Form Soc 876 - In-Home Supportive Services (Ihss) Program Notice Of Provisional Approval Health Care Certification Exception Granted

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE OF PROVISIONAL APPROVAL
HEALTH CARE CERTIFICATION EXCEPTION GRANTED
TO:
County of:
Notice Date:
Case Number:
IHSS Office Address:
IHSS Office Telephone:
The county has provisionally approved your application for In -Home Supportive Services (IHSS).
Here’s what that means:
State law requires that before you can get IHSS, you have to provide the county with a health care
certification, or alternative documentation, completed and signed by a licensed health care
professional, and you have to have an assessment of your needs completed in your own home.
The county has granted an exception so that you can get IHSS on a temporary basis before you
meet these requirements, but you still have to provide the county with the health care certification,
or alternative documentation, (if you have not already provided it) . You will temporarily get the
services/hours shown below once you return to your own home . These services/hours are based
on a preliminary assessment of your needs done while you were in a medical facility.
When you provide the county with the health care certification, or alternative documentation, the
county will determine your eligibility to continue getting IHSS . If you are determined eligible, the
county will do an in-home assessment to complete the determination of your services/hours.
The county asked you to provide the health care certification , or alternative documentation, by
________________.
DATE
SOC 876 (5/17)
PAGE 1 OF 4

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