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This version of the form is not currently in use and is provided for reference only. Download this version of
Form SOC873
for the current year.
Form SOC873 In-home Supportive Services (Ihss) Program Health Care Certification Form - California
What Is Form SOC 873?
Form SOC 873, In-Home Supportive Services (IHSS) Program Health Care Certification Form , is a medical certification form filled out by a licensed health care professional to enable disabled, blind, or elderly individuals to receive services from the In-Home Supportive Services (IHSS) program.
Alternate Name:
- IHSS Certification Form.
The California IHSS program aids California residents who are at risk of being placed in out-of-home care such as assisted living, board and care facilities, or skilled nursing facilities. It allows people to remain in their homes by providing care services, including but not limited to meal preparation, laundry, shopping for necessities, cleaning, assistance with respiration and feeding, protective supervisions, and paramedical services. To qualify for these services, Form SOC 873 must be signed by a health care professional and submitted to the IHSS prior to the authorization of services.
The latest version of the form was issued by the California Department of Social Services on October 1, 2016 , with all previous editions obsolete. Form SOC 873 fillable version is available for download below.
In-Home Supportive Services (IHSS) Program Health Care Certification Form
The IHSS certification form must be completed by the local county welfare department, the applicant/recipient, and the licensed health care professional:
- Applicant/Recipient Information. The county welfare department worker must state the applicant/recipient's full name, date of birth, address, county of residence. It is required to submit an IHSS case number. The document must contain the IHSS worker name, phone number, and fax number.
- Authorization to Release Health Care Information. The applicant/recipient must authorize the release of health care information that relates to the physical and/or mental condition. The applicant (recipient/legal guardian/conservator) has to sign and date the form. It is also necessary to obtain the signature of a witness.
- Health Care Information. The licensed health care professional (physician, physical therapist, psychiatrist, etc.) has to indicate if the recipient of services is unable to independently perform activities of daily living and if IHSS services are required to prevent the out-of-home care. The description of any condition or illness that led to the need for assistance must be provided. The health care professional has to state if the individual's condition is expected to last for a year or expected to result in death within a year. It is recommended to outline the nature of the services provided to the individual, the duration, and the frequency of contact. The IHSS worker may ask for additional information to determine the eligibility of the individual.
- Licensed Health Care Professional Certification. The health care professional certifies that all the information provided in the form is true and correct. The form must be signed and dated. Additionally, the health care professional has to submit the full name, the title, the address, the phone number, the fax number, and the professional license number. After that, the document is returned to the IHSS worker whose contact information is stated on the first page of the form.
Download Form SOC873 In-home Supportive Services (Ihss) Program Health Care Certification Form - California
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