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  • Live Long Live Well Marin County Aging and Adult Services

  • 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.

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  • Kaiser release of information will need to be faxed to 415-473-3960
  • Does the applicant agree to apply for IHSS services?*

  • Applicant Information

  • Do you have a Social Security Number?*
  • Do you have an ITIN?*

  • 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*
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  • Sex
  • Is the application for a minor foster child?*
  • Is the mailing address same as above?*

  • 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 sex was listed on your original birth certificate?

  • Veteran Information

  • Are you a Veteran?
  • Are you the spouse/child of a Veteran?

  • SSI/SSP Information

  • 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?

  • Supplemental Application Questions

  • Check your type of living arrangement*

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

  • Please check or describe your 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?*
  • Are you a Kaiser member?*

  • Past IHSS Information

  • Have you received In-Home Support Services (IHSS) in the past?*
  • Date when service was last received
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  • Household Information

  • Marital Status*

  • Ethnic and Language Information

  • 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*
  • Applicant is Visually Impaired*

  • 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.

  • Should be Empty: