Fillable Multipurpose Senio r Services Program (MSSP) Referral (CalOptima)

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Multipurpose Senio r Services Program (MSSP) Referral (CalOptima)

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Multipurpose Senio
r Services Program
(MSSP) Referral
Date _____/_____/_____
Print Your Name__________________ Telephone#_______________ Email Address:_________________
Agency_______________________________Address_________________________________________
Member’s Information: Aid Code: _______County Code: _______ DOB ___/___/___ Age____
Member Name_________________________________________________ Gender: Female Male
Last First
Address __________________________________________________________________________________
+ city/zip_________________________________ Telephone/Cell Number(s) __________________________
Marital Status:______________________ Ethnicity______________________ Speaks English: Yes No
Language Spoken_______________ Social Security/ID number ____________________________________
Emergency Contact / Responsible Party ___________________________ Relationship______________
Language Spoken______________
Address ___________________________________ Telephone Number_____________________
Primary Care Physician_______________________ Telephone Number _____________________
Diagnoses/History of illness _______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Current Status:
Visually impaired
Hearing impaired
Alert
Confused
Wheelchair-bound
Use a cane or walker
Bed-ridden
Needs ass’t w/eating
Needs ass’t w/dressing
Needs ass’t w/transferring
Needs ass’t w/bathing
Needs ass’t w/household tasks
Needs ass’t w/meals
Needs ass’t w/money
management
Needs ass’t w/transportation
Does the member live alone?
Does the member take 6 or
more medications?
Does the member receive
IHSS hours?
Does the member have a
regular caregiver
Drives
Recent falls
Explain MSSP Needs:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Completed by______________________________________________ Date __________________________________
For questions, please contact Kelly Diaz De Leon @ 714-347-5709 or Charlene Esparza @ 714-246-8665
Send Referral To:
CalOptima
Attn: MSSP Dept.
Fax: 714-246-8680
Email:
MSSP@caloptima.org
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Multipurpose Senio r Services Program (MSSP) Referral (CalOptima)

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Completed 11 March 2021

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