Form Na 1253l - Notice Of Action - In-Home Supportive Services (Ihss) Change Page 2
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5NOTICE OF ACTION IN-HOME SUPPORTIVE SERVICES
COUNTY OF
1) If there is a zero in the "Authorized Amount of Service You Can Get" column or the amount is less than the "Total
Amount of Service Needed" column, the reason is explained on the next page(s).
2)"Not Needed" means that your social worker found that you do not require assistance with this task.
(MPP 30-756.11)
3)"Pending" means the county is waiting for more information to see if you need that service.
See the next page(s) for more information.
TOTAL
ADJUSTMENTS
AMOUNT OF
SERVICES
AMOUNT OF
FOR OTHERS
SERVICES
THE SERVICE
YOU REFUSED
THE SERVICE
WHO SHARE
Note: See the “Description of Services” insert
YOU NEED
OR GET FROM
NEEDED
THE HOME
for a short description of each service.
OTHERS
HRS:MINS
(PRORATION)
HRS:MINS
DOMESTIC SERVICES (per MONTH)
RELATED SERVICES (per WEEK)
Prepare Meals
Meal Clean-up
Routine Laundry
Shopping for Food
Other Shopping/Errands/Reading Services
NON-MEDICAL PERSONAL SERVICES (per WEEK)
Respiration Assistance (Help w/ Breathing)
Bowel, Bladder Care
Feeding
NON-MEDICAL PERSONAL SERVICES (per WEEK)
Routine Bed Bath
NA 1253L (3/15) IHSS CHANGE
Case No.
PAGE 2 of 5
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