Item HA4 - MOU with CalOptima Health

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CalOptima Health PHA MOU Page 16 of 18 Exhibit A CalAIM Housing and Health Services Voluntary Consent Form to Release, Share, and Disclose Confidential Information Orange County Health Authority dba CalOptima Health is a public agency that provides health care coverage for Orange County residents who a re eligible for Medi-Cal. CalOptima Health is working alongside the [insert Public Housing Authority name] (Housing Authority) to ensure that any interested housing choice or special purpose voucher applicants/participants are not only enrolled for Medi-Cal, if eligible, but also, receiving any and all benefits that they are eligible for and interested in receiving, including ava ilable housing navigation opportunities. By signing below, I voluntarily agree to allow the Housing Authority to disclose to CalOptima Health the minimum information necessary about me to confirm enrollment in Medi-Cal and provide the services described herein, including confidential information and personally identifying information,1 for the following purposes: 1. To determine my current enrollment status in Medi-Cal or my interest in registering for Medi-Cal. 2. To aid me in accessing the benefits available through CalAIM,2 including case management, and assist in providing temporary and or/permanent housing opportunities. 3. To assist in making referrals for various health care benefits, including, but not limited to, CalAIM Enhanced Care Management and Community Supports.3 4. To monitor the services, I receive to ensure they are beneficial. By signing below, I further acknowledge and agree that CalOptima Health may contract with third party Medi-Cal providers to provide services to me . For purposes of this form, CalOptima’s contracted Medi-Cal providers include providers that perform the following categories of services: CalAIM Enhanced Care Management and Community Supports . I understand, agree, and authorize Housing Authority and CalOptima to disclose information about me for the purposes described above. Please note that the list of CalOptima’s contracted Medi -Cal providers can change frequently and without notice, and therefore the website should be consulted for the most recent list: https://www.caloptima.org/en/ForMembers/Medi-Cal/FindAProvider. This Voluntary 1 For example, this information may include full name, date of birth, social security number and contact information to assist in coordinating Medi -Cal related benefits or CalOptima services. 2 CalAIM is the California Advancing and Innovating Medi -Cal initiative, which the California Department of Health Care Services launched to improve quality of life and health outcom es for the Medi-Cal population by using Medi -Cal as a tool to address challenges facing Medi -Cal members. CalOptima, as a Medi-Cal health plan, participates in CalAIM and assists its Medi-Cal members in obtaining benefits under CalAIM. 3 These services may include: housing transition navigation services, housing deposits, housing tenancy and sustaining services, short-term post-hospitalization housing, recuperative care, respite services, day habilitation services, asthma remediation, medically tailored meals/medically-supportive food, community transition services/nursing facility transition to a home, personal care and homemaker services, environmental accessibility adaptations, and nursing facility transition/diversion to assisted living facilities such as residential care facilities for elderly and adult residential facilities. CalOptima will assist you in determining for which CalAIM services you are eligible. EXHIBIT 1