Form Na 1253l - Notice Of Action - In-Home Supportive Services (Ihss) Change Page 3
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5NOTICE OF ACTION IN-HOME SUPPORTIVE SERVICES COUNTY OF
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
Ambulation (Help with Walking, including
Getting In/Out of Vehicles)
Transferring (Help Moving In/Out of Bed,
On/Off Seats, etc.)
Bathing, Oral Hygiene, Grooming
Rubbing Skin, Repositioning
Help with Prosthesis (Artificial Limb, Visual/
Hearing Aid) and/or Setting up Medications
ACCOMPANIMENT (per WEEK):
To/From Medical Appointments
To/From Places You Get Services in Place
of IHSS
PROTECTIVE SUPERVISION (per WEEK)
PARAMEDICAL SERVICES (per WEEK)
TIME LIMITED SERVICES (per MONTH)
Heavy Cleaning
Yard Hazard Abatement
Remove Ice, Snow
Teaching and Demonstration
TOTAL HRS:MINS OF TIME LIMITED SERVICES YOU CAN GET PER MONTH:
NA 1253L (3/15) IHSS CHANGE
Case No.
PAGE 3 of 5
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