HCBA Waiver Application

Home and Community-Based Alternatives (HCBA) Waiver Application
Complete and submit this four-page application to apply for the HCBA Waiver.
Para recibir esta información en español, por favor llámenos al número siguiente: 1-800-852-9887
Sex:
Married:
Where is the applicant currently residing?
Date of admission: Estimated date of discharge:
Date of admission: Estimated date of discharge:
Applicant’s Current Mailing Address
Street Address (if different from Mailing Address)
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Health Care Insurance
Medi-Cal?
Medicare?
If yes, what part?
Other Insurance?
Check the boxes that identify the applicant's current medical needs. Use the blank spaces below to identify additional medical needs that are not listed. You may provide additional information and comments on Page 5 of the application.
hours
hours
hours
treatments
Medical diagnoses continued on the next page
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If this application is being submitted for the applicant?
1. Who has the legal authority to make the applicant’s health care decisions?
Email
2. If applicable, was the applicant or the legal representative notified that this application was submitted to enroll the applicant in the HCBA Waiver?
Primary Caregivers and Back-up Caregivers Information:
Primary Care Physician:
*Annual Physician visits are required to keep medical records current.
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Identify all of your current service providers:
Type of services received:
To obtain IHSS eligibility information, contact the applicant's county of Department of Social Services office and ask for the IHSS Intake Department.
Another Medi-Cal Waiver:
Does the school provide medical care services at school?
MSSP is an HCBS waiver benefit for Medi-Cal beneficiaries over the age of 65 that provides general services and nursing support. For further information on this program, go to:
http://www.dhcs.ca.gov/services/medi-cal/Pages/MSSPMedi-CalWaiver.aspx
Hospice is a Medicare/Medi-Cal benefit for beneficiaries with a terminal diagnosis. For further information on this benefit, contact the applicant's physician.
PACE is a Medi-Cal benefit that provides all needed preventative, primary, acute, long-term care, social and rehabilitative services through one comprehensive program to eligible seniors, 55 years or older. For further information, call 1-888-633-7223, or go to: www.CALPACE.org.
SCAN Health Plan, as a Medicare Advantage Special Needs Plan, offers health and long-term care services to eligible Medicare/Medi-Cal beneficiaries over the age of 65 years. For further information, call 1-877-452-5898, or go to: www.scanhealthplan.com.
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Please provide any additional information and/or Explanation:
IMPORTANT INFORMATION

HCBA Waiver Agencies are local, non-governmental organizations contracted with the Department of Health Care Services to enroll HCBA Waiver Participants, perform level of care assessments, provide case management, and develop and review participant Plan of Treatments. HCBA Waiver Participants are assigned to HCBA Waiver Agencies based on their geographical locations.

The HCBA Waiver provides care management services to persons at risk of nursing home or institutional placement. The care management services are provided by a multidisciplinary Care Management Team (CMT) comprised of a nurse and social worker.

The CMT coordinates Waiver and State Plan services (i.e. medical, behavioral health, In-Home Supportive Services, etc.), and arranges for other long-term services and supports available in the local community. Care management and Waiver services are provided in the participant's community-based residence. This residence can be privately owned, secured through a tenant lease arrangement, or the residence of a participant's family member.

The HCBA Waiver Program is a Medi-Cal Program and all applicants must have Medi-Cal Benefits in place or be in the process of applying for Medi-Cal Benefits.

All HCBA Waiver Participants and/or their Legal Representatives are required to have an active and current Plan of Treatment. Participants and/or their Legal Representatives are required to review and sign their Plan of Treatment timely, AND ensure their Primary Care Physicians (PCPs) sign the Plan of Treatment and return it to Access TLC Home Health Care in a timely manner.

All HCBA Waiver Participants and/or their Legal Representatives must ensure current Medical Records (less than 8 months old) are submitted to Access TLC Home Health Care in a timely manner.

When complete, mail or fax this application to the following:

Access TLC Home Health Care
5401 Tech Circle
Attn: HCBA Intake
Moorpark, CA 93021
1-800-856-9887
or
Submit the application by secure Fax:
1-805-764-4430

As a contracted delegate of Department of Health Care Services, Access TLC Home Health Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

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CALL 800-TLC-9887