Ihss Referral Form ≡ Fill Out Printable PDF Forms Online

Ihss Referral Form PDF 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.

Question	Answer
Form Name	Ihss Referral Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	ihss application pdf, ihss recipient application form, ihss orientation, ihss forms

12

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)

Pa g e 2 o f 2

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