Documents

” IHSS Child Ranking Evaluation Patient’s Name SSN DOB Date Patient last seen: Duration of the needs indicated below __3-month __6 months __ 1 year __ Indefinite Please check the level of assistance needed 2. Feeding 3. Bed Baths 1. Bathing, Oral Hygiene 5. Dressing 4. Bowel & Bladder Care 6. Reposition 7 Skin Care 9. Transferring from Bed 8. Ambulation None Able to perform the function, but needs verbal assistance, such a reminding, guidance. Can perform the function with some human assis- tance including physical help for a provider. Can perform the function but only with substantial human assistance. Cannot perform the function with or without human assistance. Other children of the same age do not routinely need this service. CERTIFICATION – I certify that I am licensed to practice in the State of California and that all information above is true and correct. Physician Signature MD Provide # Date CCWRO 2018-11-IHSS IHSS Ranking Evaluation: SSN: DOB: Date Patient last seen: 9 Skin Care: California and that all information above is true and correct: Check Box1: Off Check Box3: Off Check Box4: Off Check Box5: Off Check Box7: Off Check Box8: Off Check Box9: Off Check Box10: Off Check Box11: Off Check Box12: Off Check Box13: Off Check Box14: Off Check Box15: Off Check Box16: Off Check Box17: Off Check Box18: Off Check Box25: Off Check Box2: Off Check Box27: Off Check Box28: Off Check Box29: Off Check Box30: Off Check Box31: Off Check Box32: Off Check Box33: Off Check Box34: Off Check Box35: Off Check Box36: Off Check Box37: Off Check Box38: Off Check Box39: Off Check Box40: Off Check Box41: Off Check Box42: Off Check Box43: Off Check Box44: Off Check Box45: Off Check Box46: Off Check Box47: Off Check Box48: Off Check Box49: Off Check Box50: Off Check Box51: Off Check Box52: Off Check Box53: Off Check Box54: Yes Check Box55: Yes Check Box56: Off Check Box57: Off Check Box58: Off Check Box59: Off Check Box60: Yes Check Box61: Yes Check Box6: Off Check Box68: Off Check Box681: Off Check Box683: Off Check Box68′;kn’kn: Off ”

” IHSS Ranking Evaluation Patient’s Name SSN DOB Date Patient last seen: Duration of the needs indicated below __3-month __6 months __ 1 year __ Indefinite Please check the level of assistance needed 1. Preparation of meals 2. Meal Clean- up 3. Feeding 4. Bed Baths 5. Bathing, Oral Hygiene 6. Dressing 7, Bowell & Bladder Care 8. Reposition 9. Skin Care 10. Transferring from Bed 11. Ambulation None Able to perform the function, but needs verbal assistance, such a reminding, guidance. Can perform the function with some human assis- tance including physical help for a provider. Can perform the function but only with substantial human assistance. Cannot perform the function with or without human assistance. CERTIFICATION – I certify that I am licensed to practice in the State of California and that all information above is true and correct. Physician Signature MD Provide # Date IHSS Ranking Evaluation: SSN: DOB: Date Patient last seen: California and that all information above is true and correct: 11 Ambulation: Check Box1: Off Check Box3: Off Check Box4: Off Check Box5: Off Check Box6: Off Check Box7: Off Check Box8: Off Check Box9: Off Check Box10: Off Check Box11: Off Check Box12: Off Check Box15: Off Check Box16: Off Check Box134t: Off Check Box1 this: Off Check Box19: Off Check Box111: Off Check Box1112: Off Check Box20: Off Check Box21: Off Check Box22: Off Check Box23: Off Check Box25: Off Check Box26: Off Check Box27: Off Check Box29: Off Check Box1209k: Off Check Box31: Off Check Box32: Off Check Box33: Off Check Box34: Off Check Box36: Off Check Box37: Off Check Box=38: Off Check Box39: Off Check Box40: Off Check Box41: Off Check Box42: Off Check Box44: Off Check Box45: Off Check Box46: Off Check Box50: Off Check Box51: Off Check Box52: Off Check Box54: Off Check Box55: Off Check Box57: Off Check Box58: Off Check Box1 year: Off =2 yer: Off 3 yer: Off lb jbjk: Off pg9pgyu80y: Off 9-]-0tf: Off Check B’o;ugv;b: Off ‘bobjlklm: Off Check Box56nlkn: Off Check Box56 kl\/’ioih: Off ”

” REQUEST FOR IHSS REASSESSMENT TO: County of _______________________ Name of Social Worker: ______________________________________ IHSS Case # _______________________________________ I, ____________________________________________________________ Name of IHSS Recipient request a reassessment because my needs for services has changed and I need more hours. Thank you for your consideration of my request for reassessment. Dated:_________ ___________________________________________ Signature of IHSS Recipient\/Representative FORM INSTRUCTION: This form should be mailed to the IHSS recipient’s social worker anytime the IHSS recipient believes that he or she has a change and in needs more hours. If the county does not act on this request within 30 days file for a state hearing at: https:\/\/secure.dss.cahwnet.gov\/shd\/pubintake\/cdss- request.aspx IHSS State Regulation Number 30-761.219 The county shall reassess the recipient’s need for services: (a) Any time the recipient notifies the county of a need to adjust the service hours authorized due to a change in circumstances; or (b) When there is other pertinent information which indicates a change in circumstances affecting the recipient’s need for supportive services. For Assistance contact CCWRO at 916-712-0071 or email [email protected] Additional Areas of Services Requested Type of Service Current hours per week Hours requested per week Rank Reason for request Domestic Services Respiration Bowel\/bladder care Feeding Be bath Dressing Min. Care Ambulation Transfer Bathing Medical Appointment Protective superviusion TOCountyof: Name ofSocialWorker: undefined: I: Dated: undefined_2: Current hours per weekDomest i c Services: Hours requested per weekDomest i c Services: RankDomest i c Services: Reason for requestDomest i c Services: Current hours per weekResp i rat i on: Hours requested per weekResp i rat i on: RankResp i rat i on: Reason for requestResp i rat i on: Reason for requestBowe l b l adder care: Current hours per weekFeed i ng: Hours requested per weekFeed i ng: RankFeed i ng: Reason for requestFeed i ng: Current hours per weekBe bath: Hours requested per weekBe bath: RankBe bath: Reason for requestBe bath: Current hours per weekDress i ng: Hours requested per weekDress i ng: RankDress i ng: Reason for requestDress i ng: Current hours per weekMin Care: Hours requested per weekMin Care: RankMin Care: Reason for requestMin Care: Current hours per weekAmbu l at i on: Hours requested per weekAmbu l at i on: RankAmbu l at i on: Reason for requestAmbu l at i on: Current hours per weekTransfer: Hours requested per weekTransfer: RankTransfer: Reason for requestTransfer: Current hours per weekBath i ng: Hours requested per weekBath i ng: RankBath i ng: Reason for requestBath i ng: Reason for requestMed i ca l Appo i ntment: Reason for requestProtect i ve superviusion: adder: adder1: adder2: ntment: ntment1: ntment2: superviusion: superviusion1: superviusion2: ”

” IHSS Protective Supervision Hazard\/Injury Log Name of IHSS recipient\/applicant _____________________________ Case Number ____________________ Risk of Injury or Harm Activities Would this happen if you were not watching this person 7 days a week, 24- hour a day? Would they do: Dates of Occurrence if this has happened? Comments Wandering out of the house and getting lost Yes No Letting strangers in the house Yes No Turning the stove on and forgetting to turn it off Yes No Starting fires in the microwave Yes No Lighting small fires around the home Yes No Leaving water running Yes No Eating dangerous products or unhealthy foods, like soap or laundry detergent Yes No Eating inappropriate food for medical condition. For example: drinking unlimited soda when a person has diabetes Yes No Head banging, self-biting and scratching Yes No Using knives or other unsafe household objects Yes No Climbing onto a high place and jumping off because he or she is trying to fly Yes No Hiding in the refrigerator Yes No Sticking items in light socket or electrical outlet Yes No Sticking hands in dirty toilet Yes No Wandering into the street without regard for oncoming traffic Yes No Jumping into a swimming pool without knowing how to swim Yes No Trying to move furniture when the individual lacks needed balance and strength Yes No Using a SOS pads or non-cloth scrubbers to bathe and clean himself or herself Yes No Trying to walk when it is unsafe to walk unassisted Yes No Hiding dirty diapers Yes No Playing with feces Yes No Hitting mirrors or television Yes No Standing\/sitting on glass table Yes No DECLARATION I am a resident of ___________________________ County, State of California and I declare under the penalty of perjury that the information provided above is true and correct. SIGNATURE OF DECLARANT: NAME OF DECLARANT DATE: ADDRESS: CITY\/ZIP TELEPHONE: ( ) DOCTOR CERTIFICATION I certify that I am licensed to practice in the State of California and that the information provided above is correct. SIGNATURE OF PHYSICIAN OR MEDICAL PROFESSIONAL: MEDICAL SPECIALTY: DATE: ADDRESS: LICENSE NO.: TELEPHONE: ( ) Name ofIHSSrecipientapplicant: Case Number: RiskofInjuryor Harm Activities: Dates of Occurrence if this has happenedYes No: CommentsYes No: Dates of Occurrence if this has happenedYes No_2: CommentsYes No_2: Dates of Occurrence if this has happenedYes No_3: CommentsYes No_3: CommentsYes No_4: Dates of Occurrence if this has happenedYes No_5: CommentsYes No_5: Dates of Occurrence if this has happenedYes No_6: CommentsYes No_6: Dates of Occurrence if this has happenedYes No_7: CommentsYes No_7: Dates of Occurrence if this has happenedYes No_8: CommentsYes No_8: Dates of Occurrence if this has happenedYes No_9: CommentsYes No_9: Dates of Occurrence if this has happenedYes No_10: CommentsYes No_10: Dates of Occurrence if this has happenedYes No_11: CommentsYes No_11: Dates of Occurrence if this has happenedYes No_12: CommentsYes No_12: Dates of Occurrence if this has happenedYes No_13: CommentsYes No_13: Dates of Occurrence if this has happenedYes No_14: CommentsYes No_14: Yes No: Yes No_2: Yes No_3: Yes No_4: Yes No_5: Hidingdirty diapers: Yes No_6: Playingwithfeces: Yes No_7: Yes No_8: Yes No_9: above is true and correct: SIGNATURE OF DECLARANT: NAME OF DECLARANT: DATE: ADDRESS: CITYZIP: TELEPHONE: SIGNATURE OF PHYSICIAN OR MEDICAL PROFESSIONAL: MEDICAL SPECIALTY: DATE_2: ADDRESS_2: LICENSE NO: TELEPHONE_2: Check Box1: Off Check Box2: Off Check Box4: Off Check Box5: Off Check Box6: Off Check Box7: Off Check Box8: Off Check Box9: Off Check Box10: Off Check Box11: Off Check Box12: Off Check Box13: Off Check Box14: Off Check Box15: Off Check Box16: Off Check Box17: Off Check Box18: Off Check Box21: Off Check Box22: Off Check Box23: Off Check Box24: Off Check Box31: Off Check Box32: Off Check Box3: Off Check Box33: Off Check Box34: Off Check Box35: Off Check Box36: Off Check Box37: Off Check Box40: Off Check Box41: Off Check Box42: Off Check Box43: Off Check Box44: Off Check Box45: Off Check Box46: Off Check Box48: Off Check Box49: Off Check Box50: Off Check Box1[pin: Off oi64waw: Off ”

” REQUEST FOR IHSS ADVANCE PAY TO: County of _______________________ Name of Social Worker: ______________________________________ IHSS Case # _______________________________________ I, (name of IHSS beneficiary) _____________________________________________________ request advance pay effective immediately. Thank you for your consideration of my request for reassessment. Dated:________ ___________________________________________ Signature of IHSS Recipient\/Representative FORM INSTRUCTION: This form should be mailed or emailed to the IHSS beneficiary’s social worker anytime the IHSS beneficiary. If the county does not act on this request within 30 days file for a state hearing at: CCWRO.ORG IHSS Advance Pay State Regulations MPP 30-769.731 Severely impaired recipients as defined under Section 30-753, shall have the option of choosing to directly receive their payment at the beginning of each authorized month. Such payment shall be the net amount exclusive of the appropriate withholdings. MPP 30-701(s) (1) Severely Impaired Individual means a recipient with a total assessed need, as specified in Section 30-763.5, for 20 hours or more per week of service in one or more of the following areas: (A) Any personal care service listed in Section 30-757.14. (B) Preparation of meals. (C) Meal cleanup when preparation of meals and consumption of food (feeding) are required. (D) Paramedical services. For Assistance Contact CCWRO at 916-712-0071 or email [email protected] OPTIONAL: If you want help with this please sign below. Thank You I hereby authorize Kevin Aslanian to be my authorized representative. Date Your Signature ”

” STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES REQUEST FOR ORDER AND CONSENT – PARAMEDICAL SERVICES TO: Dear Doctor: This patient has applied for In-Home Supportive Services (IHSS) and stated that he\/she needs certain paramedical services in order for him\/her to remain at home. You are asked to indicate on this form what specific services are needed and what specific condition necessitates the services. In-Home Supportive Services is authorized to fund the provision of paramedical services, if you order them for this patient. For the purpose of this program, paramedical services are activities which, due to the recipient’s physical or mental condition, are necessary to maintain the recipient’s health and which the recipient would perform for himself\/herself were he\/she not functionally impaired. These services will be provided by In-Home Supportive Services providers who are not licensed to practice a health care profession and will rarely be training in the provision of health care services. Should you order services, you will be responsible for directing the provision of the paramedical services. Your examination of this patient is reimbursable through Medi-Cal as an office visit provided that all other applicable Medi- Cal requirements are met. If you have any questions, please contact me. DATE SOC 321 (11\/99) PATIENT’S NAME MEDI-CAL IDENTIFICATION NUMBER SIGNED TITLE TELEPHONE NUMBER TO BE COMPLETED BY LICENSED PROFESSIONAL NAME OF LICENSED PROFESSIONAL OFFICE TELEPHONE OFFICE ADDRESS (IF NOT LISTED ABOVE) TYPE OF PRACTICE TYPE OF PRACTICE \u25a0 Physician\/Surgeon \u25a0 Podiatrist \u25a0 Dentist CONTINUED ON BACK RETURN TO: (COUNTY WELFARE DEPARTMENT) Does the patient have a medical condition which results in a need for IHSS paramedical services? Is YES, list the condition(s) below: \u25a0 YES \u25a0 NO List the paramedical services which are needed and should be provided by IHSS in your professional judgement. * Indicate the number of times a service should be provided for a specific time period: (Example: two times daily, etc.) Additional comments: SEE ADDENDUM TO THIS SOC 321 CERTIFICATION \u25a0 IF CONTINUED ON ANOTHER SHEET, CHECK HERE I certify that I am licensed to practice in the State of California as specified above and that this order falls within the scope of my practice. In my judgement the services which I have ordered are necessary to maintain the recipient’s health and could be performed by the recipient for himself\/herself were he\/she not functionally impaired. I shall provide such direction as is needed, in my judgement, in the provision of the ordered services. I have informed the recipient of the risks associated with the provision of the ordered services by his\/her IHSS provider. PATIENT’S INFORMED CONSENT I have been advised of risks associated with provision of the services listed above and consent to provision of these services by my In-Home Supportive Services provider. SIGNATURE DATE SIGNATURE DATE \u25bc \u25bc TYPE OF SERVICE TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMED FREQUENCY* HOW LONG SHOULD THIS SER- VICE BE PROVIDED? # OF TIMES TIME PERIOD ADDENDUM TO SOC 321 Type of Paramedical Service How many times a Day? Time to do the service each time How many months\/years? injections breathing treatments, nebulizer pulmonary toileting (pounding lung areas of back and chest to loosen secretions catheter changes or helping void urine with a catheter ostomy or bricker bag irrigation or changes and cleaning and maintaining the stoma site range of motion exercises and other home therapy programs prescribed by a physician nasal-gastric tube or G-Tube feedings & care of stoma site skin and wound care if there is a decubitus ulcer (bed or pressure sore) or a diabetes related wound or, if the person has a history of ecubiti, checking the body for hot spots that could turn into a decubitus ulcer including tracheal (deep) suctioning bowel program for those with spinal cord injuries or neurological bowel program for those with spinal cord injuries or neurological impairment impacting the gastro-intestinal system digital stool removal insertion of suppositories or administration of an enema adjustment, monitoring and connecting tubing and ventilator; C- PAP or BiPAP machine adjustment, putting on mask CERTIFICATION – I certify that I am licensed to practice in the State of California as specified above and that this order falls within the scope of my practice. In my judgement the services which I have ordered are necessary to maintain the recipient’s health and could be performed by the recipient for himself\/herself were he\/she not functionally impaired. I shall provide such direction as is needed, in my judgement, in the provision of the ordered services. I have informed the recipient of the risks associated with the provision of the ordered services by his\/her IHSS provider. SIGNATURE DATE \u25bc SOC321-Paramedical form ADDENDUM TO SOC 321 TYPE OF SERVICERow1: TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMEDRow1: OF TIMESRow1: TIME PERIODRow1: HOW LONG SHOULD THIS SER VICE BEPROVIDEDRow1: TYPE OF SERVICERow2: TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMEDRow2: OF TIMESRow2: TIME PERIODRow2: HOW LONG SHOULD THIS SER VICE BEPROVIDEDRow2: TYPE OF SERVICERow3: TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMEDRow3: OF TIMESRow3: TIME PERIODRow3: HOW LONG SHOULD THIS SER VICE BEPROVIDEDRow3: TYPE OF SERVICERow4: TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMEDRow4: OF TIMESRow4: TIME PERIODRow4: HOW LONG SHOULD THIS SER VICE BEPROVIDEDRow4: Type of Paramedical Service: How many times a Dayi n j ections: Time to do the service each timei n j ections: How many monthsyearsi n j ections: How many times a Daybreath i ng treatments nebulizer: Time to do the service each timebreath i ng treatments nebulizer: How many monthsyearsbreath i ng treatments nebulizer: How many times a Daypu l monary to i l eting pound i ng l ung areas of back and chest to l oosen secretions: Time to do the service each timepu l monary to i l eting pound i ng l ung areas of back and chest to l oosen secretions: How many monthsyearspu l monary to i l eting pound i ng l ung areas of back and chest to l oosen secretions: How many times a Daycatheter changes or he l p i ng vo i d ur i ne w i th a catheter: Time to do the service each timecatheter changes or he l p i ng vo i d ur i ne w i th a catheter: How many monthsyearscatheter changes or he l p i ng vo i d ur i ne w i th a catheter: How many times a Dayostomy or br i cker bag i rr i gation or changes and c l ean i ng and ma i nta i n i ng the stoma s i te: Time to do the service each timeostomy or br i cker bag i rr i gation or changes and c l ean i ng and ma i nta i n i ng the stoma s i te: How many monthsyearsostomy or br i cker bag i rr i gation or changes and c l ean i ng and ma i nta i n i ng the stoma s i te: How many times a Dayrange of motion exerc i ses and other home therapy programs prescr i bed by a physician: Time to do the service each timerange of motion exerc i ses and other home therapy programs prescr i bed by a physician: How many monthsyearsrange of motion exerc i ses and other home therapy programs prescr i bed by a physician: How many times a Daynasalgastr i c tube or GTube feed i ngs care of stoma s i te: Time to do the service each timenasalgastr i c tube or GTube feed i ngs care of stoma s i te: How many monthsyearsnasalgastr i c tube or GTube feed i ngs care of stoma s i te: cer: How many times a Dayi nc l ud i ng trachea l deep suction i ng: Time to do the service each timei nc l ud i ng trachea l deep suction i ng: How many monthsyearsi nc l ud i ng trachea l deep suction i ng: How many times a Daybowe l program for those w i th sp i na l cord i n j ur i es or neurological bowe l program for those w i th sp i na l cord i n j ur i es or neuro l og i ca l i mpa i rment i mpacting the gastro i ntestina l system: Time to do the service each timebowe l program for those w i th sp i na l cord i n j ur i es or neurological bowe l program for those w i th sp i na l cord i n j ur i es or neuro l og i ca l i mpa i rment i mpacting the gastro i ntestina l system: How many monthsyearsbowe l program for those w i th sp i na l cord i n j ur i es or neurological bowe l program for those w i th sp i na l cord i n j ur i es or neuro l og i ca l i mpa i rment i mpacting the gastro i ntestina l system: How many times a Dayd i g i ta l stoo l remova l: Time to do the service each timed i g i ta l stoo l remova l: How many monthsyearsd i g i ta l stoo l remova l: How many times a Dayi nsertion of suppos i tor i es or adm i n i stration of an enema: Time to do the service each timei nsertion of suppos i tor i es or adm i n i stration of an enema: How many monthsyearsi nsertion of suppos i tor i es or adm i n i stration of an enema: How many times a Dayad j ustment mon i tor i ng and connecting tub i ng and venti l ator CPAP or B i PAP mach i ne ad j ustment putting on mask: Time to do the service each timead j ustment mon i tor i ng and connecting tub i ng and venti l ator CPAP or B i PAP mach i ne ad j ustment putting on mask: How many monthsyearsad j ustment mon i tor i ng and connecting tub i ng and venti l ator CPAP or B i PAP mach i ne ad j ustment putting on mask: qr3: Off rveew: Off Check Box2: Off Check Box3r3: Off Check Box3 v1: Off Check Box3v3r3r1: Off Text1q: Text1w: Text15: Text16: Text17: Text18: Text19: vrr3: Text1: Text20: Text201: Text202: Text203: qerrv: qrwvr3t490: ”

” IHSS Provider Change Request Form CURRENT PROVIDER Recipient Provider NEW PROVIDER Recipient New Provider New Provider DOB New Provider SSN New Provider Address New Provider Phone New Provider Email Date: _______ Signatute________________________________________________ Authorization Form I, ______________________________, hereby authorize CCWRO & Kevin Aslanian, 1111 Howe Ave., Sacramento, Suite 635, CA 95825 Tel. – 916-736-0616 FAX – 916-736-2645 or any other person\/attorney designated by him, to be my authorized representative, and to represent me, relative to my public social services matter, or any other matter, including the right to make statements on my behalf, or the filing for any fair hearing and the initiation of any litigation. This authorization shall also be construed as an authorization to release any and all information to CCWRO or any person designated by them, including an attorney, to review my case file, including my IHSS case records. I further authorize CCWRO or any other persons designated by them to apply for and represent me during all aspects of the application process or any other matter relative to the process of eligibility determination for any and all benefits that I and\/or my family may be eligible for. Dated: __________________ Signature__________________________________ CURRENT PROVIDER: undefined: NEW PROVIDER: undefined_2: New Provider DOB: New Provider SSN: New Provider Address: New Provider Phone: New Provider Email: Date: Dated: undefined_3: ”

” IHSS Provider Travel Time Claim ACL 17-25 Date Name of Doctor Address Travel Time from home to medical appointment Estimated on duty wait time Mode of transportation Car Bus ___________________________________ _______________________________ Provider Signature Date____ IHSS Beneficiary Signature Date:_____ DateRow1: Name of DoctorRow1: AddressRow1: Travel Time from home to medical appointmentRow1: Estimated on duty wait timeRow1: DateRow2: Name of DoctorRow2: AddressRow2: Travel Time from home to medical appointmentRow2: Estimated on duty wait timeRow2: DateRow3: Name of DoctorRow3: AddressRow3: Travel Time from home to medical appointmentRow3: Estimated on duty wait timeRow3: DateRow4: Name of DoctorRow4: AddressRow4: Travel Time from home to medical appointmentRow4: Estimated on duty wait timeRow4: DateRow5: Name of DoctorRow5: AddressRow5: Travel Time from home to medical appointmentRow5: Estimated on duty wait timeRow5: DateRow6: Name of DoctorRow6: AddressRow6: Travel Time from home to medical appointmentRow6: Estimated on duty wait timeRow6: DateRow7: Name of DoctorRow7: AddressRow7: Travel Time from home to medical appointmentRow7: Estimated on duty wait timeRow7: DateRow8: Name of DoctorRow8: AddressRow8: Travel Time from home to medical appointmentRow8: Estimated on duty wait timeRow8: DateRow9: Name of DoctorRow9: AddressRow9: Travel Time from home to medical appointmentRow9: Estimated on duty wait timeRow9: DateRow10: Name of DoctorRow10: AddressRow10: Travel Time from home to medical appointmentRow10: Estimated on duty wait timeRow10: DateRow11: Name of DoctorRow11: AddressRow11: Travel Time from home to medical appointmentRow11: Estimated on duty wait timeRow11: DateRow12: Name of DoctorRow12: AddressRow12: Travel Time from home to medical appointmentRow12: Estimated on duty wait timeRow12: DateRow13: Name of DoctorRow13: AddressRow13: Travel Time from home to medical appointmentRow13: Estimated on duty wait timeRow13: DateRow14: Name of DoctorRow14: AddressRow14: Travel Time from home to medical appointmentRow14: Estimated on duty wait timeRow14: DateRow15: Name of DoctorRow15: AddressRow15: Travel Time from home to medical appointmentRow15: Estimated on duty wait timeRow15: Prov: der S: gnature: Date: IHSS Benefic: ary S: gnature_2: Date_2: Check Box1: Off Check Box2: Off ”

” ATTN: IHSS Screener Letter of Request for IHSS Services Authorization to A.R. FORM Name________________________________________________________________ Address _____________________________________________________________ DOB ___________ SSN _________ _____ _________ Contact Number Sex : Male __ Female ___ Language: ___Armenian ___Russian ___Spanish ___other The applicant is receiving SSI\/CAPI benefits at this time? Yes__No__ Living Arrangements : ___Self ___Relative ___Spouse ___Family How many people at this address? _____ Reason for Seeking IHSS Assistance Various medical problems. The applicant will provide medical verifi- cation of this need. Please provide the applicant with the form needed so the applicant can have the doctor complete the form and the applicant will provide the county with the medical verifica- Types of Assistance Needed __ Domestic Services __ Shopping for Food __ Doctor Visits __ Preparation of Meals __ Meal Cleanup __ Pers. Hygiene __ Dressing __ Feeding __ Ambulation __ Moving in and out of bed __ Respiration __ Bowel and Bladder __ Other Shopping & Errants __ Forgetful __ Disoriented __ Loses things __ Confusion __ Protective Services Dated: ________ Signature of applicant _________________________________________ Regarding Waiver of Confidentiality. PLEASE TAKE NOTICE that I hereby REFUSE to waive my rights to confidentiality. I also refuse to sign the HIPPA release of information form, also known as the Form 2099 series. Any signing of such forms will be obtained through coercion by DHS and they are invalid, void and immoral. I, ______________________________________________________, hereby authorize __________________________, at _______________________________________________________________________________________________ or any other person\/attorney designated him or __________________________________________________________, to be my authorized representative in this matter or any other matter relative to my public assistance case, including the right to make statements on my behalf, or the filing for any fair hearing and the initiation of litigation. This authorization shall also be construed as an authorization to release any and all information to __________________ or any person designated by them, including an attorney. I further authorize _________________________________________________________________________________ or any other persons designated by them to apply for and represent me during all aspects of the application process or any other matter relative to the process of eligibility determination for any and all benefits that I and\/or my family may be eligible for. Text2: Text3: Text4: Text5: Text6: Check Box7: Off Check Box8: Off Check Box9: Off Check Box10: Off Check Box11: Off Check Box12: Off Check Box13: Off Check Box14: Off Check Box15: Off Check Box16: Off Check Box17: Off Check Box18: Off Check Box19: Off Check Box20: Off Check Box21: Off Check Box22: Check Box23: Check Box24: Off Check Box25: Off Check Box26: Off Check Box27: Off Check Box28: Check Box29: Off Check Box30: Off Check Box31: Off Check Box32: Off Check Box33: Off Check Box34: Off Check Box35: Off Text36: Text37: Name: Text7: Text1: Has Medi-Cal Text8: Check Box36: Off Text38: advocate: adv address: ”