CalAIM Transitional Rent Request Form

Transitional Rent provides up to six months of rental assistance in interim and permanent settings to members who are experiencing or at risk of homelessness, have certain clinical risk factors, and have either recently undergone a critical life transition (such as exiting an institutional or carceral setting or foster care) or who meet other specified eligibility criteria.

For more information, please review Department of Health Care Services (DHCS) Community Supports Policy Guide Vol. 2, updated April 2025.

Important: At this time, the Transitional Rent program is available only to Health Net Medi‑Cal members. Members must also be engaged in sustainability services and have all required documentation ready to upload as part of this application.

CalAIM Transitional Rent Program

Initial Attestation

Important: This authorization request is not eligible for submission if any Initial Attestation question is answered “No.” These questions confirm the member’s initial eligibility for the Transitional Rent program and must all be met before a request can be submitted.

Has the member consented to the Transitional Rent authorization request?(Required)

Yes

Date member consented:(Required)

MM slash DD slash YYYY

Is the member Behavioral Health Services Act (BHSA)-eligible?(Required)

Yes

Will the member be able to transition to a BHSA Housing Intervention or housing subsidy at the expiration of Transitional Rent?(Required)

Yes

Is the member’s Housing Support Plan included with this authorization request?(Required)

Yes

Is the member experiencing homelessness or at risk of homelessness?(Required)

Yes

Thank you for submitting your information. Unfortunately, at this time you don’t qualify for the transitional rent program.

All the answers above must be a “YES” to be eligible. You may return to the form at a later date when all the answers are a “YES”.

Behavioral Health Population of Focus Eligibility

Important: This request is not eligible for submission if the member does not meet the requirement stated below. This requirement confirms the member’s initial eligibility for the Transitional Rent program.

Member is already receiving or has a history of receiving services in the past 12 months through the SMHS/DMC/DMC-ODS delivery systems.(Required)

Yes

Please submit additional supporting documentation describing the member’s behavioral health needs with the request form.(Required)

– Documentation supporting the member’s behavioral health condition or SUD needs, from treating primary care physician, specialist or mental health provider. – Entire patient chart for Housing Trio or ECM services.

Drop files here or

Max. file size: 2 MB.

Thank you for submitting your information. Unfortunately, at this time you don’t qualify for the transitional rent program.

All the answers above must be a “YES” to be eligible. You may return to the form at a later date when all the answers are a “YES”.

BHSA Case Manager Contact Information:

Case Manager Name:(Required)

Phone(Required)

Email(Required)

Eligibility Criteria

Members are eligible for Transitional Rent if they meet all of the following criteria**:

Clinical Risk Factor Requirement(Required)

Must have one or more of the following qualifying clinical risk factors:

Meets the access criteria for SMHS

Meets the access criteria for DMC or DMC-ODS

Experiencing or at risk of homelessness

Individual must meet one of the following requirements:(Required)

Transitioning out of an institutional or congregate residential setting

Transitioning out of a carceral setting

Transitioning out of interim housing

Transitioning out of Recuperative Care or Short-Term Post-Hospitalization Housing

Transitioning out of foster care

Experiencing unsheltered homelessness

Eligible for Full-Service Partnership (FSP)

Member Information

Member Name:(Required)

First Middle Last

Date of Birth:(Required)

MM slash DD slash YYYY

Medi-Cal ID Number:(Required)

Preferred Language:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Email Address:(Required)

Contact Name:

(If different than the member)

First Last

Relationship To Member:

Phone Number:

Preferred Language:

Email Address:

Referring Provider Information

Organization Name:(Required)

Staff Name:(Required)

Title:(Required)

Phone Number:(Required)

Staff Email Address:(Required)

Additional Services Needed

Please Select Which Additional Services You Might Need

Housing Transition & Navigation

Housing Deposits

Housing Tenancy & Sustainability

Enhanced Care Management

Additional Services Needed

Has the member utilized Recuperative Care, Short-Term Post-Hospitalization Housing or Transitional Rent with Health Net or any other Managed Care Plan once within the demonstration period?(Required)

*Transitional Rent cannot exceed a duration of six months or 182 days per rolling 12-month period (but may be authorized for a shorter period based on individual needs) and is subject to the six months or 182 days global cap on room and board services.

Yes

Unsure

If yes, how many total days did the member receive these services?(Required)

Which health plans?(Required)

Required Documentation:

Housing Documentation Requirements

Permanent Housing: Lease agreement / Intent to Rent
Interim Housing: Bed/Room agreement or equivalent
Landlord/Property Management W-9
Transitional Population: Documentation of the date of the transition event (discharge date, date of release)
Housing inspection form
Housing Support Plan: Attach member’s Housing Support Plan that explicitly outlines the following:
- Identify the permanent housing strategy, including payment sources that will support the member in maintaining housing after Transitional Rent benefits are exhausted (must document the member’s income, BHSA Housing Voucher, or other long-term subsidies).
- Outline the full range of housing supports that will help the member sustain tenancy (e.g., tenancy sustaining services, utilities).
- Ensure the plan is informed by member preferences and needs, and reviewed/revised as needed based on changes in member circumstances.
Note: Upon move-in, Transitional Rent must be requested within 30 calendar days of the move-in date listed on the lease agreement or interim setting agreement.

Upload Required Documentation(Required)

Drop files here or

Max. file size: 2 MB.

Housing Setting Information:

Note: The UWCCR Eligibility Specialist will calculate the monthly reimbursable ceilings once request is received. If the unit rate exceeds the monthly reimbursable ceilings, the request will be denied unless the referring provider is able to negotiate the rent or temporary housing costs to align with the established reimbursable limits.

Move-In Date:(Required)

MM slash DD slash YYYY

Select The Housing Setting The Member Is Moving Into

Housing Setting Category(Required)

Bedroom Size(Required)

Permanent Setting(Required)

Shared housing where two or more people live in one rental unit. Select the option that’s most accurate to you.

Interim Setting(Required)

Interim setting with a small number of individuals per room. Select the option that’s most accurate to you.

Housing ZIP Code(Required)

Household Composition

Please identify the household composition.

Member Household(Required)

Household Members Table

List All Individuals In Household(Required)

Name

Date of Birth

Medi-Cal Number (CIN)

Additional Comments

Add anything you want included with your submission and we’ll be sure to review it.

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Important: At this time, the Transitional Rent program is available only to Health Net Medi‑Cal members. Members must also be engaged in sustainability services and have all required documentation ready to upload as part of this application.

CalAIM Transitional Rent Program

Initial Attestation

Behavioral Health Population of Focus Eligibility

BHSA Case Manager Contact Information:

Eligibility Criteria

Member Information

Referring Provider Information

Additional Services Needed

Additional Services Needed

Required Documentation:

Housing Documentation Requirements

Housing Setting Information:

Select The Housing Setting The Member Is Moving Into

Household Composition

Household Members Table

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