Start completing the fillable fields and carefully type in required information. Includes the steps and resources to apply for in-home services, Includes finding, hiring, and managing your IHSS Provider, Also includes hearing requests, and abuse and fraud reporting. Hours worked over 40 hours in a workweek as overtime (OT); Wait time at medical appointments under certain conditions; Time needed for traveling directly from one recipient to another on the same day, up to seven hours per workweek; and. Return Completed SOC 2298 Forms to: IHSS - IRS Live-In Self-Certification P.O. Continue reporting your hours worked on your timesheet as you always have. The Extraordinary Circumstances exemption is available to care providers working for multiple recipients who are at risk of out-of-home placement. Add the date and place your e-signature. The In-Home Supportive Services (IHSS) program can provide homemaker and personal care assistance to eligible individuals who are receiving Supplemental Security Income or who have a low income and need help in the home to remain independent. Complete Health Care Certification Repair services Sitting with you to visit or watch TV Taking you on social outings Applying as a Care Recipient 1. Protective supervision is an IHSS service for recipients who require 24/7 supervision to prevent injury to themselves or others due to severely impaired judgment, orientation, and/or memory (their words). How to Apply Contact IHSS at (408) 792-1600 or fill out the application and submit using one of the options below. Demonstrate a need for help with activities of daily living. Effective January 17, 2023, the IHSS Hawthorne and Rancho Dominguez Offices have Moved! You are considered your provider's employer and, therefore, it is your responsibility to hire, train, supervise, and fire your provider. The cookies is used to store the user consent for the cookies in the category "Necessary". Amendment to the September 28, 2021, Public Health Order, Questions & Answers: Adult Care Facilities and Direct Care Worker Vaccine Requirement, COVID-19 Vaccination Exemption Form- Spanish(Espaol), COVID-19 Vaccination Exemption Form- Armenian(), COVID-19 Vaccination Exemption Form- Chinese(), COVID-19 Vaccination Exemption Form- Cambodian(), COVID-19 Vaccination Exemption Form- Farsi(), COVID-19 Vaccination Exemption Form- Korean(), COVID-19 Vaccination Exemption Form- Russian(), COVID-19 Vaccination Exemption Form- Tagalog(Tagalog), COVID-19 Vaccination Exemption Form- Vietnamese(Ting Vit), Personal Assistance Services Council (PASC), SOC 873 - In-Home Supportive Services Program Health Care Certification Form, Provides services to a family member(s); and, Obtain a weekly COVID-19 test at one of the State testing sites (, Wear a surgical mask or N95 mask, at all times, while providing services in your home. In-Home Supportive Services (IHSS) 1505 E Warner Ave Santa Ana, CA 92705 Phone: 714-825-3000, Monday - Friday, 8:00 a.m. to 5:00 p.m. ), Legal Services of Northern California Please note Placer County IHSS and Public Authority do not require proof of vaccination or exemption. Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors. S.F. Provider Forms. %}yB) _(`[:8%pq~;5 SOC 295 - Application For In-Home Supportive Services, SOC 295L - Application For In-Home Supportive Services (Large Print), SOC 426A - In-Home Supportive Services Program Designation of Provider, [Espaol] [] [] [] [] [] [Tagalog] [Ting Vit] [], SOC 838 - In-Home Supportive Services Recipient Request for Assignment of Authorized Hours to Provider, SOC 840 - In-Home Supportive Services Program Provider or Recipient Change of Address and/or Telephone, SOC 873 - In-Home Supportive Services Program Health Care Certification Form, SOC 321- Request for Order and Consent Paramedical Services, SOC 825 - Protective Supervision 24-Hours-A-Day Coverage Plan, SOC 839 - In-Home Supportive Services Designation of Authorized Representative, [Espaol][][][][][][Tagalog][Ting Vit], SOC 2256 - In-Home Supportive Services Program Recipient and Provider Workweek Agreement, [Espaol][][][][][][Tagalog][Ting Vit][], SOC 2274 - In-Home Supportive Services Program Accompaniment to Medical Appointment, SOC 2279 - In-Home Supportive Services Program Live-In Family Care Provider Overtime Exemption, SOC 2326 - In-Home Supportive Services Recipients Responsibility to Stop Sexual Harassment in the Workplace, PA 2457 - Civil Rights Information Notice, PUB 13 - Your Rights Under California Welfare Programs, PUB 13 Your Rights Under California Welfare Programs (Large Print). 1. In-Home Supportive Services. IMPORTANT:If your provider tests positive forCOVID-19, they should not be providing IHSS services. *Also available in the following languages: To qualify for the qualified medical reason exemption, your provider must include a written statement signed by the doctor, nurse practitioner, or other licensed medical professional under the license of a physician, stating that the provider qualifies for the exemption and indicating the length of the exemption (may be unknown or permanent). Is my provider allowed to claim this time? Provider Forms. Case Management, Information and Payrolling System (CMIPS) will automatically check for Medi-Cal eligibility. A Share of Cost (also referred to as a SOC) is the amount of money you are responsible to pay towards your medical related services, supplies, or equipment before Medi-Cal will begin to pay. COVID-19 sick leave benefits are available for IHSS & WPCS providers. Recipient Forms Recipient Forms Recipient Forms If you need assistance completing any of these forms, please contact the IHSS Helpline at (888) 822-9622. The cookie is used to store the user consent for the cookies in the category "Performance". If you do not work for Placer County - Contact your IHSS county for submission instructions. If approved, IHSS will tell you the types of services, start date, and the number of IHSS hours per month that have been authorized for you. Complete the SOC 295 Application For IHSS, _________________________________________________________________. To be eligible for the Extraordinary Circumstances exemption, the provider must work for two or more IHSS recipients whose circumstances put them at risk of placement in out-of-home care. Fill out, sign and return this form in person to the office or location designated by the county. The California Department of Public Health issued a public health order on September 28, 2021, requiringcertainproviders to be fully vaccinated with the COVID-19 vaccine by November 30, 2021. SOC 332 In-Home Supportive Services Recipient Employee Responsibilities Checklist, SOC 426A In-Home Supportive Services Program Designation of Provider, SOC 838 In-Home Supportive Services Recipient Request for Assignment of Authorized Hours to, SOC 839 In-Home Supportive Services Recipient Timesheet Signature Authorization, SOC 840 In-Home Supportive Services Program Provider or Recipient Change of Address and/or Telephone, SOC 864 In-Home Supportive Services Back-Up Plan and Risk Assessment, SOC 873 In-Home Supportive Services Program Health Care Certification Form, SOC 2256 In-Home Supportive Services Program Recipient and Provider Workweek Agreement, SOC 2274 In-Home Supportive Services Program Accompaniment to Medical Appointment, SOC 2279 In-Home Supportive Services Program Live-In Family Care Provider Overtime Exemption, TEMP 3000 In-Home Supportive Services Program Overtime and Workweek Requirements Recipient Declaration, SOC 426 In-Home Supportive Services Provider Enrollment Form, SOC 829 In-Home Supportive Services Provider Direct Deposit Enrollment/Change/Cancellation Form, SOC 840 In-Home Supportive Services Program Provider or Recipient Change of Address and/or Telephone Form, SOC 846 In-Home Supportive Services Program Provider Enrollment Agreement, SOC 847 Important Information For Prospective Providers IHSS Provider Enrollment Process, SOC 2255 In-Home Supportive Services (IHSS) Program Provider Workweek & Travel Time Agreement, SOC 2279 In-Home Supportive Services (IHSS) Program Live-In Family Care Provider Overtime Exemption, W-4 Employees Withholding Allowance Certificate (Federal), DE-4 Employees Withholding Allowance Certificate (State). A county social worker will interview to determine your eligibility and need for IHSS. Find the Ihss Application Form Pdf you require. The cookie is used to store the user consent for the cookies in the category "Analytics". The social worker needs to document all service needs and justify the services and hours authorized. Mail In-Home Supportive Services PO Box 11018 San Jose, CA 95103-1018 Email SSA_IHSS_ARCCI_Fax@ssa.sccgov.org In Person Box 1677 West Sacramento, CA 95691-6677 What do I do for wages paid before my Self-Certification Form is received? You must apply for Medi-Cal if you are not already receiving. You can fax requested documents to your IHSS District Office using its secure fax: IHSS Office eFax #, Burbank (818)563-9105, Chatsworth (818) 450-0241, El Monte (626) 380-4960, Hawthorne (310) 943-2125, Lancaster (661) 424-7849, Metro IHSS (213) 947-4591, Pomona (909) 752-9402, Rancho Dominguez (310) 943-2125. Click on Done following twice-checking all the data. By using this site you agree to our use of cookies as described in our, Something went wrong! Your provider may request for an exemption from the vaccine requirement for a qualified medical reason or religious belief. The PASC is the Public Authority for Los Angeles County. County IHSS Case #: 3. I attended the required provider enrollment orientation for IHSS providers and I . Video instructions and help with filling out and completing ihss application form, Instructions and Help about apply for ihss online form, Narrator In Home Supportive Services is the largest publicly funded non-medical service to help people with disabilities remain inhere homes Applying to the program can be daunting To start the application process contact the IHSS program in your county A representative will gather information about your income disability and what services you may need Elizabeth Worker Some people need a service called Protective Supervision This is an I-H-S-S service for people with cognitive or mental health disabilities in need of 24-hour observation and monitoring to protect them from injuries hazards or accidents Make sure you tell the representative promise that you want protective supervision for your family member if you think they need the service Narrator The county will give you a form called form S-O-C-821 also referred to as assessment of need for protective supervision for in-home supportive services program The doctor will need to fill out this form Explain to the physician that your family member needs constant supervision to keep him or her safe Describe that your family members memory orientation and judgment are impaired and how it affects his or her life It is helpful to provide the doctor with copy of our publication called In-Home Supportive Services Protective Supervision which is available on our website Elizabeth Your family members doctor should check the boxes on the form indicating whether your family member is severely impaired moderately impaired or unimpaired in memory orientation or judgment The doctor should be as detailed as possible and include specific examples Narrator If the doctor runs out of spaceheshe may attach a letter to the form to continue explaining your condition Return the form to your social worker and keep a copy for your own records once it is complete Applying for protective supervision is not guarantee of services If your application is denied request a hearing to appeal the Counties decision or call Disability Rights California for assistance, If you believe that this page should be taken down, please follow our DMCA take down process, This site uses cookies to enhance site navigation and personalize your experience. IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM PROVIDER ENROLLMENT FORM INSTRUCTIONS: Use black or blue ink to fill out. Sacramento, CA 95814, Summaries of select CalWORKs, CalFresh, Health and Housing Regulations, Individuals have the right to apply for IHSS services or make an application through another person on their behalf. On Friday, September 1, 2014. The paper enrollment form is available on the CDSS website for those who want to use it. Not eligible for IHSS? You must live at home or a dwelling of your own choosing (acute care hospital, long-term care facilities, and licensed community care facilities are not considered "own home"). Box 1912. The SOC may change from month to month. Provider Phone: 510.577.5694. In-Home Supportive Services, also known as IHSS, can help pay for services if youre a low-income elderly, blind or disabled individual, including children, so that you can remain safely in your own home. To apply for In-Home Supportive Services, please complete the application (PDF) and first page of the Health Care Certification (PDF).Your Licensed Health Care Professional (LHCP) will need to complete the second page of the Health Care Certification.Fax them to 916-787-8922, ATTN: IHSS Intake and call the Placer County Adult Intake number at 916-787-8860 or toll free at 888-886-5401. Paperwork will be mailed to you and must be returned within 60 days of your video or phone assessment. To enroll, IHSS recipients will choose a Recipient Authentication Number (RAN) which is similar to a PIN. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. If denied services, you can appeal the decision at the state level. Eligibility criteria for allIHSS applicants and recipients: DPSS offers IHSS providers and recipients an online customer service center to access program information, submit questions through a helpdesk system and chat live with a DPSS agent during normal business hours. 4. Counties must reassess individuals IHSS eligibility every year, and each time a recipient notifies the county of a change in circumstances. Assessments will temporarily occur on a video or phone call. Over 550,000 IHSS providers currently serve over 650,000 recipients. COVID-19 VACCINE BOOSTER DOSE REQUIREMENT. In-Home Supportive Services Referral Form Date Sent Please answer all questions and print clearly 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. 7 Note: the current SOC 321 Form (discussed further below) limits who can authorize paramedical services to a "Physician/Surgeon," "Podiatrist" and "Dentist." IHSS Public Authority; IHSS Recipient/Consumer Education Videos (provided by CDSS) Transportation Services; Print information clearly. This cookie is set by GDPR Cookie Consent plugin. Receive Medi-Cal or qualify for Medi-Cal. Preparing for Power Outages - Recipient Registration Register for the IHSS Website to: View your timesheet and payment statuses Enter and submit timesheets No longer mail paper timesheets Request additional timesheets Enroll in direct deposit Claim sick leave Registration FAQs (PDF) Once completed and signed by the Recipient (or their authorized representative), the Hiring Agreement can be submitted by: Mail to: County of Fresno Department of Social Services. The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". 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