CA IHSS 3012 - San Francisco 2017 free printable template

Income Supportive Services Referral Form Fax to SF HSA Department of Aging and Adult Services Program: (415) 5575271 Questions? Call: (415) 3556700 or email us at: ihss@ci.sf.ca.us Please answer all

How to fill out CA IHSS 3012 - San Francisco

How to fill out CA IHSS 3012 - San Francisco

1. Obtain the CA IHSS 3012 form from the official website or local IHSS office.
2. Read the instructions carefully to understand what information is required.
3. Fill in your personal information, including your name, address, and contact details at the top of the form.
4. Provide information regarding the individual receiving services, including their name and relationship to you.
5. Detail the specific services you are requesting assistance for.
6. Indicate the hours of service needed per week.
7. Sign and date the form to authenticate it.
8. Submit the completed form to the appropriate IHSS office for processing.

Who needs CA IHSS 3012 - San Francisco?

1. Individuals who require in-home support services due to a disability or medical condition.
2. Family members or guardians of individuals eligible for IHSS assistance.
3. Caregivers seeking to receive compensation for caring for someone who qualifies for IHSS.

Instructions and Help about CA IHSS 3012 - San Francisco

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

People Also Ask about

How do I check my IHSS application status?

Please contact the IHSS Service Desk at (866) 376-7066 during normal business hours of 8am- 5pm Monday through Friday, excluding major holidays.

What income qualifies for IHSS?

Effective April 2023 – March 2024, the monthly income limit for the IHSS program for a single applicant is $1,677. When both spouses are applicants, there is a couple income limit of $2,269 / month.

How long does it take for IHSS to approve application?

Of those who do get approved, it can take anywhere from two weeks to several months to finally receive benefits. This is due to the meticulous amount of paperwork involved, as well as the process of the case worker assessment, background check, and other procedures.

How do I apply to be a recipient of IHSS?

If you already have Medi-Cal or once you are approved for it, call or visit your county In-Home Supportive Services (IHSS) office to complete an IHSS application. Once IHSS gets the application, a caseworker will contact you and schedule a time to visit your home and understand your needs.

What disqualifies you from being an IHSS provider?

Generally, misdemeanor crimes involving violence or threats of violence would disqualify a person from being an IHSS provider. Minor infractions, such as traffic violations, would not disqualify a person from being an IHSS provider. 10. WHAT HAPPENS IF I'M CONVICTED OF A CRIME AFTER I'M ENROLLED AS AN IHSS PROVIDER?

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What is CA IHSS 3012 - San Francisco?

CA IHSS 3012 is a form used in San Francisco for the In-Home Supportive Services program, which provides assistance to individuals with disabilities or elderly individuals who need help with daily living activities.

Who is required to file CA IHSS 3012 - San Francisco?

Individuals receiving In-Home Supportive Services in San Francisco are required to file CA IHSS 3012 to report their essential information and maintain eligibility for the program.

How to fill out CA IHSS 3012 - San Francisco?

To fill out CA IHSS 3012, provide personal details, information about the services received, caregiver information, and any other relevant details as specified on the form. Ensure all sections are completed accurately.

What is the purpose of CA IHSS 3012 - San Francisco?

The purpose of CA IHSS 3012 is to gather necessary information for the assessment and ongoing eligibility of individuals in the In-Home Supportive Services program, ensuring that they receive appropriate support.

What information must be reported on CA IHSS 3012 - San Francisco?

CA IHSS 3012 requires reporting personal information about the recipient, details of the services being provided, caregiver information, and any changes in circumstances that may affect eligibility.