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 2 Points In Santa Clara
Category:
State:
Multi-State
County:
Santa Clara
Control #:
US-00458BG
Format:
Word;
Rich Text
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FAQ
Applying for IHSS If you already have Medi-Cal or once you are approved for it, call or visit your county In-Home Supportive Services (IHSS) office to complete an IHSS application. Once IHSS gets the application, a caseworker will contact you and schedule a time to visit your home and understand your needs.
To enroll as an IHSS Provider: Go to the IHSS Independent Provider Enrollment Center for Santa Cruz County Website. Click on the “Start” button and complete the Provider Information section. Click on the “Watch the Orientation Video” button and watch the mandatory provider videos.
Postal service: IHSS, PO Box 11018 San Jose, CA 95103-1018. Fax: (408) 792-1601. In-person: 353 W. Julian Street, San Jose.
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.
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.
Apply for In-Home Supportive Services Gather important information. You will need your contact information, date of birth, social security number, and Medi-Cal number. Apply for IHSS. Turn in a completed IHSS application by email, fax, mail, or in-person. Home visit. Service approval. Hire provider(s).
You are blind, live with a disability or are 65 years of age or older. You must live at home in Santa Clara County. You must have Medi-Cal. Apply for Medi-Cal.
More info
The interest form is a short job application, which needs to be filled out completely and clearly and must include two references. The non-minor should complete this form listing only their income and resources.The form should not include any income and resources of the legal guardian. At Home Support offers professional caregiver services in SF Bay Area with offices in San Bruno and Los Altos. Reach out today to find out more! If you are interested in this Temporary Respite Caregiver Support Grant, call Institute on Aging at 415.750. Families and Caregivers of children, adolescents and TAY are welcome to contact the NAMI Helpline Help Desk for support and assistance with resources. Santa Clara County is planning to expand its home visitation program to help parents with babies, toddler, and young children who are in need of services. Description: The Office for the Aging offers in-home respite services for caregivers of frail or disabled elderly. The purpose of this page is to provide various points of contact you can reach out to regarding your use of HealthShare Referral Manager (HSRM).