InHome Supportive Services Referral Form SF HSA Department of Disability and Aging Services Program, Fax: (415) 3552463 Questions? Call: (415) 3556700, extension 3, or email us at ihss sfgov.org Please.
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How to fill out the CA IHSS 3012 - San Francisco online
Filling out the CA IHSS 3012 form online is an important step in accessing essential services for individuals who require in-home support. This guide provides clear and detailed instructions to help users complete the form accurately and efficiently.
Follow the steps to successfully fill out the CA IHSS 3012 form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin with the IHSS applicant section. Enter the applicant's last name, first name, middle initial (if applicable), street address, apartment number (if applicable), zip code, social security number, birth date, phone number, and email address. Ensure all information is printed clearly.
- Provide the applicant's gender identity by selecting the option that best describes it, as well as specifying sex at birth and sexual orientation. Fill in the ethnicity and languages spoken by the applicant.
- Indicate whether the applicant receives Supplement Security Income (SSI) and if they are enrolled in Medi-Cal. Respond to inquiries about interest in CALFRESH.
- In the referent information section, enter the referent's name, phone number, relationship to the applicant, and agency or organization details, if applicable.
- Complete the residence and discharge information by specifying the living situation, whether the applicant lives alone, and details about any household members.
- If applicable, answer questions about the client's marital status and provide necessary details about any spouse or other IHSS recipients in the household.
- For on-call home care services, indicate your request and explain the need for these services, along with how service needs will be met until eligibility is established.
- Fill in the applicant's physician or clinic information, including name, address, and contact details.
- Provide information regarding medical or mental health diagnoses, along with additional concerns that could impact service needs.
- Complete the emergency contact information section by listing contacts, their relations, and phone numbers.
- Assess the functional ability of the individual by indicating their level of dependence for various daily activities.
- Indicate any risks present and describe how service needs are currently being met.
- List any services currently received and express interest in additional services, as needed.
- Once all sections of the form are completed, save changes, and select options to download, print, or share the form as required.
Start filling out the CA IHSS 3012 form online today to access essential in-home support services.
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