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?*

YesNo
If no, please complete the following.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Your Relationship to Applicant*
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?*

YesNo
Applicant Information
Name*

First NameLast Name
Do you have a Social Security Number?*

YesNo
Social Security Number*
Do you have an ITIN?*

YesNo
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
Sex

MaleFemale
Is the application for a minor foster child?*

YesNo
Is the mailing address same as above?*

YesNo
If no, please enter the mailing address.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sexual Orientation and Gender Identity (Optional)
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?

MaleFemale
Veteran Information
Are you a Veteran?

YesNo
Please give Veteran name
Claim Number
Are you the spouse/child of a Veteran?

YesNo
Please give Veteran name
Claim Number
SSI/SSP Information
Verification of Medi-Cal eligibility is required before applying for IHSS services.
Are you currently receiving Medi-Cal?*

YesNo
If not, have you applied for Medi-Cal?*

YesNo

Do you receive SSI/SSP benefits?

YesNo
Supplemental Application Questions
Check your type of living arrangement*

Independent LivingAny Licensed FacilityHome of AnotherShared Living with Spouse or OthersOther
Individuals living in a licensed facility may not be eligible to receive IHSS benefits/resources
Please check or describe your need for IHSS Services

Domestic Services - Household cleaning, meal preparation, laundry, shopping for food.Personal Care - Bathing, bowel and bladder care, dressing, feeding, grooming, menstrual care, and othersTransportation - Medical appointments and health related servicesParamedical CareOther
Describe other need for IHSS Services
Do you have a condition preventing you from completing any activities of daily living (ADLs)?*

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

YesNo
Please describe your condition/diagnosis *
Name of Primary Care Physician*
Are you a Kaiser member?*

YesNo
Enter Kaiser number here*
Past IHSS Information
Have you received In-Home Support Services (IHSS) in the past?*

YesNo
Date when service was last received

MonthDayYear
Total Monthly Hours:
County where service was last received
Name Used
Household Information
List Family Members in Household:
Marital Status*

Married/SpouseSingle
Ethnic and Language Information
A. My Ethnic Origin is
B1. What language do you prefer to read?
B2. What language do you prefer to speak?
Communication Accommodations
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*

YesNo
Applicant is Visually Impaired*

YesNo
Affirmation
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*
Should be Empty:

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

Affirmation