Form Na 1253l - Notice Of Action - In-Home Supportive Services (Ihss) Change Page 4
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5NOTICE OF ACTION IN-HOME SUPPORTIVE SERVICES (IHSS)
COUNTY OF
HOURS YOU CAN
SERVICES
GET
Note: See the “Description of Services” insert
HRS:MINS
for a short description of each service.
NOW
WAS
+/-
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
Routine Bed Bath
Dressing
Menstrual Care
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)
TOTAL WEEKLY HRS:MINS OF SERVICE YOU CAN GET:
MULTIPLY BY 4.33 (average # of weeks per month)
x4.33=
TO CONVERT TO MONTHLY HRS:MINS:
SUBTOTAL MONTHLY HRS:MINS
OF SERVICE YOU CAN GET:
ADD MONTHLY DOMESTIC HRS:MINS
OF SERVICE YOU CAN GET (from above):
TOTAL HRS:MINS OF SERVICE
YOU CAN GET PER MONTH:
NA 1253L (3/15) IHSS CHANGE
Case No.
PAGE 4 of 5
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