State of California—Health and Human Services Agency Department of Health Care Services
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State of California—Health and Human Services Agency Department o
f Health Care Services
REFERRAL FORM FOR THE ASSISTED LIVING (AL) WAIVER
Date: AL Waiver Contact:
To: County:
From: Department of Health Care Services
Monitoring and Oversight Section
Phone number: E-Mail:
Fax:
This notice concerns the individual named below
Individual Name: Case Name:
Address: City/State/Zip Code:
Date of birth: Phone number:
This individual:
Has been screened medically eligible for the AL Waiver
Will be disenrolled from the AL Waiver as of: _________________________
County Instructions
This individual is already eligible for no-cost Medi-Cal; no new determination is
needed; and this form does not need to be returned to the Monitoring and Oversight
Section. This referral form is to inform the county that this individual is already or will be
moving to assisted living on:_________________________________
Please determine Medi-Cal eligibility for the above individual and then e-mail or fax
this form to:
Results of county determination
If the above individual is enrolled in the AL Waiver, he/she will be eligible for Medi-Cal
with:
No share-of-cost Medi-Cal
A Medi-Cal share-of-cost of $_______________
MC 0027 Eng (03/10)
