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) SOC 426 - In-Home Supportive Services Program Provider Enrollment Form . 1. People at imminent risk of out of home placement can be granted IHSS immediately, and be given 45 days to submit the health care certification, and can have up to 90 days for good cause. 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. (, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), COVID-19 CalFresh emergency allotment for July, 2021. Expect an eligibilityworker to contact you to schedule an interview. 1. 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. To qualify as severely impaired, an applicant must need at least 20 total hours per week of services in one or more of the following IHSS areas: non-medical personal services, preparation of meals, meal cleanup (when preparation of meals and feeding are also required), and paramedical services. Counties should prioritize Communities First Choice Options (CFCO) annual reassessments because these recipients are typically most vulnerable. Have a complex medical and/or behavioral need that must be met by the provider who lives in the same home as the recipient(s); or, Live in a rural or remote area where available providers are limited; or. (MPP 30-767.6) The county also has a grievance procedure it must follow when a grievance or complaint is received about the processing of payment for IHSS services for recipients that get IHSS under the Personal Care Services (PCSP) Program. How to Submit Forms to IHSS There are three ways that you can submit forms to IHSS: By US Mail: DSS- IHSS PO Box 1912 Fresno, CA 93718-1912 By Fax: (559) 600-5400 (health care certifications, paramedical and protective supervision forms) (559) 600-7762 (change of address, provider terminations) 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) Contact Our Registry! The provider's wages are paid twice per month after the work has been performed. SOC 295 - Application For In-Home Supportive Services [Espaol] [] [] Find the right form for you and fill it out: No results. 2 Apply in one of the following ways: Call (415) 355-6700. What if a provider works for more than one recipient, are they allowed to submit more than one claim? Be signed and dated by the LHCP within 60 calendar days of submission to the Social Worker. Is my provider allowed to claim this time? You may also be asked for a list of your prescribed medications and doctors information. 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. Use the Cross or Check marks in the top toolbar to select your answers in the list boxes. 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). Address: 20101 Hamilton Avenue Suite 250 Torrance, CA 90502, Hours of Operation: Monday - Friday from 8:00 am to 5:00 pm, ___________________________________________________________________________________________________________________________. 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. Working with a recipient with a physical disability, In-Home Supportive Services Recipient Employee Responsibilities Checklist, In-Home Supportive Services Program Designation of Provider, In-Home Supportive Services Recipient Request for Assignment of Authorized Hours to, In-Home Supportive Services Recipient Timesheet Signature Authorization, In-Home Supportive Services Program Provider or Recipient Change of Address and/or Telephone, In-Home Supportive Services Program Health Care Certification Form, In-Home Supportive Services Program Recipient and Provider Workweek Agreement, In-Home Supportive Services Program Accompaniment to Medical Appointment, In-Home Supportive Services Program Live-In Family Care Provider Overtime Exemption, In-Home Supportive Services Program Overtime and Workweek Requirements Recipient Declaration, In-Home Supportive Services Provider Enrollment Form, In-Home Supportive Services Provider Direct Deposit Enrollment/Change/Cancellation Form, In-Home Supportive Services Program Provider or Recipient Change of Address and/or Telephone Form, In-Home Supportive Services Program Provider Enrollment Agreement, Important Information For Prospective Providers IHSS Provider Enrollment Process, In-Home Supportive Services (IHSS) Program Provider Workweek & Travel Time Agreement, In-Home Supportive Services (IHSS) Program Live-In Family Care Provider Overtime Exemption, In-Home Supportive Services (IHSS) Program and Waiver Personal Care Personal Services (WPCS) Live-In Self-Certification Form for Federal and State Wage Exclusion, Employees Withholding Allowance Certificate (State). I . SOC 2298 In-Home Supportive Services (IHSS) Program and Waiver Personal Care Personal Services (WPCS) Live-In Self-Certification Form for Federal and State Wage Exclusion W-4 Employees Withholding Allowance Certificate (Federal) DE-4 Employees Withholding Allowance Certificate (State) Forms; Become a Provider; IHSS Care Providers Support (SIP) IHSS Public Authority; . That form states that I have the legal right to work in the United States. Prior to authorization of IHSS services, recipients must submit a Health Care Certification form (SOC 873) completed by a licensed health care professional, except when the recipient is at imminent risk of out of home placement. Welcome to the County of Orange Social Services Agency In-Home Supportive Services (IHSS) website. 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. 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. Continue reporting your hours worked on your timesheet as you always have. the form must be provided and the form must include your signature and the date you signed the form. You must sign the acknowledgement in PART C of this form. Find out how to schedule your vaccination. Over 550,000 IHSS providers currently serve over 650,000 recipients. Based on your ability to safely perform certain tasks for yourself, the social worker will assess the types of services you need and the number of hours the county will authorize for each of these services. The paper enrollment form is available on the CDSS website for those who want to use it. The social worker needs to document all service needs and justify the services and hours authorized. Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. The pay rate in Contra Costa is presently $16.00 per hour. By using this site you agree to our use of cookies as described in our, Something went wrong! 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). Fill in the empty fields; engaged parties names, places of residence and numbers etc. Provider's Name: 4. IMPORTANT:If your provider tests positive forCOVID-19, they should not be providing IHSS services. You also have the option to opt-out of these cookies. Existing Recipients and Providers: Clients: to access your case information, click here. We will also accept the completed form via email or fax to: Email: [emailprotected] Fax: 530-886-3690. Recipient's Name: 2. 4. 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. Click on Done following twice-examining everything. County IHSS Case #: 3. For questions regarding SOC, contact your Social Worker at (888) 822-9622. If you do not have your registration code, you can call the TTS help desk at 1-833-342-5388 or you can call your IHSS Social Worker for assistance. Add the date and place your e-signature. The applicants protected date of eligibility is the date the applicant requests services. IHSS social workers complete a needs assessment for each applicant or recipient using the following criteria: the Functional Index Rankings, the Annotated Assessment Criteria, and the Hourly Task Guidelines (HTGs). You may be asked to perform or describe simple tasks, such as range-of-motion demonstrations. Recipients can self-register for the TTS by using the 6-digit State Registration Code. 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. 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}); The cookie is used to store the user consent for the cookies in the category "Analytics". In-Home Supportive Services. Start completing the fillable fields and carefully type in required information. The IHSS recipient also has the right to choose the licensed health care professional who completes the Paramedical order. 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). View the IHSS Services and Assessment video (English|Espaol|) for more information. Fill out, sign and return this form in person to the office or location designated by the county. IHSS recipients are responsible for reporting work-related injuries to the Public Authority. Medical Accompaniment for Vaccine Appointments, MEDICAL ACCOMPANIMENT COVID VACCINE CLAIM FORM, Placer County IHSS Recipients should mail the completed form: Placer County IHSS, 11512 B. Ave., Auburn, CA 95603. 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. If the applicant is ineligible for Medi-Cal when they apply, they may be authorized services back to the protected date of eligibility. Provider Phone: 510.577.5694. Complete Health Care Certification Counties are required to accept IHSS applications by telephone, by fax, or in person. Once your application is reviewed, you mustqualify for Medi-Cal. Although CDSS requires 100% compliance with reassessments, CDSS will issue a Quality Improvement Action Plan for counties that are below 90% compliance rate for CFCO recipients and an 80% compliance rate for all other recipients. Click on Done following twice-checking all the data. Home and Community Based Alternatives Waiver Agencies (in Los Angeles): Be 65 years old or older, blind, and/or disabled as defined by Social Security Administration (SSA) standards. ), Legal Services of Northern California Housing and Urban Development Secretary Julin Castro talks to the media about President Barack Obama's budget for fiscal 2015 at the Treasury Department in Washington, D.C., Wednesday, October 13, 2014. Individuals have the right to apply for IHSS services or make an application through another person on their behalf. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. Mail In-Home Supportive Services PO Box 11018 San Jose, CA 95103-1018 Email SSA_IHSS_ARCCI_Fax@ssa.sccgov.org In Person Placer County IHSS Recipients should mail the completed form: Placer County IHSS, 11512 B. 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