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Ihss application form

unable to perform some activity of daily living independently and without IHSS the individual would be at risk of placement in out-of-home care. This health care certification form must be completed and returned to the IHSS worker listed above. The IHSS worker will use the information provided to evaluate the individual’s , и The below form(s) are required, depending on your circumstances. Please review the descriptions after each form to help determine when to complete a form. For information on the enrollment process for new providers (never been paid in IHSS), please select this link to take you to the New Provider Enrollment web page . To submit an IHSS application via fax, fax your application to 805-654-3206 (Ventura, Ojai, Camarillo, Oxnard area) or 805-906-7910 (Thousand Oaks, Simi Valley area) Changes have been made to the Application for In-Home Supportive Services (SOC 295) to gather information the State is required to collect. , , , , , , , In-Home Supportive Services (IHSS) is a federal, state and locally funded program providing assistance to eligible aged, blind, and disabled individuals receiving Medi-Cal benefits who are unable to remain safely in their own homes without assistance. Individuals who want to receive In-Home Supportive Services (IHSS) complete an application, then a Department of Health and Human Services (DHHS) employee will come to the individual’s home and assess the individual’s abilities to live safely at home. .

You must have a physician or other licensed health care professional fill out a Health Care Certification (SOC 873) form and you must return it to the county before care services can be authorized. You will be notified if your application for IHSS has been approved or denied. If denied, you will be notified of the reason for the denial. APPLICATION FOR IN-HOME SUPPORTIVE SERVICES SOC 295 (9/18) Page 1 of 8 To the Applicant: All sections of this form must be completed. Information provided is subject to verification. NOTE: Retain your copy of your completed application. Regarding your Social Security Located in northern California, the Official website of the County of Santa Clara, California, providing useful information and valuable resources to County residents.

choose an Authorized Representative for the IHSS program and identifies the functions the Authorized Representative may perform on his/her behalf. This form is only for the IHSS program. • To choose an authorized representative to represent the applicant/recipient at a state administrative hearing, complete a separate form, DPA 19 (Authorized You can also apply by completing and submitting the IHSS application, SOC 295 – Application for In-Home Supportive Services. If needed, an application can be printed upon request at any of the IHSS regional offices. Completed IHSS applications may be submitted by: Email : [email protected] Facsimile (fax): 619-344-8077 Javascript get child element by nameOr hard copies of the IHSS Application (SOC 295) will be available outside the front door of our office. Our office is located at 1505 E. Warner Avenue, Santa Ana, CA 92705. Email: E-mail completed applications to [email protected] in-home supportive services (ihss) program health care certification form note: the ihss worker may contact you for additional information or to clarify the responses you provided above. c. health care information (to be completed by a licensed health care professional only) In-Home Supportive Services (IHSS) Printer-friendly version Government program assists older persons and adults with disabilities remain in their own homes by helping to pay for services such as: In-Home Supportive Services . The In-Home Supportive Services (IHSS) program is California's largest in-home care program. IHSS is a Medi-Cal program that provides personal, domestic and related services to aged, blind and/or disabled individuals in their own homes. IHSS is intended to be an alternative to out-of-home care. In-Home Supportive Services (IHSS) Program . The IHSS Program is a federal, state and locally funded program designed to help pay for services provided to you so that you can remain safely in your own home. To be eligible, you must be over 65 years of age, or disabled, or blind. Disabled children are also eligible for IHSS. .

IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM PROVIDER ENROLLMENT FORM CONTINUE READING THE INFORMATION BELOW CAREFULLY . BEFORE YOU BEGIN TO COMPLETE THIS FORM Individual Waiver of an Exclusion for Conviction for a Tier 2 Crime . If you are found ineligible based on a conviction for a Tier 2 exclusionary crime but an , APPLICATION FOR IN-HOME SUPPORTIVE SERVICES SOC 295 (9/18) Page 1 of 8 To the Applicant: All sections of this form must be completed. Information provided is subject to verification. NOTE: Retain your copy of your completed application. Regarding your Social Security To become an IHSS Provider, contact Riverside’s HOME Call Center at (888) 960-4477. Phones are answered Monday – Friday from 8:00 AM to 5:00 PM Pacific time, excluding County holidays. In-Home Supportive Services Providers will need to: Complete a Livescan fingerprint process; Complete and submit form SOC 426a

Your share of cost would be $1,197.50 - $943.72 = $253.78 per month. That means you’d have to pay $253.78 each month for the in-home support services you get and the IHSS program would pay the rest. In-Home Supportive Services (IHSS) is a federal, state and locally funded program providing assistance to eligible aged, blind, and disabled individuals receiving Medi-Cal benefits who are unable to remain safely in their own homes without assistance. и A home care program that helps elders, dependent adults and minors live safely in their own homes or other non-institutional settings. If you would like more information or if you would like to apply for IHSS, please call us toll free at 1-888-960-4477.