Ihss Referral Form – Fill Out and Use This PDF

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:

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?

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