Eligibility and Service Authorization

Used by Medi-Cal Field Office or Managed Healthcare Plan nursing staff to determine eligibility.

Please contact CDA-CBAS to obtain the CBAS Eligibility Determination Tool.

CDA has approved the CAADS H&P form available at the following link. Providers may chose to use an alternative form.

• CAADS History & Physical Form

• 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 DHCS Medi-Cal “Provider Manuals” 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 DHCS Medi-Cal “Provider Manuals” page. Go to the “Inpatient/Outpatient” category and click on “Community-Based Adult Services (formerly Adult Day Health Care Centers).” Scroll down to the four sections titled “Community-Based Adult Services (CBAS)”.

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)