California Form Soc 295 PDF Details

Navigating the intricate process of applying for In-Home Supportive Services (IHSS) in California is made significantly simpler with the SOC 295 form, a document crucial for applicants seeking essential assistance. As a comprehensive application form issued by the State of California Health and Human Services Agency, it covers a wide array of information sections that applicants must complete, from personal identification to specific service requests. The importance of providing accurate details cannot be overstated, as these are subject to verification to ensure eligibility and proper coordination with other public agencies. Furthermore, the SOC 295 form addresses the applicant's privacy and rights, offering sections for voluntary disclosure of sexual orientation and gender identity, which emphasizes California's commitment to inclusivity and respecting individual identity. This aspect reflects the progressive strides in acknowledging and catering to the diverse needs of California's population. Likewise, the form includes provisions for veterans, showcasing a recognition of their service and particular needs they may have. Additionally, it accommodates individuals with disabilities, specifying options for communication accommodations such as Braille or audio CD for visually impaired applicants, ensuring that the application process is accessible to everyone. Lastly, the form encapsulates the responsibility of the applicant as an employer for their in-home support provider, highlighting the importance of engaging in a responsible and ethical employment practice. Whether it's filling out personal information, sexual orientation and gender identity, details about household members, or providing ethnic and language information, the SOC 295 form stands as a critical step towards accessing supportive services in the home environment, making it an essential document for many Californians.

QuestionAnswer
Form NameCalifornia Form Soc 295
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namescalifornia application social, ca soc 295, form soc 295 social, soc 295 services

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State of California – Health and Human Services Agency

California Department of Social Services

APPLICATION FOR IN-HOME SUPPORTIVE SERVICES

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 Number, it is mandatory that you provide your Social Security Number(s) as required in 42 USC 405, or that you apply for a Social Security Number(s) with the Social Security Administration. This information will be used in eligibility determination and coordinating information with other public agencies.

Date of Application:

Case Number (if known):

 

 

 

 

 

 

Section 1 – Personal Information

 

 

 

 

 

 

 

Name of Applicant:

 

 

Social Security Number:

 

 

 

 

 

 

Street Address:

 

 

 

City:

 

 

 

 

 

State:

 

Zip Code:

Telephone:

 

 

 

 

 

 

 

 

 

 

 

Email:

 

 

 

 

 

 

 

Date of Birth:

 

 

Sex: Male

Female

 

 

 

 

 

 

Section 2 – Sexual Orientation and Gender Identity (Optional)

Providing responses in the sections below is optional and confidential. Any information you provide in this section will not be used in your eligibility determination.

What is your gender identity?

(check the box that best describes your current gender identity)

…Female

…Male

…Transgender: male to female

…Transgender: female to male

…Non-Binary (neither male nor female)

…Another gender identity

…Decline to state

SOC 295 (9/18)

Page 1 of 8

State of California – Health and Human Services Agency

California Department of Social Services

 

 

 

 

What sex was listed on your original birth certificate? Female Male

How do you describe your sexual orientation?

Select one answer.

 

 

… Straight/heterosexual

… Another sexual orientation

… Gay or lesbian

… Unknown

… Bisexual

… Decline to state

… Queer

 

 

Section 3 – Veteran Information

 

 

 

 

 

Are you a Veteran?

 

Are you a Spouse/Child of a Veteran?

Yes No

 

Yes No

 

 

 

If YES, give Veteran name and Claim Number:

Section 4 – SSI/SSP Information

Do you receive SSI/SSP benefits? Yes

No

 

If yes, check your type of living arrangement:

Independent Living

Board and Care

Home of Another

Services being requested:

Section 5 – Past IHSS Information

Have you received In-Home Supportive Services (IHSS) in the past? Yes No

If Yes, complete the following.

Date and county where service was last received:

Total Monthly Hours:

Name Used (if different from above):

SOC 295 (9/18)

Page 2 of 8

State of California – Health and Human Services Agency

California Department of Social Services

 

 

 

 

 

 

Section 6 – Household Information

 

List Household Members:

 

 

 

 

 

 

 

 

Name of Spouse:

 

 

 

 

 

 

 

 

 

Birthdate:

 

 

 

Social Security Number:

 

 

 

 

 

 

Name of:

Parent

Child

Other Relative

Non-Relative

 

 

 

 

 

Birthdate:

 

 

 

Social Security Number:

 

 

 

 

 

 

Name of:

Parent

Child

Other Relative

Non-Relative

 

 

 

 

 

Birthdate:

 

 

 

Social Security Number:

 

 

 

 

 

 

Name of:

Parent

Child

Other Relative

Non-Relative

 

 

 

 

 

Birthdate:

 

 

 

Social Security Number:

 

 

 

 

 

 

Name of:

Parent

Child

Other Relative

Non-Relative

 

 

 

 

 

Birthdate:

 

 

 

Social Security Number:

 

 

 

 

 

 

Name of:

Parent

Child

Other Relative

Non-Relative

 

 

 

 

 

Birthdate:

 

 

 

Social Security Number:

 

 

 

 

 

 

Section 7 – Ethnic and Language Information

The law requires that information on ethnic origin and primary language be collected.

If you do not complete this section, social service staff will make a determination. The information will not affect your eligibility for service.

A. My Ethnic Origin is:

PLEASE CHOOSE ONE

(See Page 8 for a list of Ethnicities and Codes)

B1. What language do you prefer to read?

PLEASE CHOOSE ONE

B2. What language do you prefer to speak?

PLEASE CHOOSE ONE

(Please choose one from the list of Languages and Codes on Page 8)

SOC 295 (9/18)

Page 3 of 8

State of California – Health and Human Services Agency

California Department of Social Services

 

 

 

 

Section 8 – Communication Accommodations

To accommodate blind or visually-impaired applicants, IHSS information is available

in the following alternative formats. Please indicate which format you would prefer, if applicable. Providing information in this section will not affect your eligibility for

services.

I am Blind: Yes No

If yes, please choose one of the following for each of the three types of Department of Social Services (DSS) documents listed.

For Notices of Action: No accommodation is needed

Braille Documents

Audio CD

Data CD

 

County Support

 

 

 

(If County Support, describe requested support)

 

 

 

 

For IHSS Required forms:

No accommodation is needed

Braille Documents

Audio CD

Data CD

 

County Support

 

 

 

(If County Support, describe requested support)

 

 

 

For Timesheets: No accommodation is needed

 

Telephonic System (4 Digit RAN:

)

County Support

Electronic Timesheet System (ETS) (Applicants and providers must first register at https://www.etimesheets.ihss.ca.gov)

(If County Support, describe requested support)

I am Visually Impaired: Yes No

If yes, please choose one of the following for each of the three types of Department of Social Services (DSS) documents listed.

SOC 295 (9/18)

Page 4 of 8

State of California – Health and Human Services Agency

California Department of Social Services

 

 

 

 

 

 

 

 

 

For Notices of Action:

No accommodation is needed

 

18 point font documents

Audio CD

Data CD

County Support

 

 

(If County Support, describe requested support)

 

For IHSS Required forms: No accommodation is needed

 

18 point font documents

Audio CD

Data CD

County Support

(If County Support, describe requested support)

For Timesheets: No accommodation is needed

Telephonic System (4 Digit RAN:

)

18 point font documents

County Support

Electronic Timesheet System (ETS) (Applicants and providers must first register at

https://www.etimesheets.ihss.ca.gov)

(If County Support, describe requested support, including blind-only services)

Section 9 – Affirmation

I affirm that the above information is true to the best of my knowledge and belief. I agree to cooperate fully if verification of the above statements is required in the future.

I also understand that as the employer of my IHSS provider(s) I am responsible for:

1.Hiring, training, supervising, scheduling and, when necessary, firing my provider(s).

2.Ensuring the total hours reported by all providers who work for me do not exceed my IHSS authorized hours each month.

3.Referring any individual I want to hire to the County IHSS office to complete the provider eligibility process.

4.Notifying the County IHSS office within 10 days when I hire or fire a provider.

SOC 295 (9/18)

Page 5 of 8

State of California – Health and Human Services Agency

California Department of Social Services

 

 

 

 

In addition, I understand and agree to the following terms and limitations regarding payment for services by the IHSS program:

1.In order for any individual to be paid by the IHSS program, they must be approved as an IHSS eligible provider.

2.If I choose to have an individual work for me who has not yet been approved as an eligible IHSS provider, I will be responsible for paying him/her if he/she is not approved.

3.The IHSS program will not pay for any services provided to me until my application for services is approved and then will only pay for those services that are authorized for me to receive by the IHSS Program.

4.I will be responsible for paying for any services I receive that are not included in my IHSS authorization.

5.I will be responsible for paying my Share-of-Cost (SOC) and informing my individual provider(s) of that SOC.

I also understand and agree to cooperate with the following as a part of my eligibility for IHSS:

To promote program integrity and quality assurance, I may be subject to (un)announced visits to my home and that I or my provider(s) may receive letters identifying program requirement concerns from the State Department of Health Care Services (DHCS), California Department of Social Services (CDSS) and/or the County in which I receive services.

The purpose of the visits and letters is to ensure that program requirements are being followed and that the authorized services are necessary for you to remain safely in your home. The visit will also verify that the authorized services are being provided, that the quality of those services is acceptable, and that your well-being is protected.

If it is found that IHSS services are not required or not being properly provided, you and/or your provider may be subject to a Medi-Cal fraud investigation. If fraud is substantiated, you and/or your provider will be prosecuted for Medi-Cal fraud.

SOC 295 (9/18)

Page 6 of 8

State of California – Health and Human Services Agency

California Department of Social Services

 

 

 

 

Section 10 – Signature(s)

Signature of Applicant:

Date:

Signature of Applicant’s Representative (only if applicable): Date:

Representative’s Relationship to Applicant (only if applicable):

Representative’s Telephone Number (only if applicable):

Representative’s Address (only if applicable):

To report suspected fraud or abuse in the provision or receipt of IHSS services, please call the fraud hotline at 1-800-822-6222, email at stopmedicalfraud@dhcs.ca.gov, or go to http://www.dhcs.ca.gov/individuals/Pages/StopMedi-CalFraud.aspx.

FOR AGENCY USE ONLY

Income Eligible:

Status Eligible:

Medi-Cal Aid Code:

Yes No

Yes No

 

 

 

 

 

MAGI Eligible Recipient:

 

Verification:

 

Disabled 12 months or longer

 

 

At risk without IHSS

 

 

 

 

 

 

 

Notes:

 

 

 

Signature of Social Worker or Agency Representative:

Telephone Number:

SOC 295 (9/18)

Page 7 of 8

State of California – Health and Human Services Agency

 

California Department of Social Services

 

 

 

 

Ethnic Codes:

Language Codes:

A. White.

1.

American Sign Language

B. Hispanic.

 

(AMISLAN or ASL).

C. Black.

2.

Spanish - NOA will be issued

D. Other Asian or Pacific Islander.

 

in Spanish.

E. American Indian or Alaskan Native.

3.

Cantonese.

F. Filipino.

4.

Japanese.

G. Chinese.

5.

Korean.

H. Cambodian.

6.

Tagalog.

I. Japanese.

7.

Other non-English.

J. Korean.

8.

English.

K. Samoan.

9.

Spanish - NOA will be issued

L. Asian Indian.

 

in English.

M. Hawaiian.

10. Other Sign Language.

N. Guamanian.

11.

Mandarin.

O. Laotian.

12. Other Chinese Languages.

P. Vietnamese.

13. Cambodian.

Q. Other.

14. Armenian.

R. Mixed Ethnicity.

15. Ilacano.

 

16. Mien.

 

17. Hmong.

18. Lao.

19. Turkish.

20. Hebrew.

21. French.

22. Polish.

23. Russian.

24. Portuguese.

25. Italian.

26. Arabic.

27. Samoan.

28. Thai.

29. Farsi.

30. Vietnamese.

SOC 295 (9/18)

Page 8 of 8

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ca soc 295 conclusion process detailed (portion 2)

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ca soc 295 writing process detailed (stage 3)

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