Staying Healthy Assessment
The Staying Healthy Assessment (SHA) will be completed for all Medi-Cal managed care patients within 120 days of enrollment as part of their Initial Health Assessment. The assessment will provide dialogue between the provider and patient, identify health education needs, and identify potential interventions, referrals and follow up. This is a Department of Health Care Services requirement for all Medi-Cal providers. Completing this form is voluntary but it will help your doctor understand your health needs. Forms range by age, please print and complete the appropriate form and turn it in the day of your appointment.
- Staying Healthy Assessment 0-6 Months
- Staying Healthy Assessment 7-12 Months
- Staying Healthy Assessment 1-2 Years
- Staying Healthy Assessment 3-4 Years
- Staying Healthy Assessment 5-8 Years
- Staying Healthy Assessment 9-11 Years
- Staying Healthy Assessment 12-17 Years
- Staying Healthy Assessment Adult
- Staying Healthy Assessment Senior
If you do not have health insurance, you may be eligible to receive discounted health services. Your discount is based on your income level and family size. Please refer to the 2014-2015 Federal Poverty Level Guidelines to calculate your FPL%. Please note: You must bring proof of income and proof of family size to be eligible to receive discounted health services. Acceptable forms of proof of income include: income tax return; pay check stub; unemployment verification; official documents citing child support or alimony; paperwork documenting retirement, disability or SSI benefits; or a letter from your employer stating your income. Acceptable forms of proof of family size include: most recent tax return showing household size; social security cards; birth certificates; medi-cal cards for dependent children; driver’s license or state ID cards; court or government documents that indicate the number of household members.