Request for order and consent - California Department of Social - cdss ca 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and Medi-Cal identification number at the top of the form.
3. In the section addressed to the doctor, clearly indicate what specific paramedical services are needed and describe the condition necessitating these services.
4. Complete the fields for the licensed professional's information, including their name, title, office telephone number, and address if not listed above.
5. Answer whether the patient has a medical condition requiring IHSS paramedical services by selecting 'YES' or 'NO'. If 'YES', list the conditions below.
6. Detail the required paramedical services, including type of service, time required for each performance, frequency, and duration for which these services should be provided.
7. Ensure that both the licensed professional and patient sign and date their respective sections to confirm informed consent.

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