CBAS MEMBER DISCHARGE PLAN AND REASON
CBAS CENTER NAME:
Long-Term Services and Supports/CBAS
Phone: (855) 227-1314 Fax: (714) 481-6423
Please Type or Print Legibly
Member Information
Name: Date Last Attended:
Date Discharged:
Client Identification Number (CIN): Date of Birth:
Address: Name of Physician(s):
City, State, ZIP: CBAS Authorization Number:
Discharge
Plan
Most Recent Multidisciplinary Team (MDT) Meeting Date: _____________________
Discharge Plan: ______________________________________________________
___________________________________________________________________
___________________________________________________________________
CBAS Representative Signature: ______________________ Date:_____________
Discharge Reason
Discharge Reason (mark appropriate answer):
Death
Moved out of plan area
Ineligible with CalOptima
Long-term nursing facility placement
Transferred to a different CBAS center
Behavioral problems
30-day no-show
Member chooses to leave CBAS program (e.g., poor attendance, unable to
contact, unwillingness, declined health, too weak, etc.)
Receives other services (e.g., assisted living, board and care, PACE, IHSS,
MSSP, hospitalization, etc.) _________________________________________
Signature
Signature of Center Representative: ____________________ Date: ____________
Notify CalOptima within five business days of discharge.
Rev. 3/2015
