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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PHYSICIAN’S CERTIFICATION OF MEDICAL NECESSITY
DATE:
This form must be completed to determine Personal
Care Services Program eligibility and annually
for recertification.
After completion, return this form to the agency
address indicated below.
PATIENT’S NAME CASE NUMBERDATE OF BIRTH
Dear Doctor:
The Personal Care Services Program provides assistance through In-Home Supportive Services, to those eligible
individuals who are limited in their ability to care for themselves and would be unable to remain safely in their own
homes without this service.
Your patient has requested help with one or more of the following personal care services: assistance with ambulation;
bathing; oral hygiene; grooming; dressing; care and assistance with prosthetic devices; bowel, bladder and menstrual
care; repositioning, skin care, range of motion exercises and transfers; feeding and assurance of adequate fluid intake;
respiration; or assistance with self-administration of medications.
Your examination of this patient may be reimbursable through Medi-Cal as an office visit provided that all other
applicable Medi-Cal requirements are met, or through Medi-Care.
AGENCY SERVICE WORKER SERVICE WORKER NUMBER
AGENCY ADDRESS (Street, City, Zip) PHONE
( )
SERVICE WORKER’S SIGNATURE DATE
PATIENT AUTHORIZATION
By signing this form, I hereby authorize the release of information, including information regarding alcoholism, drug abuse,
mental illness or HIV infection, pertaining to my medical necessity for personal care services to the above named agency
.
PATIENT’S SIGNATURE (Or Authorized Representative) DATE
FOR PHYSICIAN’S USE ONLY
PHONE
PHYSICIAN’S NAME
( )
OFFICE ADDRESS (Street, City, Zip)
DIAGNOSIS
DATE LAST SEEN BY PHYSICIAN
PROGNOSIS (If Known)
I recommend one or more of the above listed personal care services for this
patient in order to prevent out-of-home placement.
■ Yes ■ No
PHYSICIAN’S SIGNATURE
DATE
PROVIDER NUMBER
SOC 425 (7/03)
