Form SOC2307 "In-home Supportive Services (Ihss) Program Extraordinary Circumstances Secondary Evaluation Worksheet" - California

What Is Form SOC2307?

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 January 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;

Download a fillable version of Form SOC2307 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 SOC2307 "In-home Supportive Services (Ihss) Program Extraordinary Circumstances Secondary Evaluation Worksheet" - California

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State of California – Health and Human Services Agency
California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
EXTRAORDINARY CIRCUMSTANCES SECONDARY EVALUATION
WORKSHEET
CONFIDENTIAL DOCUMENT – FOR COUNTY USE ONLY
County Name:
Provider Name:
Provider Number:
RECIPIENT #1
Name: _______________________________
Case #: ______________________________
Referral Criteria:
A
B
C
Provider Lives in Same Home as Recipient?
Yes
No
Provider Relationship to the Recipient: ________________________
Total Number of Authorized IHSS Hours: _______________________
WPCS Hours: _____________________
Functional Ranks – Memory: ____ Orientation: _____ Judgement: _____ Ambulation: _____
Bowel/Bladder/Menstrual: _____ Transfer: _____ Feeding: _____ Respiration: ____
Paramedical Services Authorized?
Yes
No
Lives in a Rural/Remote Area with Limited Providers?
Yes
No
N/A
No Other Suitable Providers Speaking Same Language?
Yes
No
N/A
RECIPIENT #2
Name: _______________________________
Case #: ______________________________
Referral Criteria:
A
B
C
Provider Lives in Same Home as Recipient?
Yes
No
Provider Relationship to the Recipient: ________________________
Total Number of Authorized IHSS Hours: _______________________
WPCS Hours: _____________________
Functional Ranks – Memory: ____ Orientation: _____ Judgement: _____ Ambulation: _____
Bowel/Bladder/Menstrual: _____ Transfer: _____ Feeding: _____ Respiration: ____
Paramedical Services Authorized?
Yes
No
Lives in a Rural/Remote Area with Limited Providers?
Yes
No
N/A
No Other Suitable Providers Speaking Same Language?
Yes
No
N/A
SOC 2307 (1/18)
Page 1 of 3
State of California – Health and Human Services Agency
California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
EXTRAORDINARY CIRCUMSTANCES SECONDARY EVALUATION
WORKSHEET
CONFIDENTIAL DOCUMENT – FOR COUNTY USE ONLY
County Name:
Provider Name:
Provider Number:
RECIPIENT #1
Name: _______________________________
Case #: ______________________________
Referral Criteria:
A
B
C
Provider Lives in Same Home as Recipient?
Yes
No
Provider Relationship to the Recipient: ________________________
Total Number of Authorized IHSS Hours: _______________________
WPCS Hours: _____________________
Functional Ranks – Memory: ____ Orientation: _____ Judgement: _____ Ambulation: _____
Bowel/Bladder/Menstrual: _____ Transfer: _____ Feeding: _____ Respiration: ____
Paramedical Services Authorized?
Yes
No
Lives in a Rural/Remote Area with Limited Providers?
Yes
No
N/A
No Other Suitable Providers Speaking Same Language?
Yes
No
N/A
RECIPIENT #2
Name: _______________________________
Case #: ______________________________
Referral Criteria:
A
B
C
Provider Lives in Same Home as Recipient?
Yes
No
Provider Relationship to the Recipient: ________________________
Total Number of Authorized IHSS Hours: _______________________
WPCS Hours: _____________________
Functional Ranks – Memory: ____ Orientation: _____ Judgement: _____ Ambulation: _____
Bowel/Bladder/Menstrual: _____ Transfer: _____ Feeding: _____ Respiration: ____
Paramedical Services Authorized?
Yes
No
Lives in a Rural/Remote Area with Limited Providers?
Yes
No
N/A
No Other Suitable Providers Speaking Same Language?
Yes
No
N/A
SOC 2307 (1/18)
Page 1 of 3
State of California – Health and Human Services Agency
California Department of Social Services
CONFIDENTIAL DOCUMENT – FOR COUNTY USE ONLY
RECIPIENT #3
Name: _______________________________
Case #: ______________________________
Referral Criteria:
A
B
C
Provider Lives in Same Home as Recipient?
Yes
No
Provider Relationship to the Recipient: ________________________
Total Number of Authorized IHSS Hours: _______________________
WPCS Hours: _____________________
Functional Ranks – Memory: ____ Orientation: _____ Judgement: _____ Ambulation: _____
Bowel/Bladder/Menstrual: _____ Transfer: _____ Feeding: _____ Respiration: ____
Paramedical Services Authorized?
Yes
No
Lives in a Rural/Remote Area with Limited Providers?
Yes
No
N/A
No Other Suitable Providers Speaking Same Language?
Yes
No
N/A
RECIPIENT #4
Name: _______________________________
Case #: ______________________________
Referral Criteria:
A
B
C
Provider Lives in Same Home as Recipient?
Yes
No
Provider Relationship to the Recipient: ________________________
Total Number of Authorized IHSS Hours: _______________________
WPCS Hours: _____________________
Functional Ranks – Memory: ____ Orientation: _____ Judgement: _____ Ambulation: _____
Bowel/Bladder/Menstrual: _____ Transfer: _____ Feeding: _____ Respiration: ____
Paramedical Services Authorized?
Yes
No
Lives in a Rural/Remote Area with Limited Providers?
Yes
No
N/A
No Other Suitable Providers Speaking Same Language?
Yes
No
N/A
Note: If there are additional recipients included under the exemption request, please ensure
to add the name, case #, and criteria selection of each additional recipient to the referral
justification.
SOC 2307 (1/18)
Page 2 of 3
State of California – Health and Human Services Agency
California Department of Social Services
CONFIDENTIAL DOCUMENT – FOR COUNTY USE ONLY
Secondary Reviewer’s Statement of Eligibility:
All Recipients meet extraordinary circumstances criteria.
Yes
No
Note: Describe why the recipients meet or do not meet the criteria. Include diagnosis information,
description of care needs and other evidence supporting the determination.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Recipients or their authorized representative have made reasonable attempts to hire a
provider.
Yes
No
Note: Describe the reasonable attempts made. List the name of individuals contacted and the
outcome of the attempts.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
RENEWAL ONLY
Additional providers were hired since the last exemption review period.
Yes
No
Note: Describe why the additional provider(s) was hired on the case when it was previously
determined that no other provider could provide services to the recipient. Determine whether the
need for an exemption still exists. (i.e., Can the authorized hours be distributed to the providers
without the need of an exemption? Can another provider be hired to assist with the provision of IHSS
services? If not, why?)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
ELIGIBILITY DETERMINATION:
APPROVED 1 YR
INELIGIBLE
FINAL APPROVAL:
Name:
Phone #:
Title:
E-mail:
SOC 2307 (1/18)
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