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There are problem(s) with the following item(s):

List the applicant’s current medical diagnoses. (main illness or injury)

Check the boxes that identify the applicant's current medical needs. Use the "other" options below to identify additional medical needs that are not listed.


Is this application being submitted for the applicant?

Who has the legal authority to make the applicant's health care decisions?


Please identify all of your current service providers.

MSSP is an HCBS waiver benefit for Medi-Cal beneficiaries over the age of 65 that provides general services and nursing support. For further information on this program, go to:
Hospice is a Medicare/Medi-Cal benefit for beneficiaries with a terminal diagnosis. For further information on this benefit, contact the applicant's physician.
PACE is a Medi-Cal benefit that provides all needed preventative, primary, acute, long-term care, social and rehabilitative services through one comprehensive program to eligible seniors, 55 years or older. For further information, call 1-888-633-7223, or go to:
SCAN Health Plan, as a Medicare Advantage Special Needs Plan, offers health and long-term care services to eligible Medicare/Medi-Cal beneficiaries over the age of 65 years. For further information, call 1-877-452-5898, or go to:

When complete, click this button to submit your application to the County of Sonoma.

County of Sonoma 3725 Westwind Blvd.
Suite 100, Santa Rosa, CA 95403
Fax # (707) 565-5398

As a contracted delegate of the Department of Health Care Services, County of Sonoma complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.