Eligibility and Service Authorization

CBAS Assessment Information Release Form/Authorization for Release of Protected Health Information
CBAS Eligibility Determination Tool (DHCS CEDT Version 2.0)
Used by Medi-Cal Field Office or Managed Healthcare Plan nursing staff to determine eligibility.
- DHCS CEDT form
- DHCS CEDT Instructions
History & Physical (H&P)
CDA has approved the California Association for Adult Day Services (CAADS) H&P form. Contact CAADS to access this form: (916) 552-7400; caads@caads.org. Providers may choose to use an alternative form.
Individual Plan Of Care (IPC) (DHCS 0020) (Rev 07/2019)
- Individual Plan of Care (IPC)
- Instructions – Community-Based Adult Services (CBAS): IPC and TAR Form Completion (community IPC)
  The link above will take you to the Part 2 - Community-Based Adult Services page. Scroll down to Community-Based Adult Services (CBAS): IPC and TAR Form Completion (community ipc) link.
- CBAS sections of the Medi-Cal Provider Manual
  The link above will take you to the Part 2 - Community-Based Adult Services page. Scroll down to the four sections titled "Community-Based Adult Services (CBAS)".
Participation Agreement (01/17)
Standardized form required for use by all ADHC/CBAS providers to meet state and federal requirements.
- ADHC/CBAS Participation Agreement (CDA 7000)
- ADHC/CBAS Participation Agreement Instructions (CDA 7000i)