Please rate Ihss Referral Form Rev. 05-25
A completed Health Certification Form (SOC 873) is required to complete the IHSS application process. It can be submitted via fax to 415-355-2463 or emailed to ihss@sfgov.org.
Consent: does applicant consent to IHSS services? If not, please do not proceed with this application.
Emergency home care: DAS is unable to authorize emergency home care services without a completed Health Care Certification form SOC 873.
Medi-Cal: in order to receive IHSS, the applicant must be on full-scope Medi-Cal and may still have a share of cost (based on income).
Questions: please call (415) 355-6700 extension 3.
| Question | Answer |
|---|---|
| Form Name | Form 3012 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 88 |
| Avg. time to fill out | 15 min |
| Edition | Rev. 05/25 |
| Issuing agency | San Francisco Department of Disability and Aging Services |
| Where to send | Department of Disability and Aging Services P.O BOX 7988 San Francisco, CA 94120 |
| Matches the agency's file | Yes, checked October 4, 2026 |
| Other names | Form 3012, 3012, IHSS referral form, In-Home Supportive Services Referral Form |
| Official source | Form 3012 (Rev 05/25), San Francisco Department of Disability and Aging Services |
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Please rate Ihss Referral Form Rev. 05-25
