CalOptima Health Homes Program Referral Form
Please complete this referral form and fax to _____________________________. Eligible Members will
be directly contacted by their health network with information on their designated Care Coordinator.
Date: ____________________
Contact Person: ___________________________ Phone/email: ___________________________
Member Name: _______________________________________________________________________
Date of Birth: _____________________________ Medi-Cal CIN: ___________________________
Primary Phone: ____________________________ Secondary Phone: ________________________
Primary Care Provider Name/Agency/Phone: ________________________________________________
#1: Please check all diagnoses that apply and attach documentation of diagnoses as available
Physical Health Conditions Mental Health Conditions Substance Use Disorders
Chronic Obstructive
Pulmonary Disease
Traumatic Brain Injury
Chronic or Congestive Heart
Coronary Artery Disease
Chronic Liver Disease
Chronic Renal Disease
Other: _________________
Major Depression Disorders
Bipolar Disorder
Psychotic Disorders
Chronic Alcohol Abuse
Alcohol Liver Disease
Cocaine Abuse
Opioid Abuse
Substance Abuse
Other: _________________
#2: Please check any categories below that pertain to the applicant being referred
Poor Connectivity to Care
No Primary care provider
No connection to specialty doctor or other
Difficulty with compliance (does not keep
appointments, non-adherence to
medications, etc.)
Inappropriate emergency department use (3
or more in 12 months)
Recent release from incarceration
Chronic homelessness
Cannot be effectively treated in an
appropriately resourced patient centered
medical home
Repeated recent hospitalizations for
preventable conditions (medical or
psychiatric 2 or more in 12 months)
Other: ________________________________
Other Significant Behavioral, Medical or Social Risk Factors
Recent discharge from psychiatric
Probable risk for adverse event
Lack of/inadequate social, family or housing
Deficits in Activities of Daily Living
Learning or cognition issues
Other: _______________________________
(the Member's Health Network - found on Page 2)
Health Homes Program (HHP) Health Network Contact Information
Health Network Member Phone Number Referral Fax Number
AltaMed Medical Group 866-880-7805 (option 1, then 3) 323-201-3225
AMVI Care Health Network 714-347-5843 714-938-5168
Arta Western Health Network 800-780-8879 714-436-4716
CHOC Health Alliance 800-387-1103 714-628-9178
CalOptima Direct/ CalOptima
Community Network (COD/CCN)
888-587-8088 714-481-6432
Family Choice Medical Group 800-611-0111 818-817-5155
Heritage-Regal Medical Group 844-292-5173 714-244-4537
Kaiser Permanente 866-551-9619 877-515-6591
Monarch HealthCare 888-656-7523 949-923-3572
Noble Mid-Orange County 714-699-5143 714-947-8796
Prospect Medical Group 714-347-5843 714-938-5168
Talbert Medical Group 800-297-6249 714-436-4716
United Care Medical Group
New number effective 6/1/20:
New number effective 6/1/20:
Last Updated: 5/8/2020