Did you know that the Department of Public Social Services (DPSS) offers a variety of benefits and services to qualifying individuals and families? One such service is the DPSS 3809 Form. This form is used to apply for Medi-Cal, a government-sponsored health care program. In this blog post, we will provide an overview of the DPSS 3809 Form and how to complete it. We will also discuss who is eligible for Medi-Cal and how to access its benefits. So, if you are interested in learning more about the DPSS 3809 Form, keep reading!
| Question | Answer |
|---|---|
| Form Name | DPSS 3809 Form |
| Form Length | 1 pages |
| Fillable? | Yes |
| Fillable fields | 49 |
| Avg. time to fill out | 10 min 7 sec |
| Other names | dpss1917, dpss 1917, riverside county dpss affidavit form, riverside county department of public social services affidavit form dpss 1917 |
Riverside County Department of Public Social Services – Children’s Services
Placement Packet Document Inventory Sheet – DPSS 3809
(Left Side of Packet)
Documents to Review with Caregiver
PUB 132 The Child Abuse and Neglect Reporting Law (Eng. & Span.)
PUB 395 You Have Rights Too! (Eng.)
PUB 13 Your Rights under California Welfare Programs (Eng., Span., & 14 other languages)
DPSS 3373A The Complaint Process (Eng. & Span.)
DPSS 3373 |
Resolving Grievances |
DPSS 3694 |
Caregiver Incident Report |
DPSS 3566 |
Instructions for |
Caregiver Information Form (Eng., |
|
|
Span., & 3 other languages) |
PUB 183 |
Child Health & Disability Prevention |
|
(CHDP) Program (Eng.) |
PUB 184 |
Child Health & Disability Prevention |
|
(CHDP) Program (Span.) |
PM 357 |
CHDP Referral (Eng. only) |
DPSS 2004 |
Verification of Dependent Medical |
|
and Dental (Eng. or Span.) |
N/A |
JDP and CASA Case Manager E- |
|
mail and Telephone List |
DPSS 2787 |
A Guide to Legal Guardianship and |
|
Adoption |
DPSS 3333 |
Family Matters |
DPSS 3372 |
Family Support Pamphlet |
DPSS 3668 |
Team Decision Making Pamphlet |
|
(Eng. or Span.) |
Additional Items for Caregivers
Birth Certificate
Medical Card (i.e.
Immunization Card
Social Security Card
Medication currently required:
Other:
Caregiver’s Signature:
Date:
(Right Side of Packet)
Agreements
SOC 156
SOC 154
DPSS 738 Placement Request
Relative/NREFM Placement Information
DPSS 2688
DPSS 3265 Verification of NREFM
DPSS 1765A Request for Criminal History Records Check (3 Copies)
DPSS 1917C Affidavit (3 Copies) (Eng. & Span.)
BCII 8016 Request for Live Scan Services (Carbonized Set of 3)
SOC 815 Approval of Family Caregiver Home
SOC 817 Checklist of Health and Safety Standards for Approval of Family Caregiver Home
SOC 818 Relative or NREFM Caregiver Assessment
DPSS 3413 Documented Alternative Plan (DAP) DPSS 3555 Relative/NREFM to RAU
DPSS 3558 Notification of a Choice of a Relative/ NREFM Caregiver by the Social Worker
DPSS 3612 Reference Letter Request
DPSS 3190 Potential Caregiver Letter (Eng. or Span.)
Documents for All Placement Types
DPSS 2724 Child’s Personal Belongings and Medication Inventory (Eng. or Span.)
DPSS 2757 Foster Child’s Needs and Case Plan Summary
DPSS 3231 Child’s Personal Rights Summary (Eng. or Span.)
DPSS 3637 Caregiver’s Authorization Affidavit (Eng. or Span.)
DPSS 2769 Statement of Dangerous Behavior
/Ambulatory Status
Social Worker’s Signature:
Date:
DPSS 3809 (08/09) Placement Packet Document Inventory Sheet |
Page 1 of 1 |