Fillable IHSS COMMUNICATION FORM (CalOptima)

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IHSS COMMUNICATION FORM (CalOptima)

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____________________________________________________________________________________________
____________________________________________________________________________________________
Comments: _________________________________________________________________________________________________________________
ADL/IADL limitations: _________________________________________________________________________________________________________
Current conditions: ___________________________________________________________________________________________________________
IHSS COMMUNICATION FORM
ihss@caloptima.org, Phone: (714) 246-8510, Fax: (714) 481-6382
Expedited (1-day turnaround to SSA from CalOptima) Routine (3-day turnaround to SSA from CalOptima)
MEMBER INFO
DATE:
Gender:
PATIENT NAME: _____________________________________________________________________ DATE OF BIRTH: ____/____/____ M F
LAST FIRST
MEDI-CAL NUMBER (CIN): ____________________________________________ CMIPS ID: _________________________________________________
LANGUAGE/ALT FORMAT: ____________________________________________ IHSS PROVIDER NAME: ______________________________________
ADDRESS: ______________________________________ CITY: ____________________________ ZIP: __________ PHONE: (_____) ________________
ALTERNATE CONTACT: ___________________________________________________________________________ PHONE: (_____) _________________
PRIMARY HEALTH CARE PROVIDER: _________________________________________________________________ PHONE: (_____) ________________
DOCUMENTS INCLUDED WITH REFERRAL: __________________________ DIAGNOSIS: ____________________________________________________
HEALTH NETWORK: __________________________________________PCC NAME: ________________________________________________________
COMMENTS: _________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
REASON FOR COMMUNICATION TO SSA
New Referral for IHSS
Interdisciplinary Care Team (ICT): ICT date: _____/ _______/____
Notification of inpatient hospitalization; Admission date: _______ ______ _________
Notification of skilled nursing facility admission; Admission date: _____/_____/_____ Facility: ____________________________________________
Notification of long-term care facility placement; Placement date: _____/_____/_____ Facility: _ _________________________________________ _
Request re-evaluation/assessment of IHSS hours due to: __________________________________________________________________________
Change in member’s medical or functional status: _______________________________________________________________________________
Recent hospitalization; Discharge date: _____/_____/_____ Reason for hospitalization: _________________________________________
Change in IHSS caregiver availability comments: _________________________________________________________________________
C _____ End Date: _____/_____/_____
n member’s eligibil
Member enrolled in CBAS PA E MSSP CM Effective Date: _____/_____/
Change i ity status: Expired Disenrolled
Pertinent Current Information:
____________________________________________________________________________________________
Revised 08/2015
IHSS COMMUNICATION TO CALOPTIMA
IHSS: Please Notify CalOptima Case Manager of Outcome IHSS@Caloptima.org
Need physician’s certification for medical necessity
Need health care certificate
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Declined services date: _______/_______/_______ Reason: ________________________________________________________________________
Last home visit date: _______ /_______/_______
Member may need an interdisciplinary team conference: __________________________________________________________________________
Member may need durable medical equipment: _________________________________________________________________________________
Member may need case management: ________________________________________________________________________________________
Change in member’s functional status: _________________________________________________________________________________________
IHSS Social Worker Email: _______________________________________________________________________________________________________
IHSS Social Worker Name: __________________________________________________________Phone: (_____) ________________________________
, Fax: 714 481-6382
DATE:
IHSS COMMUNICATION FORM
ihss@caloptima.org, Phone: (714) 246-8510, Fax: (714) 481-6382
Revised 08/2015
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IHSS COMMUNICATION FORM (CalOptima)

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Completed 11 March 2021

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