TO: LICENSED HEALTH CARE PROFESSIONAL* –
The above-named individual has applied for or is currently receiving services from the In-Home Supportive
Services (IHSS) program. State law requires that in order for IHSS services to be authorized or continued a
licensed health care professional must provide a health care certification declaring the individual above is
unable to perform some activity of daily living independently and without IHSS the individual would be at risk
of placement in out-of-home care. 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 individual’s
present condition and his/her need for out-of-home care if IHSS services were not provided. The IHSS worker
has the responsibility for authorizing services and service hours. The information provided in this form will be
considered as one factor of the need for services, and all relevant documentation will be considered in making
the IHSS determination.
IHSS is a program intended to enable aged, blind, and disabled individuals who are most at risk of being placed
in out-of-home care to remain safely in their own home by providing domestic/related and personal care
services. IHSS services include: housekeeping, meal preparation, meal clean-up, routine laundry, shopping
for food or other necessities, assistance with respiration, bowel and bladder care, feeding, bed baths,
dressing, menstrual care, assistance with ambulation, transfers, bathing and grooming, rubbing skin and
repositioning, care/assistance with prosthesis, accompaniment to medical appointments/alternative resources,
yard hazard abatement, heavy cleaning, protective supervision (observing the behavior of a non-self-direct-
ing, confused, mentally impaired or mentally ill individual and intervening as appropriate to safeguard
recipient against injury, hazard or accident), and paramedical services (activities requiring a judgment based
on training given by a licensed health care professional, such as administering medication, puncturing the skin,
etc., which an individual would normally perform for him/herself if he/she did not have functional limitations,
and which, due to his/her physical or mental condition, are necessary to maintain his/her health). The IHSS
program provides hands-on and/or verbal assistance (reminding or prompting) for the services listed above.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
HEALTH CARE CERTIFICATION FORM
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
A. APPLICANT/RECIPIENT INFORMATION (To be completed by the county)
B. AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION
(To be completed by the applicant/recipient)
SOC 873 (10/16) PAGE 1 OF 2
Applicant/Recipient Name:
Date of Birth:
Address:
County of Residence:
IHSS Case #:
IHSS Worker Fax #:
IHSS Worker Name:
IHSS Worker Phone #:
I, __________________________________________, authorize the release of health care information
related to my physical and/or mental condition to the In-Home Supportive Services program as it
pertains to my need for domestic/related and personal care services.
Signature: ______________________________________________________ Date:
____/_____/_____
Witness (if the individual signs with an “X”): ___________________________________ Date: _____/_____/_____
(PRINT NAME)
(APPLICANT/RECIPIENT OR LEGAL GUARDIAN/CONSERVATOR)
*Licensed Health Care Professional means an individual licensed in California by the appropriate California regulatory agency, acting within
the scope of his or her license or certificate as defined in the Business and Professions Code. These include, but are not limited to:
physicians, physician assistants, regional center clinicians or clinician supervisors, occupational therapists, physical therapists,
psychiatrists, psychologists, optometrists, ophthalmologists and public health nurses.
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM HEALTH CARE CERTIFICATION FORM
NOTE: THE IHSS WORKER MAY CONTACT YOU FOR ADDITIONAL INFORMATION OR TO
CLARIFY THE RESPONSES YOU PROVIDED ABOVE.
C. HEALTH CARE INFORMATION (To be completed by a Licensed Health Care Professional Only)
NOTE: ITEMS #1 & 2 (AND 3 & 4, IF APPLICABLE) MUST
BE COMPLETED AS A CONDITION
OF IHSS ELIGIBILITY.
D. LICENSED HEALTH CARE PROFESSIONAL CERTIFICATION
SOC 873 (10/16)
PAGE 2 OF 2
5. Describe the nature of the services you provide to this individual (e.g., medical treatment, nursing care,
discharge planning, etc.):
6. How long have you provided service(s) to this individual?
7. Describe the frequency of contact with this individual (e.g., monthly, yearly, etc.):
8. Indicate the date you last provided services to this individual: ____ / ____ / ____
1. Is this individual unable
to independently perform one or more activities of daily
living (e.g., eating, bathing, dressing, using the toilet, walking, etc.)
or instrumental activities of daily living (e.g., housekeeping, preparing meals,
shopping for food, etc.)?
2. In your opinion, is one or more IHSS service recommended in order to prevent
the need for out-of-home care (See description of IHSS services on Page 1)?
If you answered “NO” to either Question #1 OR #2, skip Questions #3 and #4 below, and complete the
rest of the form including the certification in PART D at the bottom of the form.
If you answered “YES” to both Question #1 AND #2, respond to Questions #3 and #4 below, and
complete the certification in PART D at the bottom of the form.
3. Provide a description of any physical and/or mental condition or functional limitation that has
resulted in or contributed to this individual’s need for assistance from the IHSS program:
4. Is the individual’s condition(s) or functional limitation(s) expected to last at
least 12 consecutive months OR expected to result in death within 12 months?
Please complete Items # 5 - 8, to the extent you are able, to further assist the IHSS worker in determining
this individual’s eligibility.
By signing this form, I certify that I am licensed in the State of California and all information provided above is
correct.
YES
NO
YES
NO
YES
NO
Name:
Address:
Phone #:
Signature:
Professional License Number:
Title:
Fax #:
Date:
Licensing Authority:
PLEASE RETURN THIS FORM TO THE IHSS WORKER LISTED ON PAGE 1.
Applicant/Recipient Name:
IHSS Case #:
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