IHSS Portal - Apply

Language of Submission

Attention: IHSS is a Medi-Cal funded program benefit. Verification of Medi-Cal eligibility is required before IHSS services can be authorized. Please understand that submission of this IHSS inquiry form will not guarantee eligibility or authorization of IHSS benefits.

Are you applying to receive caregiver services for yourself?

If no, please complete the following.

Name

First NameLast Name

Phone Number

Area CodePhone Number

Your Relationship to Applicant

Please Enter Community Agency

Please enter Health Plan Provider

Enter Kaiser Number Here

Kaiser release of information will need to be faxed to 415-473-3960

Other Health Plan Provider

Does the applicant agree to apply for IHSS services?

Name

First NameLast Name

Do you have a Social Security Number?

Social Security Number

Do you have an ITIN?

ITIN Number

If the applicant needs an ITIN and does not have one please visit the following site to apply: How to apply for an ITIN.

Birthdate

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Does this email belong to the applicant?

Provide the name of the person this email belongs to here:

First NameLast Name

Sex

Is the application for a minor foster child?

Is the mailing address same as above?

If no, please enter the mailing address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Providing responses in the sections below is optional and confidential. Any information you provide in this section will not be used in your eligibility determination.

What is your gender identity?

How do you describe your sexual orientation?

What sex was listed on your original birth certificate?

Are you a Veteran?

Please give Veteran name

Claim Number

Are you the spouse/child of a Veteran?

Please give Veteran name

Claim Number

Verification of Medi-Cal eligibility is required before applying for IHSS services.

Are you currently receiving Medi-Cal?

If not, have you applied for Medi-Cal?

You must submit your Medi-Cal application before IHSS services can be put in place. Medi-Cal application information can be found at https://www.c4yourself.com/c4yourself/index.jsp

Do you receive SSI/SSP benefits?

Check your type of living arrangement

Please provide the name and address of the facility or home where you live

Individuals living in a facility may not be eligible to receive IHSS benefits/resources.

Please check or describe your need for IHSS Services

Describe other need for IHSS Services

Do you have a condition preventing you from completing any activities of daily living (ADLs)?

If yes, is this a condition expected to last 12 months or longer?

Please describe your condition/diagnosis

Name of Primary Care Physician

Are you a Kaiser member?

Enter Kaiser number here

Have you received In-Home Support Services (IHSS) in the past?

Date when service was last received

MonthDayYear

Total Monthly Hours:

County where service was last received

Name Used

List Family Members in Household:

Marital Status

A. My Ethnic Origin is

B1. What language do you prefer to read?

B2. What language do you prefer to speak?

To accommodate blind or visually-impaired applicants, IHSS information is available in the following alternative formats. Please indicate which format you would prefer, if applicable. Providing information in this section will not affect your eligibility for services.

Applicant is Blind

Applicant is Visually Impaired

You must submit a complete Health Care Certification (SOC 873) within 45 days of today’s date, or your application will be denied. An email with instructions for how the Health Care Certification is to be completed will be sent to the email address you provided above. If you don’t receive an email within 5 minutes of submission, please check your spam folder – and if still not received, please call us at 415-473-4636 and request the form SOC 873. If you didn’t provide an email and don’t receive instructions via regular mail within 10 business days, please call us at 415-473-4636 and request the form SOC 873 packet.

I affirm that the above information is true to the best of my knowledge and belief. I agree to cooperate fully if verification of the above statements is required in the future.

Please verify that you are human

Applicant Information

Sexual Orientation and Gender Identity (Optional)

Veteran Information

SSI/SSP Information

Supplemental Application Questions

Past IHSS Information

Household Information

Ethnic and Language Information

Communication Accommodations

Health Care Certification Required

Affirmation