Form Soc 876 - In-Home Supportive Services (Ihss) Program Notice Of Provisional Approval Health Care Certification Exception Granted Page 2

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
If you do not provide the county with a health care certification , or alternative documentation, by
this date, the IHSS you have been getting on a temporary basis will stop. If you cannot provide
the health care certification, or alternative documentation, by this date, contact your social worker
before the due date to explain why and ask if the county can grant you more time.
If you have questions about the information in this notice, call your social worker .
TOTAL
ADJUSTMENTS
AMOUNT OF
SERVICES
AUTHORIZED
AMOUNT OF
FOR OTHERS
THE SERVICE
YOU
AMOUNT OF
THE
WHO SHARE THE
YOU NEED
REFUSED OR
SERVICE YOU
SERVICES
SERVICE
HOME
GET FROM
CAN GET
NEEDED
OTHERS
HRS:MINS
(PRORATION)
HRS:MINS
HRS:MINS
DOMESTIC SERVICES
(per MONTH)
RELATED SERVICES (per WEEK)
Prepare Meals
Meal Clean-up
Routine Laundry
Shopping for Food
Other
Shopping/Errands
NON-MEDICAL PERSONAL SERVICES (per WEEK)
Respiration Assistance
(Help with Breathing)
Bowel, Bladder Care
Feeding
Routine Bed Baths
Dressing
SOC 876 (5/17)
PAGE 2 OF 4

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