Form SOC875 "In-home Supportive Services (Ihss) Program Notice to Recipient of Health Care Certification Requirement" - California

What Is Form SOC875?

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 November 1, 2011;
  • 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 SOC875 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 SOC875 "In-home Supportive Services (Ihss) Program Notice to Recipient of Health Care Certification Requirement" - 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 TO RECIPIENT OF HEALTH CARE
COUNTY OF:
CERTIFICATION REQUIREMENT
Notice Date:
(ADDRESSEE)
IHSS Office Address:
IHSS Office Telephone Number:
Social Worker Name:
DUE BY:
To: In-Home Supportive Services (IHSS) Recipient
There has been a change in state law (Welfare and Institutions Code section 12309.1) that requires
each person getting IHSS to provide a health care certification from a licensed health care professional
(LHCP) to continue to get IHSS.
The certification must be completed by a LHCP, such as a physician (doctor), physician assistant,
regional center clinician or clinician supervisor, occupational therapist, physical therapist, psychiatrist,
psychologist, optometrist, ophthalmologist, public health nurse, etc.
The certification must state that you are not able to do some activities of daily living (ADLs) on your own
and that without help to do these activities you would be at risk of placement in out-of-home care.
Basic ADLs are: eating, bathing, dressing, using the toilet, walking, and getting out of bed or a
chair. Other ADLs are: housekeeping, preparing meals, shopping for food or other necessities, taking
medication, etc.
Attached is a blank copy of the Health Care Certification Form (SOC 873) that you can give to your
LHCP to complete. If you want, the county can send it to the LHCP for you but you will have to give the
county the LHCP’s name and address.
The county may accept alternative documentation in place of the SOC 873 as long as it meets all of the
following requirements:
1. Indicates that you are not able to do one or more ADLs on your own,
2. Describes the medical or other condition that makes you unable to do ADLs on your own and
causes you to need IHSS, and
3. Has been signed by a LHCP within the last 60 days.
Whether you give the SOC 873 to the LHCP yourself or the county sends it for you, you are
responsible for making sure it is completed and returned to the county within 45 days following your
reassessment.
If the county does not receive the completed SOC 873 or alternative documentation within 45
days following your reassessment, your IHSS may stop. As with any county action taken on
your case, you may request a state hearing if you do not agree with the county’s decision.
If you are not able to get the SOC 873 from your LHCP within 45 days, call your social worker at the
number listed above before the due date to tell him/her why you are not able to meet the due date and
ask if the county can grant you more time.
SOC 875 (11/11)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE TO RECIPIENT OF HEALTH CARE
COUNTY OF:
CERTIFICATION REQUIREMENT
Notice Date:
(ADDRESSEE)
IHSS Office Address:
IHSS Office Telephone Number:
Social Worker Name:
DUE BY:
To: In-Home Supportive Services (IHSS) Recipient
There has been a change in state law (Welfare and Institutions Code section 12309.1) that requires
each person getting IHSS to provide a health care certification from a licensed health care professional
(LHCP) to continue to get IHSS.
The certification must be completed by a LHCP, such as a physician (doctor), physician assistant,
regional center clinician or clinician supervisor, occupational therapist, physical therapist, psychiatrist,
psychologist, optometrist, ophthalmologist, public health nurse, etc.
The certification must state that you are not able to do some activities of daily living (ADLs) on your own
and that without help to do these activities you would be at risk of placement in out-of-home care.
Basic ADLs are: eating, bathing, dressing, using the toilet, walking, and getting out of bed or a
chair. Other ADLs are: housekeeping, preparing meals, shopping for food or other necessities, taking
medication, etc.
Attached is a blank copy of the Health Care Certification Form (SOC 873) that you can give to your
LHCP to complete. If you want, the county can send it to the LHCP for you but you will have to give the
county the LHCP’s name and address.
The county may accept alternative documentation in place of the SOC 873 as long as it meets all of the
following requirements:
1. Indicates that you are not able to do one or more ADLs on your own,
2. Describes the medical or other condition that makes you unable to do ADLs on your own and
causes you to need IHSS, and
3. Has been signed by a LHCP within the last 60 days.
Whether you give the SOC 873 to the LHCP yourself or the county sends it for you, you are
responsible for making sure it is completed and returned to the county within 45 days following your
reassessment.
If the county does not receive the completed SOC 873 or alternative documentation within 45
days following your reassessment, your IHSS may stop. As with any county action taken on
your case, you may request a state hearing if you do not agree with the county’s decision.
If you are not able to get the SOC 873 from your LHCP within 45 days, call your social worker at the
number listed above before the due date to tell him/her why you are not able to meet the due date and
ask if the county can grant you more time.
SOC 875 (11/11)