IHSS Referral form 2025

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4.8 out of 5

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The document is an In-Home Supportive Services (IHSS) Referral Form from the San Francisco Human Services Agency's Department of Disability and Aging Services. It collects personal information about the IHSS applicant, including demographics, living situation, medical conditions, and current support systems. The form also inquires about the applicant's eligibility for various services such as Medi-Cal and CALFRESH, and requires details on functional abilities and risks. It emphasizes the need for complete information to process requests for IHSS services.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (43 Votes)
2018	4.3 Satisfied (40 Votes)
2017	4.4 Satisfied (23 Votes)
2012	4 Satisfied (58 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What disqualifies you from being an IHSS provider?

An Authorized Representative is responsible for acting on the behalf of the IHSS recipient for purposes of the IHSS program.

What is an SOC 295 form for?

Fill out SOC 295 Application for In-Home Supportive Services. The form is available in three languages. Submit the application to your county IHSS office.

What is a SOC 2298 form for IHSS?

You have the option to self-certify your living arrangements to exclude IHSS/WPCS wages from FIT and PIT by completing and submitting a Live-In Self-Certification Form for Federal and State Tax Wage Exclusion (SOC 2298).

What is a SOC 873 form?

This health care certification form must be completed and returned to the IHSS worker listed above. The IHSS worker will use the information provided to evaluate the individuals present condition and his/her need for out-of-home care if IHSS services were not provided.

What is the maximum income to qualify for IHSS?

You (or your authorized representative) must complete PART A of this form to let the county know who you have chosen to provide your authorized services. If you have multiple providers, you must fill out a separate form for each person who will be providing authorized services for you.

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What is a SOC 839 form?

This form allows you, as the IHSS applicant/recipient or their legal representative, to choose an Authorized Representative for the IHSS program. An Authorized Representative is responsible for acting on the behalf of the IHSS recipient for purposes of the IHSS program. This form is only for the IHSS program.

IHSS Referral form 2025

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Got questions?

What disqualifies you from being an IHSS provider?

What is an SOC 295 form for?

What is a SOC 2298 form for IHSS?

What is a SOC 873 form?

What is the maximum income to qualify for IHSS?

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What is a SOC 839 form?

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