Form SOC873 "In-home Supportive Services (IHSS) Program Health Care Certification Form" - California

What Is Form SOC 873?

Form SOC 873, In-Home Supportive Services (IHSS) Program Health Care Certification Form - also called Form SOC 873 (IHSS) or the IHSS certification form for short - is a medical certification form filled out by a licensed health care professional to enable disabled, blind, or elderly individuals to receive services from the In-Home Supportive Services (IHSS) program. The California IHSS program aids California residents who are at risk of being placed in out-of-home care such as assisted living, board and care facilities, or skilled nursing facilities. It allows people to remain in their homes by providing care services, including but not limited to meal preparation, laundry, shopping for necessities, cleaning, assistance with respiration and feeding, protective supervisions, and paramedical services. To qualify for these services, the Form SOC 873 must be signed by a health care professional and submitted to the IHSS prior to the authorization of services.

The latest version of the form was issued by the California Department of Social Services in October 2016 with all previous editions obsolete. Form SOC 873 fillable version is available for download below.

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In-Home Supportive Services (IHSS) Program Health Care Certification Form

The IHSS certification form must be completed by the local county welfare department, the applicant/recipient, and the licensed health care professional:

  1. Applicant/Recipient Information. The county welfare department worker must state the applicant/recipient's full name, date of birth, address, county of residence. It is required to submit an IHSS case number. The document must contain the IHSS worker name, phone number, and fax number;
  2. Authorization to Release Health Care Information. The applicant/recipient must authorize the release of health care information that relates to the physical and/or mental condition. The applicant (recipient/legal guardian/conservator) has to sign and date the form. It is also necessary to obtain the signature of a witness;
  3. Health Care Information. The licensed health care professional (physician, physical therapist, psychiatrist, etc.) has to indicate if the recipient of services is unable to independently perform activities of daily living and if IHSS services are required to prevent the out-of-home care. The description of any condition or illness that led to the need for assistance must be provided. The health care professional has to state if the individual's condition is expected to last for a year or expected to result in death within a year. It is recommended to outline the nature of the services provided to the individual, the duration, and the frequency of contact. The IHSS worker may ask for additional information to determine the eligibility of the individual;
  4. Licensed Health Care Professional Certification. The health care professional certifies that all the information provided in the form is true and correct. The form must be signed and dated. Additionally, the health care professional has to submit the full name, the title, the address, the phone number, the fax number, and the professional license number. After that, the document is returned to the IHSS worker whose contact information is stated on the first page of the form.
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Download Form SOC873 "In-home Supportive Services (IHSS) Program Health Care Certification Form" - California

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
HEALTH CARE CERTIFICATION FORM
A. APPLICANT/RECIPIENT INFORMATION (To be completed by the county)
Applicant/Recipient Name:
Date of Birth:
Address:
IHSS Case #:
County of Residence:
IHSS Worker Name:
IHSS Worker Phone #:
IHSS Worker Fax #:
B. AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION
(To be completed by the applicant/recipient)
I, __________________________________________, authorize the release of health care information
(PRINT NAME)
related to my physical and/or mental condition to the In-Home Supportive Services program as it
pertains to my need for domestic/related and personal care services.
____/_____/_____
Signature: ______________________________________________________ Date:
(APPLICANT/RECIPIENT OR LEGAL GUARDIAN/CONSERVATOR)
Witness
: ___________________________________ Date: _____/_____/_____
(if the individual signs with an “X”)
TO: LICENSED HEALTH CARE PROFESSIONAL* –
The above-named individual has applied for or is currently receiving services from the In-Home Supportive
Services (IHSS) program. State law requires that in order for IHSS services to be authorized or continued a
licensed health care professional must provide a health care certification declaring the individual above is
unable to perform some activity of daily living independently and without IHSS the individual would be at risk
of placement in out-of-home care. This health care certification form must be completed and returned to the
IHSS worker listed above. The IHSS worker will use the information provided to evaluate the individual’s
present condition and his/her need for out-of-home care if IHSS services were not provided. The IHSS worker
has the responsibility for authorizing services and service hours. The information provided in this form will be
considered as one factor of the need for services, and all relevant documentation will be considered in making
the IHSS determination.
IHSS is a program intended to enable aged, blind, and disabled individuals who are most at risk of being placed
in out-of-home care to remain safely in their own home by providing domestic/related and personal care
services. IHSS services include: housekeeping, meal preparation, meal clean-up, routine laundry, shopping
for food or other necessities, assistance with respiration, bowel and bladder care, feeding, bed baths,
dressing, menstrual care, assistance with ambulation, transfers, bathing and grooming, rubbing skin and
repositioning, care/assistance with prosthesis, accompaniment to medical appointments/alternative resources,
yard hazard abatement, heavy cleaning, protective supervision (observing the behavior of a non-self-direct-
ing, confused, mentally impaired or mentally ill individual and intervening as appropriate to safeguard
recipient against injury, hazard or accident), and paramedical services (activities requiring a judgment based
on training given by a licensed health care professional, such as administering medication, puncturing the skin,
etc., which an individual would normally perform for him/herself if he/she did not have functional limitations,
and which, due to his/her physical or mental condition, are necessary to maintain his/her health). The IHSS
program provides hands-on and/or verbal assistance (reminding or prompting) for the services listed above.
*Licensed Health Care Professional means an individual licensed in California by the appropriate California regulatory agency, acting within
the scope of his or her license or certificate as defined in the Business and Professions Code. These include, but are not limited to:
physicians, physician assistants, regional center clinicians or clinician supervisors, occupational therapists, physical therapists,
psychiatrists, psychologists, optometrists, ophthalmologists and public health nurses.
SOC 873 (10/16)
PAGE 1 OF 2
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
HEALTH CARE CERTIFICATION FORM
A. APPLICANT/RECIPIENT INFORMATION (To be completed by the county)
Applicant/Recipient Name:
Date of Birth:
Address:
IHSS Case #:
County of Residence:
IHSS Worker Name:
IHSS Worker Phone #:
IHSS Worker Fax #:
B. AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION
(To be completed by the applicant/recipient)
I, __________________________________________, authorize the release of health care information
(PRINT NAME)
related to my physical and/or mental condition to the In-Home Supportive Services program as it
pertains to my need for domestic/related and personal care services.
____/_____/_____
Signature: ______________________________________________________ Date:
(APPLICANT/RECIPIENT OR LEGAL GUARDIAN/CONSERVATOR)
Witness
: ___________________________________ Date: _____/_____/_____
(if the individual signs with an “X”)
TO: LICENSED HEALTH CARE PROFESSIONAL* –
The above-named individual has applied for or is currently receiving services from the In-Home Supportive
Services (IHSS) program. State law requires that in order for IHSS services to be authorized or continued a
licensed health care professional must provide a health care certification declaring the individual above is
unable to perform some activity of daily living independently and without IHSS the individual would be at risk
of placement in out-of-home care. This health care certification form must be completed and returned to the
IHSS worker listed above. The IHSS worker will use the information provided to evaluate the individual’s
present condition and his/her need for out-of-home care if IHSS services were not provided. The IHSS worker
has the responsibility for authorizing services and service hours. The information provided in this form will be
considered as one factor of the need for services, and all relevant documentation will be considered in making
the IHSS determination.
IHSS is a program intended to enable aged, blind, and disabled individuals who are most at risk of being placed
in out-of-home care to remain safely in their own home by providing domestic/related and personal care
services. IHSS services include: housekeeping, meal preparation, meal clean-up, routine laundry, shopping
for food or other necessities, assistance with respiration, bowel and bladder care, feeding, bed baths,
dressing, menstrual care, assistance with ambulation, transfers, bathing and grooming, rubbing skin and
repositioning, care/assistance with prosthesis, accompaniment to medical appointments/alternative resources,
yard hazard abatement, heavy cleaning, protective supervision (observing the behavior of a non-self-direct-
ing, confused, mentally impaired or mentally ill individual and intervening as appropriate to safeguard
recipient against injury, hazard or accident), and paramedical services (activities requiring a judgment based
on training given by a licensed health care professional, such as administering medication, puncturing the skin,
etc., which an individual would normally perform for him/herself if he/she did not have functional limitations,
and which, due to his/her physical or mental condition, are necessary to maintain his/her health). The IHSS
program provides hands-on and/or verbal assistance (reminding or prompting) for the services listed above.
*Licensed Health Care Professional means an individual licensed in California by the appropriate California regulatory agency, acting within
the scope of his or her license or certificate as defined in the Business and Professions Code. These include, but are not limited to:
physicians, physician assistants, regional center clinicians or clinician supervisors, occupational therapists, physical therapists,
psychiatrists, psychologists, optometrists, ophthalmologists and public health nurses.
SOC 873 (10/16)
PAGE 1 OF 2
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM HEALTH CARE CERTIFICATION FORM
IHSS Case #:
Applicant/Recipient Name:
C. HEALTH CARE INFORMATION (To be completed by a Licensed Health Care Professional Only)
NOTE: ITEMS #1 & 2 (AND 3 & 4, IF APPLICABLE) MUST BE COMPLETED AS A CONDITION
OF IHSS ELIGIBILITY.
1. Is this individual unable to independently perform one or more activities of daily
living (e.g., eating, bathing, dressing, using the toilet, walking, etc.)
YES
NO
or instrumental activities of daily living (e.g., housekeeping, preparing meals,
shopping for food, etc.)?
2. In your opinion, is one or more IHSS service recommended in order to prevent
YES
NO
the need for out-of-home care (See description of IHSS services on Page 1)?
If you answered “NO” to either Question #1 OR #2, skip Questions #3 and #4 below, and complete the
rest of the form including the certification in PART D at the bottom of the form.
If you answered “YES” to both Question #1 AND #2, respond to Questions #3 and #4 below, and
complete the certification in PART D at the bottom of the form.
3. Provide a description of any physical and/or mental condition or functional limitation that has
resulted in or contributed to this individual’s need for assistance from the IHSS program:
4. Is the individual’s condition(s) or functional limitation(s) expected to last at
YES
NO
least 12 consecutive months OR expected to result in death within 12 months?
Please complete Items # 5 - 8, to the extent you are able, to further assist the IHSS worker in determining
this individual’s eligibility.
5. Describe the nature of the services you provide to this individual (e.g., medical treatment, nursing care,
discharge planning, etc.):
6. How long have you provided service(s) to this individual?
7. Describe the frequency of contact with this individual (e.g., monthly, yearly, etc.):
8. Indicate the date you last provided services to this individual:
____ / ____ / ____
NOTE: THE IHSS WORKER MAY CONTACT YOU FOR ADDITIONAL INFORMATION OR TO
CLARIFY THE RESPONSES YOU PROVIDED ABOVE.
D. LICENSED HEALTH CARE PROFESSIONAL CERTIFICATION
By signing this form, I certify that I am licensed in the State of California and all information provided above is
correct.
Name:
Title:
Address:
Fax #:
Phone #:
Date:
Signature:
Licensing Authority:
Professional License Number:
PLEASE RETURN THIS FORM TO THE IHSS WORKER LISTED ON PAGE 1.
SOC 873 (10/16)
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