Respite Program – SM Wisdom Center

Privacy Statment

Notice: This form may collect personal health information (PHI). By submitting, you consent to our use and storage of this information in accordance with our Privacy Policy. DO NOT INCLUDE SENSITIVE INFORMATION IF YOU ARE NOT COMFORTABLE SUBMITTING IT ONLINE.

Name*

First Last

DOB*

Phone Number

Preferred Language

English
Spanish

Residential Address

Do you have CenCal Health as your health insurance?*

Yes, I have CenCal
No, I do not have CenCal

Only those with CenCal Health insurance are eligible for Enhanced Care Management or Housing Support Services at this time.

CenCal Health ID, or last 4 of social security number*

How did you hear about us?

What Programs are you interested in, check all that are of interest.

Enhanced Care Management
Respite Services
Adult Day Health Care

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