Transcription of IN-HOME SUPPORTIVE SERVICES (IHSS) …
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES . IN-HOME SUPPORTIVE SERVICES ( ihss ) PROGRAM. medical CERTIFICATION FORM. A. APPLICANT/RECIPIENT INFORMATION (To be completed by the county). Applicant/Recipient Name: Date of Birth: Address: County of Residence: ihss Case #: ihss Worker Name: ihss Worker Phone #: ihss Worker Fax #: B. AUTHORIZATION TO RELEASE medical INFORMATION. (To be completed by the applicant/recipient). I, _____, authorize the release of medical 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 (if the individual signs with an X ): _____ Date: _____/_____/_____. TO: LICENSED HEALTH CARE PROFESSIONAL.
**only a licensed health care professional should complete the remainder of thisform.** in-home supportive services (ihss) program medical certification form
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LIVE-IN PROVIDER SELF-CERTIFICATION, LIVE-IN PROVIDER SELF-CERTIFICATION INFORMATION NOTICE, In-Home Supportive Services, IHSS, IN-HOME SUPPORTIVE, IN-HOME SUPPORTIVE SERVICES ADVISORY COMMITTEE IHSSAC, IHSS IN-HOUSE DPSS ORIENTATION, IMPORTANT INFORMATION FOR PROSPECTIVE, California department of social services important information for prospective providers, Important Information for the In-Home, CALIFORNIA DEPARTMENT OF SOCIAL SERVICES Important Information for the