Ihss Application Details

Ihss Referral Form is a great way to connect with Ihss and get the help you need. It's important to have all of your information ready when you fill out the form, so that you can be connected with the right person as soon as possible. This form is for residents of Los Angeles County, so please make sure you are in the correct county before submitting it. The sooner you submit the form, the sooner you'll be connected with someone from Ihss who can help.

If you would like first learn how much time you will need to fill out the ihss referral form and the number of pages it's got, here is some basic data that may be helpful.

QuestionAnswer
Form NameIhss Referral Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesihss application form pdf, apply ihss online, ihss application form, application for ihss

Form Preview Example

 

 

 

 

 

 

 

In-Home Supportive Services Referral Form

 

 

Date Sent:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ple ase answe r all q ue stio ns and print c le arly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax to SF HSA Department of Aging and Adult Services Program: (415) 557-5271

 

 

 

 

 

 

 

 

Questions? Call: (415) 355-6700 or email us at: ihss@ci.sf.ca.us

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IHSS Applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse (If in the home)

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

 

 

MI

Last Name

 

 

 

 

 

 

First Name

 

 

 

 

 

MI

 

/ /

 

 

Sex (M/F)

 

/Transgender (Y/N)

 

 

 

-

-

 

 

 

 

/

/

 

 

Sex (M/F)

/Transgender (Y/N)

 

 

-

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth date

 

Sexual Orientation

 

 

 

Soc. Sec. Number

Birth date

 

 

Sexual Orientation

 

 

 

 

 

 

 

 

 

Soc. Sec. Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

Zip

(

 

)

 

 

-

 

 

 

 

Is Spouse an IHSS Recipient?

 

Y

 

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

 

 

 

 

 

Languages:

 

 

 

 

 

 

 

 

 

 

 

 

 

Is Spouse able to do housework? Y

 

 

 

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If no, why not?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does applicant receive Supplemental Security Income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s MD Information:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(SSI)? Y

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the applicant enrolled in Medi-Cal? Y

 

 

 

 

N

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CA Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone: (

)

 

-

 

Fax: (

)

-

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Contact Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relation:

 

 

 

 

 

 

 

 

Phone: (

)

 

 

 

-

 

 

Last name

 

 

 

 

 

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please circle one:

 

 

CELL-HOME-WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relation:

 

 

 

 

 

 

 

 

Phone: (

)

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last name

 

 

 

 

 

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please circle one:

 

 

CELL-HOME-WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Others in Household:

 

 

Lives Alone

 

 

 

 

 

 

 

 

 

Number of Household Members: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other IHSS Recipients in household?

 

Y

 

 

 

 

N

 

 

If yes, Soc. Sec. Number:

-

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of IHSS Recipient:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last name

 

 

 

 

 

 

 

 

 

 

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis/ Medical Condition:

 

 

 

 

 

 

 

MD Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

La st Na me

 

 

 

 

 

 

 

First Na me

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

CA Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

(

)

-

 

Ext:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax:

 

 

(

)

-

 

Ext:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referent Name: For non self‐referrals, please attach applicant’s signature of Authorization for Release of Information.

 

 

 

Phone: (

)

-

ext.

 

Last name

First name

 

 

 

 

 

 

Agency:

 

 

Re la tio n:

 

 

 

 

If hospitalized, Hospital:

 

Campus/ Site:

Room:

Bed:

Floor:

Most Recent or Anticipated discharge date /

/

 

 

 

 

 

Emergency On-Call Home Care

 

 

 

 

 

 

 

Is emergency on-call home care requested? Y

N

***we a re una ble to a utho rize ER se rvic e s witho ut

the health care certification form SOC 873 ***

 

 

 

 

 

 

*If yes, why are emergency services needed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fo rm 3012 (re v. 06/ 12)

 

 

 

 

 

 

Pa g e 1 o f 2

The information on this page will help us assess your needs and respond to your request for services. If the form is

not completed in full, your application will not be accepted.

*We a re unab le to autho rize e me rg e nc y o n-c a ll ho me c a re se rvic e s witho ut the pro visio n o f this info rmatio n*

Functional Ability

 

Unknown

Independent

 

Verbal

 

Some human

Lots of human

Dependent

 

 

 

 

 

 

Assist

 

 

help

help

 

Transfer mobility

 

 

 

 

 

 

 

 

 

 

 

 

Bathing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dressing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Toileting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eating

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Grooming

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ambulating (walking)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mobility indoors

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stair climbing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Managing medicines

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shopping

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meal prep & clean up

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transportation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Managing money

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Light housework

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heavy housework

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Laundry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Risks

 

 

 

 

 

 

 

 

 

 

Does the client currently exhibit

 

Active

Past

 

Unknown

 

 

Explain

 

or have history of…

 

 

History

 

 

 

 

 

 

 

Violent Behavior

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Financial management/ Eviction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Support System

 

 

 

 

 

 

 

 

 

 

How are your service needs currently being met? Please be as specific as possible and include information about current caregiver(s) and areas of need.

How will you be able to meet your service needs until IHSS eligibility and services are established?

Services

Please list any services you currently receive:

Are you interested in learning more about the following services?

On Lok Lifeways/ PACE program (a comprehensive Medi-Cal program that offers services including adult day health care, in-home care, and medical services)

Adult Day Health Care thro ug h Community-Based Adult Services (CBAS)

Other services:

***Please note that in order to receive IHSS you must be on full-scope Medi-Cal and may still have a share of cost (based on your income). Our staff can assist you in applying for Medi-Cal coverage.***

Fo rm 3012 (re v. 06/ 12)

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