Request For Order And Consent - Paramedical Services - Cdss
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR ORDER AND CONSENT -
PARAMEDICAL SERVICES
PATIENT’S NAME
MEDI-CAL IDENTIFICATION NUMBER
TO:
Dear Doctor:
This patient has applied for In-Home Supportive Services (IHSS) and stated that he/she needs certain paramedical
services in order for him/her to remain at home. You are asked to indicate on this form what specific services are needed
and what specific condition necessitates the services.
In-Home Supportive Services is authorized to fund the provision of paramedical services, if you order them for this patient.
For the purpose of this program, paramedical services are activities which, due to the recipient’s physical or mental
condition, are necessary to maintain the recipient’s health and which the recipient would perform for himself/herself were
he/she not functionally impaired. These services will be provided by In-Home Supportive Services providers who are not
licensed to practice a health care profession and will rarely be training in the provision of health care services. Should you
order services, you will be responsible for directing the provision of the paramedical services.
Your examination of this patient is reimbursable through Medi-Cal as an office visit provided that all other applicable
Medi-Cal requirements are met.
If you have any questions, please contact me.
SIGNED
TITLE
TELEPHONE NUMBER
DATE
TO BE COMPLETED BY LICENSED PROFESSIONAL
NAME OF LICENSED PROFESSIONAL
OFFICE TELEPHONE
OFFICE ADDRESS (IF NOT LISTED ABOVE)
TYPE OF PRACTICE
TYPE OF PRACTICE
Physician/Surgeon
Podiatrist
Dentist
CONTINUED ON BACK
RETURN TO: (COUNTY WELFARE DEPARTMENT)
SOC 321 (11/99)
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