Form SOC876 "In-home Supportive Services (Ihss) Program Notice of Provisional Approval Health Care Certification Exception Granted" - California

What Is Form SOC876?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form SOC876 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form SOC876 "In-home Supportive Services (Ihss) Program Notice of Provisional Approval Health Care Certification Exception Granted" - California

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE OF PROVISIONAL APPROVAL
HEALTH CARE CERTIFICATION EXCEPTION GRANTED
TO:
County of:
Notice Date:
Case Number:
IHSS Office Address:
IHSS Office Telephone:
The county has provisionally approved your application for In -Home Supportive Services (IHSS).
Here’s what that means:
State law requires that before you can get IHSS, you have to provide the county with a health care
certification, or alternative documentation, completed and signed by a licensed health care
professional, and you have to have an assessment of your needs completed in your own home.
The county has granted an exception so that you can get IHSS on a temporary basis before you
meet these requirements, but you still have to provide the county with the health care certification,
or alternative documentation, (if you have not already provided it) . You will temporarily get the
services/hours shown below once you return to your own home . These services/hours are based
on a preliminary assessment of your needs done while you were in a medical facility.
When you provide the county with the health care certification, or alternative documentation, the
county will determine your eligibility to continue getting IHSS . If you are determined eligible, the
county will do an in-home assessment to complete the determination of your services/hours.
The county asked you to provide the health care certification , or alternative documentation, by
________________.
DATE
SOC 876 (5/17)
PAGE 1 OF 4
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE OF PROVISIONAL APPROVAL
HEALTH CARE CERTIFICATION EXCEPTION GRANTED
TO:
County of:
Notice Date:
Case Number:
IHSS Office Address:
IHSS Office Telephone:
The county has provisionally approved your application for In -Home Supportive Services (IHSS).
Here’s what that means:
State law requires that before you can get IHSS, you have to provide the county with a health care
certification, or alternative documentation, completed and signed by a licensed health care
professional, and you have to have an assessment of your needs completed in your own home.
The county has granted an exception so that you can get IHSS on a temporary basis before you
meet these requirements, but you still have to provide the county with the health care certification,
or alternative documentation, (if you have not already provided it) . You will temporarily get the
services/hours shown below once you return to your own home . These services/hours are based
on a preliminary assessment of your needs done while you were in a medical facility.
When you provide the county with the health care certification, or alternative documentation, the
county will determine your eligibility to continue getting IHSS . If you are determined eligible, the
county will do an in-home assessment to complete the determination of your services/hours.
The county asked you to provide the health care certification , or alternative documentation, by
________________.
DATE
SOC 876 (5/17)
PAGE 1 OF 4
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
If you do not provide the county with a health care certification , or alternative documentation, by
this date, the IHSS you have been getting on a temporary basis will stop. If you cannot provide
the health care certification, or alternative documentation, by this date, contact your social worker
before the due date to explain why and ask if the county can grant you more time.
If you have questions about the information in this notice, call your social worker .
TOTAL
ADJUSTMENTS
AMOUNT OF
SERVICES
AUTHORIZED
AMOUNT OF
FOR OTHERS
THE SERVICE
YOU
AMOUNT OF
THE
WHO SHARE THE
YOU NEED
REFUSED OR
SERVICE YOU
SERVICES
SERVICE
HOME
GET FROM
CAN GET
NEEDED
OTHERS
HRS:MINS
(PRORATION)
HRS:MINS
HRS:MINS
DOMESTIC SERVICES
(per MONTH)
RELATED SERVICES (per WEEK)
Prepare Meals
Meal Clean-up
Routine Laundry
Shopping for Food
Other
Shopping/Errands
NON-MEDICAL PERSONAL SERVICES (per WEEK)
Respiration Assistance
(Help with Breathing)
Bowel, Bladder Care
Feeding
Routine Bed Baths
Dressing
SOC 876 (5/17)
PAGE 2 OF 4
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TOTAL
ADJUSTMENTS
AMOUNT OF
SERVICES
AUTHORIZED
AMOUNT OF
FOR OTHERS
THE SERVICE
YOU
AMOUNT OF
THE
WHO SHARE THE
YOU NEED
REFUSED OR
SERVICE YOU
SERVICES
SERVICE
HOME
GET FROM
CAN GET
NEEDED
OTHERS
HRS:MINS
(PRORATION)
HRS:MINS
HRS:MINS
Menstrual Care
Ambulation (Help
w/Walking, including
Getting In/Out of
Vehicles)
Transferring (Help
Moving In/Out of Bed,
On/Off Seats, etc.)
Bathing, Oral Hygiene,
Grooming
Rubbing Skin,
Repositioning
Help with Prosthesis
(Artificial Limb,
Visual/Hearing Aid)
and/or Setting up
Medications
ACCOMPANIMENT (per WEEK)
To/From Medical
Appointments
To/From Places You
Get Services in Place
of IHSS
PROTECTIVE
SUPERVISION (per
WEEK)
SOC 876 (5/17)
PAGE 3 OF 4
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TOTAL
ADJUSTMENTS
AMOUNT OF
SERVICES
AUTHORIZED
AMOUNT OF
FOR OTHERS
THE SERVICE
YOU
AMOUNT OF
THE
WHO SHARE THE
YOU NEED
REFUSED OR
SERVICE YOU
SERVICES
SERVICE
HOME
GET FROM
CAN GET
NEEDED
OTHERS
HRS:MINS
(PRORATION)
HRS:MINS
HRS:MINS
PARAMEDICAL
SERVICES (per
WEEK)
TOTAL WEEKLY HRS:MINS OF SERVICE YOU CAN GET:
MULTIPLY BY 4.33 (average # of weeks per month) TO CONVERT TO MONTHLY
x 4.33 =
HRS:MINS:
SUBTOTAL MONTHLY HRS:MINS OF SERVICE YOU CAN GET:
ADD MONTHLY DOMESTIC HRS:MINS OF SERVICE YOU CAN GET (from above):
TOTAL HRS:MINS OF SERVICE YOU CAN GET PER MONTH:
TIME LIMITED SERVICES (per MONTH)
Heavy Cleaning
Yard Hazard
Abatement
Remove Ice, Snow
Teaching and
Demonstration
TOTAL HRS:MINS OF TIME LIMITED SERVICES YOU CAN GET PER MONTH:
SOC 876 (5/17)
PAGE 4 OF 4
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