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Healthcare Professional Submitting Request*

First NameLast Name
Healthcare Professional’s Email Address*
example@example.com
Healthcare Professional’s Phone Number:
Please enter a valid phone number.
Discharging Facility
Is patient currently in-patient?*

YesNo
If“yes”, please provide an estimated discharge date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Medi-Cal Member #:*
Patient Contact #:
Please enter a valid phone number.
Patient Contact Name*

First NameLast Name
Relation to Patient*
Has patient had 3+ inpatient admissions OR 5+ ED visits in the past 6 months

YesNo
Patient Medi-Cal Health Plan*
Does Patient have a Share of Costs*

YesNoUnknown
Patient Notes:
Should be Empty: