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An ALW referral that moves: the steps to remember

The short step lists from each lesson of Make an ALW referral that moves: consent, choice, documents and timing, on one page. Print it for the station or the break room. Each list points back to its lesson, where the sources are linked.

Open the coursePrint a poster with a QR code

Decision guide

Is this referral ready to send, and is it done?

Has the person, or their legal representative if they cannot decide, said they want an ALW referral?

  • Yes

    Has the person chosen which Care Coordination Agency to contact?

    • Yes

      Has that agency told you what it needs with the referral?

      • Yes

        Are any releases the agency or home asked for signed by the right person and still in date?

        • Yes

          Has a person at the agency confirmed receipt and repeated back the next step and who owns it?

          • Yes

            Record who confirmed, when, and the next step. Tell the person who will contact them. Do not promise a date, an opening or eligibility.

          • No

            Call the agency to confirm a person received the referral. It stays yours until they acknowledge it.

        • No

          Hold the items that need a release. Ask the person, or their legal representative, to sign a current release first.

      • No

        Call the agency and ask what its referral needs. Send nothing extra while you wait. Ask the agency about eligibility questions.

    • No

      Give the person the DHCS list of Care Coordination Agencies for their county and let them choose. Do not pick one for them.

  • No

    Stop. Talk with the person about the waiver and their wishes first. Send no records until they agree.

This guide helps you send and close a referral. It decides nothing about eligibility: the Care Coordination Agency assesses that. Ask your privacy officer how HIPAA applies to your organization.

Step through it one question at a time: alwbeta.com/training/courses/alw-referral-that-moves#decision-guide

Lesson 1

Ask first, then share only what the next step needs

A referral starts with a person, not a fax. Before you send anything, you decide two things: does the person want this, and what does the receiver actually need? This lesson covers the person's agreement, what HIPAA allows, the minimum-necessary rule, family members and signed releases.

  1. Ask the person first: the waiver is theirs to accept or decline
  2. HIPAA counts a referral as treatment; that is not the person's agreement
  3. Send what the receiver asked for, not the whole chart
  4. Family: a capable person agrees or objects first
  5. A release is signed by the person or their legal representative

Lesson: alwbeta.com/training/courses/alw-referral-that-moves#lesson-ref-consent-minimum

Lesson 2

The person chooses: the waiver, the agency and the home

A referrer is often asked, "Which agency should we use?" or "Which home is good?" Federal rules and the DHCS forms put those choices with the person. This lesson shows what the person chooses, what you hand them instead of a recommendation, and when a representative signs.

  1. Waiver or nursing facility: the person chooses
  2. The agency and other providers: the person chooses
  3. Where to live: the person chooses, from options in the plan
  4. Hand over the DHCS lists; never name a favorite
  5. A representative signs only when the person cannot

Lesson: alwbeta.com/training/courses/alw-referral-that-moves#lesson-ref-free-choice

Lesson 3

The documents a home and an agency commonly ask for

Referrals stall over paper: a missing TB result, an old exam, no medication list. This lesson names what the rules ask a home to have before it accepts someone, what the agency checks about Medi-Cal, and which ALW forms are not yours to collect. Then ask each receiver for its own list.

  1. Medical assessment made within the last year, signed by a licensed medical professional
  2. TB: date given, date read, type and result
  3. Current prescribed medications
  4. Medi-Cal information, and the CIN if the agency asks
  5. DHCS 0062 and 1322: the care coordinator's step
  6. Ask each receiver for its own list

Lesson: alwbeta.com/training/courses/alw-referral-that-moves#lesson-ref-documents

Lesson 4

Timing: who does each step, and what you can promise

Families ask, "When can she move?" The honest answer depends on steps you do not control. This lesson lays out who does each step after the referral, what dates on paper can expire, and what you can say about timing without promising a date, a place or eligibility.

  1. Agency: evaluates, assesses, submits to DHCS
  2. No promise of a date, an opening or eligibility
  3. Medical assessment made within the last year
  4. Home: interview, appraisal, medical assessment, admission agreement
  5. Release: check its end date; stop if revoked

Lesson: alwbeta.com/training/courses/alw-referral-that-moves#lesson-ref-timing

Lesson 5

Close the loop: confirm receipt and name the next owner

Many referrals do not fail on a rule. They fail in silence: a fax nobody read, a voicemail nobody returned. This lesson shows how to confirm that the agency received the referral, when your responsibility ends, and what the person should know before you close your file.

  1. Sent is not received: call to confirm
  2. You own it until the receiver acknowledges it
  3. Check-back: they repeat the next step and the owner; you confirm
  4. Record who confirmed, when, and the next step
  5. Tell the person who calls next; rights concerns go to the agency or the Ombudsman, 1-800-231-4024

Lesson: alwbeta.com/training/courses/alw-referral-that-moves#lesson-ref-close-loop

Beta’s ALW team, course version 2026.10.4, text checked against its sources on October 22, 2026. Educational only. Not continuing-education, licensure or regulatory credit. Follow your employer’s current procedure and the person’s current plan. Call 911 for a medical emergency.

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