California Form Soc 295 – Fill Out and Use This PDF

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)

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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:

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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.

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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.

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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.

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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.

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State of California – Health and Human Services Agency	California Department of Social Services

Section 10 – Signature(s)

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

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:

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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.

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