Form SOC839 "In-home Supportive Services (Ihss) Designation of Authorized Representative" - California

What Is Form SOC839?

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 June 1, 2018;
  • 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;
  • Fill out the form in our online filing application.

Download a fillable version of Form SOC839 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 SOC839 "In-home Supportive Services (Ihss) Designation of Authorized Representative" - California

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State of California – Health and Human Services Agency
California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS)
DESIGNATION OF AUTHORIZED REPRESENTATIVE
INSTRUCTIONS for Designating an Authorized Representative:
This form allows the IHSS applicant/recipient or his/her legal representative to
choose an Authorized Representative for the IHSS program and identifies the
functions the Authorized Representative may perform on his/her behalf. This form is
only for the IHSS program.
To choose an authorized representative to represent the applicant/recipient at
a state administrative hearing, complete a separate form, DPA 19 (Authorized
Representative). The person authorized on the completed and submitted DPA 19
form can represent the applicant/recipient at a state administrative hearing.
The Authorized Representative must be 18 years of age or older.
Under state law, if the person chosen as the Authorized Representative is not the
applicant/recipient’s legal representative and has been convicted of or incarcerated
following a conviction for certain exclusionary crimes within the past 10 years,
he/she cannot be designated as the authorized representative. There are two
categories of exclusionary crimes:
Tier 1 crimes, as set forth in Welfare and Institutions Code (WIC) section
12305.81, include the following:
1. Specified abuse of a child (Penal Code [PC] section 273a[a]);
2. Abuse of an elder or dependent adult (PC section 368); and
3. Fraud against a government health care or supportive services program.
Tier 2 crimes, as set forth in WIC section 12305.87, include the following:
1. A violent or serious felony, as specified in PC section 667.5(c) and PC
section 1192.7(c);
2. A felony offense for which a person is required to register as a sex offender
pursuant to PC section 290(c); and
3. A felony offense for fraud against a public social services program, as
defined in WIC sections 10980(c)(2) and 10980(g)(2).
A complete listing of Tier 2 crimes is available upon request from the County IHSS
Office or IHSS Public Authority.
SOC 839 (6/18)
Page 1 of 6
State of California – Health and Human Services Agency
California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS)
DESIGNATION OF AUTHORIZED REPRESENTATIVE
INSTRUCTIONS for Designating an Authorized Representative:
This form allows the IHSS applicant/recipient or his/her legal representative to
choose an Authorized Representative for the IHSS program and identifies the
functions the Authorized Representative may perform on his/her behalf. This form is
only for the IHSS program.
To choose an authorized representative to represent the applicant/recipient at
a state administrative hearing, complete a separate form, DPA 19 (Authorized
Representative). The person authorized on the completed and submitted DPA 19
form can represent the applicant/recipient at a state administrative hearing.
The Authorized Representative must be 18 years of age or older.
Under state law, if the person chosen as the Authorized Representative is not the
applicant/recipient’s legal representative and has been convicted of or incarcerated
following a conviction for certain exclusionary crimes within the past 10 years,
he/she cannot be designated as the authorized representative. There are two
categories of exclusionary crimes:
Tier 1 crimes, as set forth in Welfare and Institutions Code (WIC) section
12305.81, include the following:
1. Specified abuse of a child (Penal Code [PC] section 273a[a]);
2. Abuse of an elder or dependent adult (PC section 368); and
3. Fraud against a government health care or supportive services program.
Tier 2 crimes, as set forth in WIC section 12305.87, include the following:
1. A violent or serious felony, as specified in PC section 667.5(c) and PC
section 1192.7(c);
2. A felony offense for which a person is required to register as a sex offender
pursuant to PC section 290(c); and
3. A felony offense for fraud against a public social services program, as
defined in WIC sections 10980(c)(2) and 10980(g)(2).
A complete listing of Tier 2 crimes is available upon request from the County IHSS
Office or IHSS Public Authority.
SOC 839 (6/18)
Page 1 of 6
State of California – Health and Human Services Agency
California Department of Social Services
The applicant/recipient or his/her legal representative can choose a new or add
another IHSS Authorized Representative at any time by completing a new form and
submitting it to the county social worker.
The Authorized Representative must act in the applicant/recipient’s best interest
and can only perform the functions authorized on this form. County IHSS
program staff will still need to meet with the applicant/recipient in person to
ask questions related to his/her care and services although the Authorized
Representative may also be present.
The Authorized Representative may perform all tasks set forth in PART B
(FUNCTIONS PERFORMED BY AUTHORIZED REPRESENTATIVE); however, the
applicant/recipient is still responsible for providing all necessary information
for program eligibility.
INSTRUCTIONS for completing this form:
Complete the section with the applicant/recipient’s name, IHSS Case Number, and
date.
Complete PART A (DESIGNATION OF AUTHORIZED REPRESENTATIVE)
and review PART B (FUNCTIONS PERFORMED BY AUTHORIZED
REPRESENTATIVE) of this form to understand what activities the authorized
representative can provide for the applicant/recipient.
If the applicant/recipient’s spouse/domestic partner is both his/her provider
and authorized representative, the only provider-related document he/she may
sign is the SOC 862 (IHSS Recipient Request for Provider Waiver). Complete
PART C (TIMESHEET AND/OR OTHER PROVIDER-RELATED DOCUMENTS
SIGNATORY) to designate a different individual to serve as the applicant/recipient’s
authorized representative to sign timesheets and other provider-related documents.
After completing this form and signing PART D (APPLICANT/RECIPIENT
ACKNOWLEDGMENT), submit this form to the county social worker.
SOC 839 (6/18)
Page 2 of 6
State of California – Health and Human Services Agency
California Department of Social Services
Applicant’s/Recipient’s Name
IHSS Case Number
Date
… I am the Legal Representative of the Applicant/Recipient.
I am the Applicant/Recipient’s
Conservator
Legal Guardian
Parent/Legally Authorized Decisionmaker
(for minor child).
I understand that I do not need to complete this form to serve as the applicant/
recipient’s Authorized Representative unless:
I will have the responsibility of signing IHSS provider timesheets and/or other
provider-related documents in which case I will need to complete
PART C (TIMESHEET AND OTHER PROVIDER-RELATED DOCUMENTS
SIGNATORY).
I will be designating another individual to serve as the Authorized
Representative for purposes of the IHSS program.
PART A. DESIGNATION OF AUTHORIZED REPRESENTATIVE
Complete this part of the form to appoint the individual the applicant/recipient or his/her
legal representative chooses to be his/her IHSS Authorized Representative.
If the applicant/recipient or his/her legal representative would like to designate multiple
IHSS Authorized Representatives to perform the functions listed in PART B, then
complete a separate form for each designated Authorized Representative.
The IHSS applicant/recipient appoints the following individual as his/her
Authorized Representative for the IHSS Program:
Authorized Representative’s Name
Authorized Representative’s
Telephone Number
Authorized Representative’s
City
Zip Code
Street Address
SOC 839 (6/18)
Page 3 of 6
State of California – Health and Human Services Agency
California Department of Social Services
WITHIN THE PAST 10 YEARS, HAS THE INDIVIDUAL DESIGNATED IN PART A.
BEEN:
Convicted of or incarcerated following a conviction for a Tier 1* crime?
a.
Yes
No
Convicted of or incarcerated following a conviction for a Tier 2* crime?
b.
Yes
No
*See Page 1 of the instructions for a definition of Tier 1 and Tier 2 crimes.
PART B. FUNCTIONS PERFORMED BY AUTHORIZED REPRESENTATIVE
The IHSS applicant/recipient gives consent for his/her Authorized Representative
to act on his/her behalf for the IHSS program and may perform the following
functions:
Scheduling interviews and meetings with county IHSS program staff.
Completing and submitting application forms for the IHSS program.
Completing and submitting any additional forms and/or providing additional records
or information for IHSS program eligibility.
Reporting within 10 days to the county IHSS program any changes regarding the
applicant/recipient’s eligibility, such as household composition, address, or phone
number, or any time the applicant/recipient will be away from the home.
Obtaining information from the county IHSS program regarding the status of his/her
application and/or continued eligibility, including authorized services and hours.
Hiring and firing of IHSS provider(s).
Instructing the applicant/recipient’s provider(s) on how to provide services to him/her
for the IHSS program.
Reviewing the IHSS case file of the applicant/recipient.
Signing IHSS provider timesheets and/or other provider-related documents.
(Complete PART C. TIMESHEET AND/OR OTHER PROVIDER-RELATED
DOCUMENTS SIGNATORY.)
SOC 839 (6/18)
Page 4 of 6
State of California – Health and Human Services Agency
California Department of Social Services
PART C. TIMESHEET AND/OR
OTHER PROVIDER-RELATED DOCUMENTS SIGNATORY
Completing this part of the form allows the Authorized Representative to sign IHSS
provider timesheets and/or other provider related documents on the applicant/
recipient’s behalf.
If the Authorized Representative also serves as the applicant/recipient’s provider
and is not a legal representative as described on page 1 of this form, the
applicant/recipient must choose a different Authorized Representative to sign
IHSS provider timesheets and/or other provider-related documents on his/her
behalf.
If the applicant/recipient or his/her legal representative would like to designate one
Authorized Representative to sign IHSS provider timesheets and a different Authorized
Representative to sign other IHSS provider-related documents, complete a form for
each Authorized Representative.
The IHSS applicant/recipient or his/her legal representative appoints the
following individual to perform the IHSS Program functions designated below:
(Select any functions below that the applicant/recipient wants the following
individual to do by marking the check boxes to the left of the functions.)
… Sign IHSS provider timesheets.
… Sign other IHSS provider-related documents.
Name of Authorized Representative to Sign Provider
Telephone Number
Timesheets and/or Other Provider-Related Documents
Street Address
City
Zip Code
SOC 839 (6/18)
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