (Instrumental Activities of Daily Living)
ADDITIONAL COMMENTS
ADDITIONAL COMMENTS
Discharge Letter or PCP
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