2. Email *
  3. Date *
  4. First Name *
  5. Last Name *
  6. Street Address *
  7. City, State, Zip *
  8. Telephone Number *
  9. Date of Birth *
  10. Contact Person (if differet than person referred)
  11. Contact Phone Number (if different than above)
  12. Medi-Cal? *
  13. Medi-Cal ID Number
  14. Issue Date
  15. Referred By *
  16. Referrer's Phone Number
  17. Primary Care Physician (PCP)
  18. PCP's Phone Number
  19. Diagnosis/Needs/Primary Concerns *
  20. Collaborative Agencies *
  21. Is the person referred aware of the referral?
  23. Submit

To qualify for the MSSP program you must be at least 65 years of age, be a Medi-Cal recipient, have a diagnosis that puts you at risk of skilled nursing placement, and be willing to work with a care manager to avoid placement in a skilled nursing facility.

For questions or more information on our program, please call (530) 226-3097. Please note that a referral does not guarantee placement on the program and they will only be placed on the program once an opening is available with a care manager. Thank you for your referral!

* = Required field.