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The In-Home Supportive Services (IHSS) Referral Form is a vital document designed to streamline the application process for those seeking assistance in managing daily living activities at home. This form collects essential information, such as personal details about the applicant and their spouse, medical backgrounds, and current living situations. Applicants are required to provide information regarding their functional abilities—ranging from independent mobility to assistance needed for activities like bathing and meal preparation. Additionally, there’s a section dedicated to identifying emergency needs for home care services, which highlights the importance of prompt support in specific situations. The form also emphasizes the necessity of providing thorough information to ensure that applications are processed efficiently, as incomplete submissions can hinder approval. By also considering other support systems and existing services, the IHSS Referral Form aims to create a comprehensive view of the applicant’s needs, ensuring they receive the appropriate assistance as quickly as possible. It’s important to approach this form with care, as it plays a pivotal role in determining eligibility and access to vital services for those who require them.

Ihss Referral 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: [email protected]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

File Breakdown

Fact Name Description
Date Sent The form must clearly indicate the date it was sent to ensure timely processing by the Department of Aging and Adult Services.
Program Information The form is specifically for In-Home Supportive Services (IHSS), which assists individuals who need help with daily tasks due to age or disability.
Emergency Contact An emergency contact is required. This person should be someone who can be reached quickly if needed.
Eligibility Requirements To qualify for IHSS, individuals must generally be enrolled in Medi-Cal and meet certain income requirements.
Non-Self Referrals If someone other than the applicant is filling out the form, a signature granting permission to release information must be attached.
Functional Ability Section This section assesses the applicant's daily living capabilities, which is essential for determining the level of care needed.

Guide to Using Ihss Referral

After completing the IHSS Referral Form, it will be processed by the appropriate department. Make sure to provide accurate and clear information to avoid any delays in service. Once submitted, you should keep an eye on your communication channels for updates regarding your application.

  1. Obtain the Form: Ensure you have the latest version of the IHSS Referral Form.
  2. Fill in Date Sent: At the top, write the date you are filling out the form.
  3. Complete Applicant Information: Fill in your last name, first name, middle initial, sex, date of birth, sexual orientation, and Social Security number.
  4. Spouse Information: If applicable, complete the same details for your spouse, including their question on being an IHSS recipient and ability to do housework.
  5. Provide Contact Information: Include your street address, zip code, and phone number. Ensure your contact details are accurate.
  6. Emergency Contact: List the name, relationship, and phone number of your emergency contact.
  7. Household Information: Indicate if you live alone and number of household members. If there are other IHSS recipients, provide their details.
  8. Medical Information: Document any medical diagnoses or conditions, along with your doctor’s information.
  9. Referral Information: If the referral is not self-directed, include the name and phone number of the person making the referral.
  10. Emergency On-Call Home Care: Indicate if this service is requested and explain why if necessary.
  11. Functional Ability: Assess and indicate your level of independence in various activities of daily living.
  12. Support System: Describe how your current service needs are being met and detail your existing support system.
  13. Current Services: List any services you currently receive and indicate interest in additional services.
  14. Submit the Form: Fax the completed form to the SF HSA Department of Aging and Adult Services at the provided number.

Get Answers on Ihss Referral

What is the IHSS Referral Form used for?

The IHSS Referral Form is utilized to apply for In-Home Supportive Services. This program provides assistance to individuals who have difficulty performing daily living activities due to age, disability, or chronic illness. By completing this form, applicants seek evaluation and enrollment in the IHSS program.

How do I submit the IHSS Referral Form?

After filling out the referral form completely, fax it to the San Francisco Human Services Agency (HSA) Department of Aging and Adult Services at (415) 557-5271. Be sure to write clearly to avoid miscommunication.

What information is required for the IHSS Referral Form?

Key details needed include:

  • Personal information of the applicant and spouse (if applicable)
  • Social Security numbers
  • Medical condition details
  • Emergency contact information
  • Current service needs and any existing aid received

Completing the form in full is essential, as omissions may result in delays or denial of application.

Can I apply for IHSS if I don’t currently receive Medi-Cal?

No, to qualify for IHSS, you must be enrolled in full-scope Medi-Cal. If you need assistance with applying for Medi-Cal, the IHSS staff can guide you through the process.

What happens if my spouse is also applying for IHSS services?

If your spouse is applying, their information should also be included in the referral form. Indicate whether they are an IHSS recipient and provide relevant details to facilitate the processing of both applications.

How can I contact the IHSS program for assistance?

If you have questions regarding the IHSS Referral Form, you can call (415) 355-6700. Alternatively, you can email your inquiries to [email protected] for assistance.

What if I need emergency home care services?

Should you require emergency on-call home care, you must indicate this on the form. Keep in mind that the authorization for these services requires a health care certification form (SOC 873). Details as to why emergency services are needed should also be provided.

What types of services can I receive through IHSS?

IHSS provides a range of services to assist with daily living tasks, which may include housework, meal preparation, and personal care. Applicants may also inquire about additional services, such as adult day health care or programs through On Lok Lifeways/ PACE.

What should I do if I have additional comments or unique needs?

The referral form includes a section for comments. You should provide as much detail as possible regarding your situation, current caregivers, and specific needs. This helps to ensure that your needs are understood and addressed promptly.

Common mistakes

Filling out the In-Home Supportive Services (IHSS) Referral Form requires careful attention to detail. Here are some common mistakes individuals make that can delay processing or affect eligibility.

One frequent error is incomplete information. Applicants must answer all questions clearly. Leaving sections blank may result in the application being rejected. Ensure that all required fields, such as names, addresses, and Social Security numbers, are filled in completely to avoid delays.

Another mistake occurs when applicants fail to provide accurate contact information. If the phone number or email address listed is incorrect, it hinders communication. Always double-check that these details are correct to facilitate prompt assistance.

People often overlook the need to indicate the applicant's relationship with other household members. Failing to specify whether spouses or other individuals living in the household are IHSS recipients can lead to confusion in assessing needs. Clearly outline the relationships and roles of all household members to provide a complete picture.

Some applicants may not recognize the importance of documenting medical information. It is essential to include any diagnosis or medical conditions that affect care needs. This information directly influences the assessment process, so provide detailed and accurate descriptions.

Additionally, many individuals neglect to answer questions regarding the applicant’s functional ability. Declaring if someone is independent, dependent, or somewhere in between provides crucial insights into the level of support needed. Omitting this information can lead to an incomplete understanding of the applicant’s care requirements.

Another common oversight is not disclosing current services received. Applicants should specify if they are already receiving other types of care or support. This prevents overlapping services and helps in planning appropriate care moving forward.

Some people forget to include authorization for release of information when submitting on behalf of someone else. If the application is a non-self-referral, ensure that the applicant has signed this authorization to avoid delays or complications.

Lastly, failing to provide a clear reason for requesting emergency services, if applicable, can lead to confusion over service needs. Be prepared to explain the necessity for such services in the provided section clearly. This clarity facilitates better support for the applicant's situation.

By avoiding these common mistakes, applicants can ensure a smoother process when applying for IHSS services. Complete, accurate, and clear submissions help meet the care needs of individuals seeking assistance.

Documents used along the form

The In-Home Supportive Services (IHSS) Referral Form is a key document for individuals seeking assistance in their daily activities. However, several other forms and documents often accompany it to ensure that all necessary information is gathered for an effective evaluation of needs. Below is a list of documents frequently used in conjunction with the IHSS Referral Form, along with a brief description of each.

  • Authorization for Release of Information: This document allows for the sharing of personal and health-related information between providers. It is essential when non-self-referrals are made, as it ensures that necessary details can be disclosed without violating privacy laws.
  • Health Care Certification Form (SOC 873): Required when emergency on-call home care services are requested, this form certifies the individual's health status and outlines the specific need for urgent assistance. No emergency services can be authorized without it.
  • Medi-Cal Application: This application is crucial for those seeking financial assistance for healthcare services. Individuals must be on full-scope Medi-Cal to qualify for IHSS, and the application helps determine eligibility and any potential cost-sharing obligations.
  • Physician's Report: This document should be completed by a healthcare provider to outline the applicant's medical condition and functional limitations. It provides valuable insights into the support needed, aiding in the assessment process.
  • Notice of Action (NOA): After evaluations are conducted, an NOA is sent to inform applicants of their eligibility status for IHSS or any decisions regarding their services. Understanding this information is vital for next steps.
  • Client Rights and Responsibilities Form: This form outlines the rights of IHSS recipients as well as their responsibilities while receiving services. It ensures clients are informed about their entitlements and obligations, promoting transparency and accountability.
  • Service Plan: Created after the assessment, this document details the specific services that will be provided, including frequency and type of assistance. It serves as a guide for clients and caregivers, ensuring everyone is on the same page regarding care expectations.
  • Emergency Contact Information Form: This form collects information about individuals who should be contacted in case of emergencies. It is essential for ensuring that help can be arranged promptly if unexpected situations arise.

Understanding these related documents is crucial for both applicants and their caregivers. Each piece plays a critical role in streamlining the process and ensuring that individuals receive the appropriate support they need in a timely manner.

Similar forms

  • Medicaid Application Form: Like the IHSS Referral Form, this application collects personal information about the applicant’s income, assets, and household composition to determine eligibility for Medicaid benefits. Both forms require clear and thorough documentation to avoid complications in processing claims.

  • Long-Term Care Application: This document is similar as it seeks detailed information regarding the individual’s care needs and medical conditions. Both forms focus on evaluating the individual’s ability to perform daily tasks, highlighting areas where assistance is needed.

  • Social Security Administration (SSA) Disability Report: This report captures an applicant’s medical, work, and personal history to assess their level of disability. Much like the IHSS form, it requires extensive detail regarding the individual’s limitations and support systems.

  • Veterans Benefits Application: Similar in function, this application seeks personal and financial information to determine eligibility for services. Both forms need comprehensive personal details to aid in determining appropriate care and assistance.

  • Home and Community-Based Services (HCBS) Waiver Application: This document gathers information about the applicant’s preferences and needs for services in a home setting. The IHSS form also emphasizes individual needs and how they can be met through community resources.

  • Supportive Services Application: Both forms require the applicant to describe their current living situation and any help they receive. This information is critical for assessing eligibility for supportive services.

  • Emergency Care Services Application: Similar to the IHSS Referral Form, this application requests information about immediate service needs, especially related to medical conditions. Both forms focus on urgent requirements and how they will be managed.

  • State Disability Insurance (SDI) Claim Form: Like the IHSS form, this document collects detailed information about the applicant's medical conditions and how these affect their ability to work or perform daily functions, thus emphasizing a person's care requirements.

  • Food Assistance Program Application: This application similarly collects personal and financial information to assess the need for food assistance. Both forms are aimed at understanding the individual’s specific needs to provide the right support.

Dos and Don'ts

Filling out the In-Home Supportive Services (IHSS) Referral Form can seem daunting. However, following a few guidelines can make the process smoother. Here’s a helpful list of things to do and avoid:

  • Do: Answer all questions completely.
  • Do: Print clearly to ensure legibility.
  • Do: Include your contact information in case there are questions.
  • Do: Attach any necessary documentation, such as authorization for release of information.
  • Don't: Leave any sections blank; an incomplete form may delay your application.
  • Don't: Assume that someone else will fill out the form for you; take responsibility for your application.
  • Don't: Provide inaccurate information, as this might lead to issues with eligibility.
  • Don't: Forget to double-check the contact information for your healthcare providers.

Misconceptions

The following are common misconceptions about the IHSS Referral Form:

  • The form can be submitted incomplete. Many believe that they can submit the form without answering all questions. However, incomplete forms will not be accepted for processing.
  • Providing emergency contacts is optional. Some individuals think listing emergency contacts is not necessary. In fact, having this information is crucial for communication and support during urgent situations.
  • Only the applicant can refer themselves. It is a misconception that only the applicant may fill out the form. Family members, caregivers, or other representatives can submit the referral on behalf of the applicant.
  • Spouse information is not required. Some may think they can skip entering spouse details if they are not applying. The form requires information about the spouse if they reside in the same household.
  • Medical information is not important for eligibility. Some individuals overlook the medical condition details. This information is critical for assessing the applicant’s eligibility for services.
  • Anyone can call for help with the form. While anyone can reach out for assistance, support is best provided to those officially involved in the application process, such as the applicant or their designated representatives.
  • Medi-Cal enrollment is not necessary to apply. It is a common misconception that you can access IHSS services without being enrolled in Medi-Cal. To qualify, applicants must have full-scope Medi-Cal coverage.

Key takeaways

  • Complete All Sections: Ensure that every question on the IHSS referral form is answered clearly. Incomplete forms will not be accepted.
  • Print Clearly: Use legible handwriting or a computer to fill out the form to avoid misunderstandings.
  • Contact Information: Provide accurate phone numbers and email addresses so the department can reach you with questions or updates.
  • Emergency Contact: List a reliable emergency contact who can be reached during the application process.
  • Medical Information: Include comprehensive details regarding medical conditions and the healthcare provider’s information.
  • Appropriate Signatures: If the applicant is not the one filling out the form, ensure that a signed authorization for the release of information is attached.
  • Household Information: Disclose details about other household members and any other IHSS recipients living at the same address.
  • Service Needs: Clearly explain how current needs are being met, including information about existing caregivers.
  • Medi-Cal Requirements: Be aware that eligibility for IHSS requires enrollment in full-scope Medi-Cal.