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
☐ Diabetes
☐ Traumatic Brain Injury
☐ Chronic or Congestive Heart
Failure
☐ Coronary Artery Disease
☐ Chronic Liver Disease
☐ Chronic Renal Disease
☐ Dementia
☐ Hypertension
☐ Asthma
☐ 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
practitioner
☐ 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
hospitalization
☐ Probable risk for adverse event
☐ Lack of/inadequate social, family or housing
support
☐ Deficits in Activities of Daily Living
☐ Learning or cognition issues
☐ Other: _______________________________
(the Member's Health Network - found on Page 2)
