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Ihss Application Form PDF

Ihss Application Form PDF

Use a ihss application form pdf template to make your document workflow more streamlined.

Housework? Y If no, why not? N Is the applicant enrolled in Medi-Cal? Y N Spouse ’s MD Information: Name : Address: City: Phone : ( ) - - Soc. Sec. Number Sexual Orientation  Is Spouse an IHSS Recipient? Y Phone Does applicant receive Supplemental Security Income (SSI)? Y First Name Sex (M/F) Birth date Languages: Ethnicity: Last Name N CA Zip: Fax: ( ) - Emergency Contact Name: Relation: Last name First name Last name First name Phone: ( Relation: Others in...
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camp;gt;camp;gt;Narrator: In Home Supportive Services is the largest publicly funded, non-medical service to help people with disabilities remain in their 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;gt;camp;gt;Elizabeth Worker: Some people need a service called Protective Supervision. This is an I-H-S-S service for people with cognitive or mental hEvalth disabilities indeed of 24-hour observation and monitoring to protect them from injuries, hazards or accidents. Make sure you tell the representative from IHSS that you want protective supervision for your family member if you think they need the;gt;camp;gt;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 wil

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