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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY (California)

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR SOCIAL SERVICES
To the Applicant: All sections of this form must be completed. Information provided is
subject to verification.
NOTE: Retain your copy of your completed application. Regarding your Social Security
Number, it is mandatory that you provide your Social Security Number(s) as required in
42 USC 405 and MPP Section 30-769.71. This information will be used in eligibility
determination and coordinating information with other public agencies.
Date of Application:
Case Number (if known):
Section 1 – Personal Information
Name:
Social Security Number:
Street Address:
City:
State:
Zip Code:
Telephone:
Birthdate:
Sex: Male Female
Section 2 – Veteran Information
Are you a Veteran?
. Yes No
. Yes No
If YES, give Veteran name and Claim Number:
Section 3 – SSI/SSP Information
Do you receive SSI/SSP benefits? Yes No
If yes, check your type of living arrangement:
.
Independent Living Board and Care Home of Another
Services being requested:
Page 1 of 7
SOC 295 (1/15)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Section 4 – Past IHSS Information
Have you received In-Home Support Services (IHSS) in the past? Yes No
If Yes, complete the following.
Date and county where service was last received:
Total Monthly Hours: Name Used (if different from above):
Section 5 – Household Information
List Family Members in Household:
Name of: Spouse Parent
Birthdate:
Social Security Number:
Name of: Child Other Relative
Birthdate:
Social Security Number:
Name of: Child Other Relative
Birthdate:
Social Security Number:
Name of: Child Other Relative
Birthdate:
Social Security Number:
Name of: Child Other Relative
Birthdate:
Social Security Number:
Page 2 of 7
SOC 295 (1/15)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Section 6 – Ethnic and Language Information
The law requires that information on ethnic origin and primary language be collected.
If you do not complete this section, social service staff will make a determination. The
information will not affect your eligibility for service.
A. My Ethnic Origin is:
(See Page 7 for a list of
Ethnicities and Codes)
If not English, my primary language is:
(See Page 7 for a list of Languages and codes)
Section 7 – Communication Accommodations
To accommodate blind or visually-impaired applicants, IHSS information is available in
the following alternative formats. Please indicate which format you would prefer, if
applicable. Providing information in this section will not affect your eligibility for
services.
I am Blind: Yes No
If yes, please choose one of the following for each of the three types of DSS
documents listed.
For Notices of Action: No accommodation is needed
Braille Documents Audio CD Data CD County Support
(If County Support, describe requested support)
For IHSS Required forms: No accommodation is needed
Braille Documents Audio CD Data CD County Support
(If County Support, describe requested support)
For Timesheets: No accommodation is needed
Telephonic System
County Support
(If County Support, describe support requesting)
Page 3 of 7
SOC 295 (1/15)
(4 Digit RAN: )
Please choose one
Please choose one
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
I am Visually Impaired: Yes No
If yes, please choose one of the following for each of the three types of DSS
documents listed.
For Notices of Action: No accommodation is needed
18 Point font documents
Audio CD Data CD County Support
(If County Support, describe requested support)
For IHSS Required forms: No accommodation is needed L
18 Point font documents Audio CD Data CD
County Support
(If County Support, describe requested support)
For Timesheets:
No accommodation is needed
18 point font documents County Support
(If County Support, describe requested support, including blind-only services)
Section 8 – Affirmation
I affirm that the above information is true to the best of my knowledge and belief. I
agree to cooperate fully if verification of the above statements is required in the future.
I also understand that as the employer of my IHSS provider(s) I am responsible for:
1) Hiring, training, supervising, scheduling and, when necessary, firing my provider(s).
2) Ensuring the total hours reported by all providers who work for me do not exceed
my IHSS authorized hours each month.
3) Referring any individual I want to hire to the County IHSS office to complete the
provider eligibility process.
4) Notify the County IHSS office when I hire or fire a provider.
In addition, I understand and agree to the following terms and limitations regarding
payment for services by the IHSS program:
Page 4 of 7
SOC 295
(1/15)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
1) In order for any individual to be paid by the IHSS program, they must be approved
as an IHSS eligible provider.
2) If I choose to have an individual work for me who has not yet been approved as an
eligible IHSS provider, I will be responsible for paying him/her if he/she is not
approved.
3) The IHSS program will not pay for any services provided to me until my application
for services is approved and then will only pay for those services that are authorized
for me to receive by the IHSS Program.
4) I will be responsible for paying for any services I receive that are not included in my
IHSS authorization.
I also understand and agree to cooperate with the following as a part of my eligibility
for IHSS:
To promote program integrity, I may be subject to unannounced visits to my home and
that I or my provider(s) may receive letters identifying program requirement concerns
from the State Department of Health Care Services (DHCS), California Department of
Social Services (CDSS) and/or the County in which I receive services.
The purpose of the visits and letters is to ensure that program requirements are being
followed and that the authorized services are necessary for you to remain safely in
your home. The visit will also verify that the authorized services are being provided,
that the quality of those services is acceptable, and that your well-being is protected.
If it is found that IHSS services are not required or not being properly provided, you
and/or your provider may be subject to a Medi-Cal fraud investigation. If fraud is
substantiated, you and/or your provider will be prosecuted for Medi-Cal fraud.
Page 5 of 7
SOC 295 (1/15)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Sect
ion 9 – Signature(s)
Signature of Applicant:
Date:
Signature of Applicant’s Representative (only if applicable):
Date:
Representative’s Relationship to Applicant
(only if applicable):
Representative Telephone Number
(only if applicable):
Representative’s Address (only if applicable):
To report suspected fraud or abuse in the provision or receipt of IHSS services, please
call the fraud hotline at 1-800-822-6222, email at stopmedicalfraud@dhcs.ca.gov
, or
go to http://www.dhcs.ca.gov/individuals/Pages/StopMedi-CalFraud.aspx .
FOR AGENCY USE ONLY
Income Eligible:
. Yes No
Status Eligible:
. Yes No
Verification:
Signature of Social Worker or Agency Representative:
Telephone Number:
Recipient Status:
. Refugee
. Cuban/Haitian Entrant
Source of Verification for Refuge or Entrant Status
(explain):
Page 6 o
f 7
SOC 295 (1/15)
Neither
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Ethnic Codes:
1. White.
2. Hispanic.
3. Black.
4. Other Asian or Pacific Islander.
5. American Indian or
Alaskan Native.
7. Filipino.
C. Chinese.
H. Cambodian.
J. Japanese.
K. Korean.
M. Samoan.
N. Asian Indian.
P. Hawaiian.
R. Guamanian.
T. Laotian.
V. Vietnamese.
Language Codes:
O. American Sign Language
(AMISLAN or ASL).
1. Spanish - NOA will be issued
in Spanish.
2. Cantonese.
3. Japanese.
4. Korean.
5. Tagalog.
6. Other non-English.
7. English.
9. Spanish - NOA will be issued
in English.
A. Other Sign Language.
B. Mandarin.
C. Other Chinese Languages.
D. Cambodian.
E. Armenian.
F. Ilacano.
G. Mien.
H. Hmong.
I. Lao.
J. Turkish.
K. Hebrew.
L. French.
M. Polish.
N. Russian.
P. Portuguese.
Q. Italian.
R. Arabic.
S. Samoan.
T. Thai.
U. Farsi.
V. Vietnamese.
Page 7 of 7
SOC 295 (1/15)
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Completed 25 July 2021

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