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

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The document is a request form from the California Department of Social Services for paramedical services needed by a patient applying for In-Home Supportive Services (IHSS). It outlines the process for healthcare professionals to indicate necessary services based on the patient's condition, ensuring that these services are authorized and reimbursable through Medi-Cal. The form requires certification from a licensed professional and informed consent from the patient regarding the risks associated with the services.

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

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Who qualifies for IHSS in California?

California Department of Social Services.

What is the income limit for IHSS in California?

When both spouses are applicants, there is a couple income limit of $2,433 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of their spouse. Only the applicant spouses income is considered, which is limited to $1,801/ month.

What is an SOC 295 form for?

CDSS offers employment services, cash aid, food services, residential care, day care, in-home care, adoption, foster care services, refugee services and more. It is broken into roughly seven divisions: Adult Program Division provides oversight of programs providing services to the aged, blinded and disabled.

What does CDSS stand for in California?

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.