This form is a sample of an agreement between an elderly or disabled client and a Caregiver who operates as an independent contractor and provides personnel to assist Client to live at home and to have as much control over the home environment and life as possible under the circumstances. Caregiver's personnel also assist Client with the activities of daily living, scheduling medication, assistance with mobility, accompanying Client on errands and appointments, and such other services as agreed between Client and Caregiver.
In this agreement, Client waives damages for simple negligence of Caregiver, but not gross negligence or misconduct that is intentional or criminal in nature. Courts generally will not enforce waivers of this type of misconduct since such a waiver would be deemed to be against public policy because it would encourage dangerous and illegal behavior.
Application Caregiver Form With Child In Oakland
Category:
State:
Multi-State
County:
Oakland
Control #:
US-00458BG
Format:
Word;
Rich Text
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FAQ
Submit a completed and signed Application for In-Home Supportive Services SOC 295 to: IHSSSOC295Apps@acgov.
Contact IHSS at (408) 792-1600 or fill out the application and submit using one of the options below. Mail. In-Home Supportive Services. PO Box 11018. San Jose, CA 95103-1018.
To be eligible for IHSS, an individual must be Medi-Cal eligible or must be receiving Supplemental Security Income (SSI) benefits. The IHSS program provides payment for non-medical in-home care for qualified individuals who are unable to remain safely in their homes without this assistance.
MY PHONE: Call 510-577-1800 weekdays from AM - 12 Noon or - PM. Once you dial, when prompted, press “1” for English and then “1” for applying for IHSS and “1” a third time to speak with an intake screener. 2. BY MAIL: Request an application to be mailed to client's home.
A county social worker will interview to determine your eligibility and need for IHSS. You must have a physician or other licensed health care professional fill out a Health Care Certification (SOC 873) form and you must return it to the county before care services can be authorized.
In-Home Supportive Services (IHSS) Program You must also be a California resident. You must have a Medi-Cal eligibility determination. You must live at home or an abode of your own choosing (acute care hospital, long-term care facilities, and licensed community care facilities are not considered "own home").
Under the law, you are ineligible to work in the IHSS program ONLY if you have been convicted within the last 10 years of: 1) fraud against a government health care or supportive services program; 2) child abuse; or 3) abuse of an elder or dependent adult.