Maui coastline

Mana Psych Respite · Community Integration Services Plus (CIS+)

Refer a member to medical respite

A short, supported place to recover and stabilize on Maui for Medicaid members with behavioral-health needs who are homeless or at risk of homelessness. Here is exactly how to refer, with both state forms ready to download.

Download the forms

Two state forms make up a complete referral. Open, complete, and submit them as described below.

Both are the July 2026 revisions published with Med-QUEST memo QI-2601A / CCS-2601A, effective July 1, 2026. They replace the December 2025 versions numbered DHS 1198 and DHS 1195. Both PDFs are fillable on screen.

New to medical respite referrals? Read the 5-minute first-referral guide below before you start.

Who Mana Psych Respite is for

Mana Psych Respite is behavioral-health-focused medical respite. It is not traditional post-surgical or wound-care respite. We work with adults whose main needs are psychiatric, mental health, and substance use, who can manage their own daily care, and who need a stable place to recover and connect to ongoing services.

We most often serve adults coming out of a psychiatric hospitalization, crisis stabilization, or another institutional stay, including members who are chronically homeless, living with serious mental illness, justice-involved, or managing co-occurring substance use. The focus is stabilization, recovery, and a warm hand-off to housing and continuing care.

Typically a good fit

  • Adults with psychiatric or behavioral-health needs, often with co-occurring substance use
  • Leaving a psychiatric hospital, crisis unit, or other institutional setting, or at risk of needing that level of care
  • Homeless or at risk of homelessness
  • Able to walk, manage daily activities, and self-administer their own medications

Usually not the right setting

  • Primary need is wound care
  • Requires skilled nursing or help with daily activities
  • Needs medication administered by staff rather than self-administered
  • Needs inpatient or higher-acuity medical care

Not sure if someone fits? Contact our intake team and we will help you screen.

Quick eligibility check

Clinical need (meet at least one)

  • A planned procedure or treatment that needs care before or after.
  • In, or coming out of, an acute hospital, psychiatric hospital, nursing facility, or other institution.
  • At risk of institutionalization, with an ongoing physical or behavioral-health need that would otherwise require institutional care.

Housing need (meet at least one)

  • Currently homeless, sheltered or unsheltered.
  • At risk of homelessness or imminent eviction.
  • Frequent institutional stays.

Plus

  • Active Hawaii Medicaid (Med-QUEST) coverage.
  • Independent with daily activities, or needing only short-term help regaining that independence.
  • For placement at Mana, able to self-administer medications.

How to make a referral

Step 1

Confirm the member is eligible

Check the clinical and housing criteria above and confirm active Medicaid. If you are unsure, contact us and we can help you screen.

Step 2

Complete the DHS 1214 authorization

Fill in the member's information, the recommended respite service type, and the clinical and social eligibility sections. Support staff or a coordinator may complete it, but a qualified health professional (MD, DO, NP, or PA) must review, approve, and sign it, and that clinician must be free from conflicts of interest with the respite provider.

If you complete this form, a separate CIS+ Referral Form is not required.

Download DHS 1214

Step 3

Have the member sign the DHS 1211 consent

The member, or their authorized representative, reviews the available CIS+ services and the benefit limits and chooses to accept or refuse enrollment. Consent is collected by the health plan or a conflict-free party such as the hospital. For a member who is admitted somewhere, consent must be obtained before discharge, and in all cases within 10 days.

Download DHS 1211

Step 4

Submit to the health plan, and tell us

Fax the completed DHS 1214 to the member's health plan, marked ATTN: Medical Respite Authorization Form, using the fax list below. The plan then has up to seven days to determine eligibility and authorize the benefit. A cover sheet is not required, but if you do not have one, you are welcome to use ours — fill in your own organization in the sender block.

So we can hold a spot and coordinate the placement, also send the referral to our intake team at referrals@manarespite.org, fax it to us at (808) 309-6001, or call (808) 736-6074. Members have the right to pick their CIS+ provider, so let the plan know if the member is choosing Mana Psych Respite.

Download fax cover sheet

Where to fax the DHS 1214

Member's health planFax number
AlohaCare808-973-0676
HMSA808-948-8243
Kaiser855-416-0995
Ohana855-637-2941
UnitedHealthcare800-267-8328
CCS (Community Care Services)855-637-2941

Fax numbers are printed on the last page of the DHS 1214 form (07/2026 revision). Always send to the plan that currently covers the member.

Sending a copy to us? The Mana Psych Respite fax is (808) 309-6001. The numbers above go to the health plans.

Frequently asked questions

We're here to help

Our intake team reviews referrals within 24 hours. We accept referrals from hospitals, shelters, outreach workers, and community providers across Maui County. First-time referrer? We will walk you through the whole process.

Have both forms ready?

Download them here, complete and sign, fax the 1214 to the health plan, and send us a copy at referrals@manarespite.org or fax (808) 309-6001 so we can coordinate placement.

Go to downloads