iqRB:\l!== Sf.ca.us IHSS Applicant Last Name / / Birth date Spouse If in the home First Name Sex M/F MI - /Transgender Y/N Zip N Is Spouse able to do housework Y If no why not Does applicant receive Supplemental Security Income Spouse s Form Popularity ihss application online form. Providers or Recipients who would like to be vaccinated may search here for options. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Change the blanks with exclusive fillable areas. We will conduct home visits if an applicant cannot participate in a video or phone assessment. Effective January 17, 2023, the IHSS Hawthorne and Rancho Dominguez Offices have Moved! Complete the SOC 295 Application For IHSS, _________________________________________________________________. Photo: Lea Suzuki, The Chronicle Buy photo Welcome to the County of Orange Social Services Agency In-Home Supportive Services (IHSS) website. If you are unable to print the form yourself, you can contact the IHSS Call Center via phone or email to receive another form: Phone: 530-889-7171 Email: Recipients authorized hours are less than the statutory maximum of 283 hours per month. Plan for this interview to take up to 90 minutes and to show proof of income and resources (bank statements). All IHSS recipients will now be assigned "maximum weekly hours." To find your recipients' maximum weekly hours, divide their total monthly authorized hours by four. Accessibility ReaderIf you have difficulty typing, moving a mouse, or reading, click the icon to the left and download a new reader / browser from eSSENTIAL Accessibility. window._Taboola = window._Taboola || []; _Taboola.push({mode: 'thumbnails-c', container: 'taboola-interstitial-gallery-thumbnails-5', placement: 'Interstitial Gallery Thumbnails 5', target_type: 'mix'}); _Taboola.push({flush: true}); Individuals have the right to apply for IHSS services or make an application through another person on their behalf. 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. _fr1K$7HBk|C6w?0&SApG(G[9$a@rRI {!Zi 3KWI]I.+YzQ5d]1|{$EY-0Z2fZ|_Ydu[ zlns^"y~->d>fy7vq&ex$N&0QNH0ilT4KpX#qS[|S|{ V[+f~e[ykp@ebjqfP$Qz:~\Ck_^QrP,~. Live in your own home (your "own home" is any place you choose to live, except a nursing home or other out-of-home care facility, licensed or not). Demonstrate a need for help with activities of daily living. This cookie is set by GDPR Cookie Consent plugin. Service authorizations are assessed during the needs assessment, which is a comprehensive review of the recipients medical history/diagnosis, medications/purpose, emergency contacts, physicians information, household composition, functional index rankings, mini-mental health assessment, necessary referrals to Adult Protective Services (APS), Child Protective Services (CPS), Fraud, community services, etc., language preferences and whether an interpreter is needed, and a full biopsychosocial assessment. By using this site you agree to our use of cookies as described in our, Something went wrong! If the applicant is ineligible for Medi-Cal when they apply, they may be authorized services back to the protected date of eligibility. In addition,you'll be responsible for hiring, supervising, and scheduling your IHSS Providers, and for signing their timesheets. Find out about other options for in-home services by visiting: Live at home or in a shelter, but not in a board and care facility, nursing home, or hospital. As of September 1, 2020, EVV is mandatory in the County of San Diego for all IHSS recipients and . Please note Placer County IHSS and Public Authority do not require proof of vaccination or exemption. You also have the option to opt-out of these cookies. 7 Note: the current SOC 321 Form (discussed further below) limits who can authorize paramedical services to a "Physician/Surgeon," "Podiatrist" and "Dentist." Need a COVID-19 vaccination? IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM PROVIDER ENROLLMENT FORM INSTRUCTIONS: Use black or blue ink to fill out. All of the following must be true to submit a claim: What if I already received my vaccine(s)? Be a California resident. How to Apply Contact IHSS at (408) 792-1600 or fill out the application and submit using one of the options below. Provider's Address: City, State, ZIP Code: 5 . 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. We also use third-party cookies that help us analyze and understand how you use this website. You must submit a completed Health Care Certification form. Your provider may request for an exemption from the vaccine requirement for a qualified medical reason or religious belief. This assessment will include information given by you and, if appropriate, by your family, friends, physician or other licensed health care professional. They operate a Provider Registry and will provide you with referrals to providers. To be eligible for IHSS, you must be one of the following: Years of Age or Older, Legally Blind, or a Disabled Adult or Disabled Child. of Public Health until they have been cleared to do so. For Recipients: How to obtain a list of providers. Photo: Associated Press CFCO provides States with 6% additional federal funding for services and supports. Be signed and dated by the LHCP within 60 calendar days of submission to the Social Worker. If the applicant is ineligible for Medi-Cal when they apply, they may be authorized services back to the protected date of eligibility. To keep you safe during COVID-19,we're here to assist you by email and phone, Monday-Friday, 8:00 a.m. to 5:00 p.m. Emailihsspaymentunits@sfgov.org. 1. Submit issues to IHSS staff, upload documents, and check status of existing issues Become a Caregiver/Provider Sign-up to be an IHSS provider Survey Send us your IHSS feedback Accessing the Electronic Services Portal Timesheets and Payroll Forms & Resources Download Commonly Used IHSS Forms Department of Justice and Verification of Employment (VOE) 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. Is there a deadline or end date for submitting this claim? In-Home Supportive Services (IHSS) Map/Directions. 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). Includes address updates, tracking your case, and assessments. Provider Phone: 510.577.5694. Case Management, Information and Payrolling System (CMIPS) will automatically check for Medi-Cal eligibility. Complete Health Care Certification Get the free ihss application form Get Form Show details Hide details 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. IHSS recipients must obtain County approval whenever you need your IHSS provider to work more than his/her maximum weekly hours when the adjustment in the work schedule results in the provider: To request the one-time exception, contact the IHSS Helpline at (888) 822-9622. 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 provider is active on the recipients case at the time of the vaccine appointment(s); The vaccine appointment(s) are separate from your typical medical appointments currently captured in your IHSS case authorization (if you are unsure what medical appointments are currently authorized in your case, contact your assigned case worker), If you are 65+ and received the vaccine(s) already you may submit a claim going back to January 1, 2021 if your provider assisted you with your appointment(s) and you meet all the criteria listed above, Recipients age 16-64 became eligible to receive the vaccine on March 15, 2021, Up to 2 hours for each appointment, with a maximum of 4 hours for each Recipient, If the same provider is accompanying you to both of your vaccine appointments, it is preferred that you wait to submit, If different providers are accompanying you to your two vaccine appointments, you will need to submit two claims (one for each appointment/provider), Yes, a separate claim must be submitted for each recipient the provider is assisting. 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