The California SOC 295 form is an application for In-Home Supportive Services (IHSS) provided by the California Department of Social Services. This form collects essential personal and household information to determine eligibility for supportive services. Completing the SOC 295 is a crucial step for individuals seeking assistance, so be sure to fill it out by clicking the button below.
The California SOC 295 form is a crucial document for individuals seeking In-Home Supportive Services (IHSS) in the state of California. This application is designed to gather essential personal information, which helps determine eligibility for these vital services. When filling out the form, applicants must provide details such as their name, address, and Social Security number, as this information is necessary for verification and coordination with other public agencies. Additionally, the form includes optional sections where applicants can share their sexual orientation and gender identity, ensuring that the application process is inclusive and respectful of individual identities. Veterans and their families are also given special consideration, with a dedicated section to capture their status. Past experiences with IHSS, household information, and ethnic and language preferences are further explored to tailor services effectively. Importantly, the form accommodates applicants with visual impairments, offering various formats to ensure accessibility. By signing the affirmation at the end, applicants confirm that the information provided is accurate and agree to take on responsibilities related to their IHSS providers. Overall, the SOC 295 form is a comprehensive tool that plays a vital role in connecting individuals with the support they need to live independently and with dignity.
State of California – Health and Human Services Agency
California Department of Social Services
APPLICATION FOR IN-HOME SUPPORTIVE SERVICES
To the Applicant: All sections of this form must be completed. Information provided is subject to verification.
NOTE: Retain your copy of your completed application. Regarding your Social Security Number, it is mandatory that you provide your Social Security Number(s) as required in 42 USC 405, or that you apply for a Social Security Number(s) with the Social Security Administration. This information will be used in eligibility determination and coordinating information with other public agencies.
Date of Application:
Case Number (if known):
Section 1 – Personal Information
Name of Applicant:
Social Security Number:
Street Address:
City:
State:
Zip Code:
Telephone:
Email:
Date of Birth:
Sex: Male
Female
Section 2 – 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?
(check the box that best describes your current gender identity)
Male
Transgender: male to female
Transgender: female to male
Non-Binary (neither male nor female)
Another gender identity
Decline to state
SOC 295 (9/18)
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What sex was listed on your original birth certificate? Female Male
How do you describe your sexual orientation?
Select one answer.
Straight/heterosexual
Another sexual orientation
Gay or lesbian
Unknown
Bisexual
Queer
Section 3 – Veteran Information
Are you a Veteran?
Are you a Spouse/Child of a Veteran?
Yes No
If YES, give Veteran name and Claim Number:
Section 4 – SSI/SSP Information
Do you receive SSI/SSP benefits? Yes
No
If yes, check your type of living arrangement:
Independent Living
Board and Care
Home of Another
Services being requested:
Section 5 – Past IHSS Information
Have you received In-Home Supportive Services (IHSS) in the past? Yes No
If Yes, complete the following.
Date and county where service was last received:
Total Monthly Hours:
Name Used (if different from above):
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Section 6 – Household Information
List Household Members:
Name of Spouse:
Birthdate:
Name of:
Parent
Child
Other Relative
Non-Relative
Section 7 – Ethnic and Language Information
The law requires that information on ethnic origin and primary language be collected.
If you do not complete this section, social service staff will make a determination. The information will not affect your eligibility for service.
A. My Ethnic Origin is:
PLEASE CHOOSE ONE
(See Page 8 for a list of Ethnicities and Codes)
B1. What language do you prefer to read?
B2. What language do you prefer to speak?
(Please choose one from the list of Languages and Codes on Page 8)
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Section 8 – 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.
I am Blind: Yes No
If yes, please choose one of the following for each of the three types of Department of Social Services (DSS) documents listed.
For Notices of Action: No accommodation is needed
Braille Documents
Audio CD
Data CD
County Support
(If County Support, describe requested support)
For IHSS Required forms:
No accommodation is needed
For Timesheets: No accommodation is needed
Telephonic System (4 Digit RAN:
)
Electronic Timesheet System (ETS) (Applicants and providers must first register at https://www.etimesheets.ihss.ca.gov)
I am Visually Impaired: Yes No
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For Notices of Action:
18 point font documents
For IHSS Required forms: No accommodation is needed
Electronic Timesheet System (ETS) (Applicants and providers must first register at
https://www.etimesheets.ihss.ca.gov)
(If County Support, describe requested support, including blind-only services)
Section 9 – 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.
I also understand that as the employer of my IHSS provider(s) I am responsible for:
1.Hiring, training, supervising, scheduling and, when necessary, firing my provider(s).
2.Ensuring the total hours reported by all providers who work for me do not exceed my IHSS authorized hours each month.
3.Referring any individual I want to hire to the County IHSS office to complete the provider eligibility process.
4.Notifying the County IHSS office within 10 days when I hire or fire a provider.
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In addition, I understand and agree to the following terms and limitations regarding payment for services by the IHSS program:
1.In order for any individual to be paid by the IHSS program, they must be approved as an IHSS eligible provider.
2.If I choose to have an individual work for me who has not yet been approved as an eligible IHSS provider, I will be responsible for paying him/her if he/she is not approved.
3.The IHSS program will not pay for any services provided to me until my application for services is approved and then will only pay for those services that are authorized for me to receive by the IHSS Program.
4.I will be responsible for paying for any services I receive that are not included in my IHSS authorization.
5.I will be responsible for paying my Share-of-Cost (SOC) and informing my individual provider(s) of that SOC.
I also understand and agree to cooperate with the following as a part of my eligibility for IHSS:
To promote program integrity and quality assurance, I may be subject to (un)announced visits to my home and that I or my provider(s) may receive letters identifying program requirement concerns from the State Department of Health Care Services (DHCS), California Department of Social Services (CDSS) and/or the County in which I receive services.
The purpose of the visits and letters is to ensure that program requirements are being followed and that the authorized services are necessary for you to remain safely in your home. The visit will also verify that the authorized services are being provided, that the quality of those services is acceptable, and that your well-being is protected.
If it is found that IHSS services are not required or not being properly provided, you and/or your provider may be subject to a Medi-Cal fraud investigation. If fraud is substantiated, you and/or your provider will be prosecuted for Medi-Cal fraud.
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Section 10 – Signature(s)
Signature of Applicant:
Date:
Signature of Applicant’s Representative (only if applicable): Date:
Representative’s Relationship to Applicant (only if applicable):
Representative’s Telephone Number (only if applicable):
Representative’s Address (only if applicable):
To report suspected fraud or abuse in the provision or receipt of IHSS services, please call the fraud hotline at 1-800-822-6222, email at stopmedicalfraud@dhcs.ca.gov, or go to http://www.dhcs.ca.gov/individuals/Pages/StopMedi-CalFraud.aspx.
FOR AGENCY USE ONLY
Income Eligible:
Status Eligible:
Medi-Cal Aid Code:
MAGI Eligible Recipient:
Verification:
Disabled 12 months or longer
At risk without IHSS
Notes:
Signature of Social Worker or Agency Representative:
Telephone Number:
Page 7 of 8
Ethnic Codes:
Language Codes:
A. White.
1.
American Sign Language
B. Hispanic.
(AMISLAN or ASL).
C. Black.
2.
Spanish - NOA will be issued
D. Other Asian or Pacific Islander.
in Spanish.
E. American Indian or Alaskan Native.
3.
Cantonese.
F. Filipino.
4.
Japanese.
G. Chinese.
5.
Korean.
H. Cambodian.
6.
Tagalog.
I. Japanese.
7.
Other non-English.
J. Korean.
8.
English.
K. Samoan.
9.
L. Asian Indian.
in English.
M. Hawaiian.
10. Other Sign Language.
N. Guamanian.
11.
Mandarin.
O. Laotian.
12. Other Chinese Languages.
P. Vietnamese.
13. Cambodian.
Q. Other.
14. Armenian.
R. Mixed Ethnicity.
15. Ilacano.
16. Mien.
17. Hmong.
18. Lao.
19. Turkish.
20. Hebrew.
21. French.
22. Polish.
23. Russian.
24. Portuguese.
25. Italian.
26. Arabic.
27. Samoan.
28. Thai.
29. Farsi.
30. Vietnamese.
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Completing the California SOC 295 form is an essential step for individuals seeking In-Home Supportive Services. Each section of the form must be filled out accurately to ensure proper processing of your application. After you complete the form, it is important to retain a copy for your records. This document will help in determining your eligibility and coordinating with other agencies.
What is the purpose of the California SOC 295 form?
The California SOC 295 form is an application for In-Home Supportive Services (IHSS). It helps individuals who need assistance with daily activities due to age, disability, or illness to receive necessary support at home. Completing this form is the first step in determining eligibility for these services.
Who needs to fill out the SOC 295 form?
Anyone seeking In-Home Supportive Services must fill out the SOC 295 form. This includes individuals who require assistance with personal care, household tasks, or other daily living activities. If you are applying on behalf of someone else, you should ensure that their information is accurately represented on the form.
Is it mandatory to provide my Social Security Number on the form?
Yes, providing your Social Security Number is mandatory as required by federal law. This information helps in verifying your identity and determining your eligibility for services. If you do not have a Social Security Number, you must apply for one with the Social Security Administration.
What if I do not want to disclose my sexual orientation or gender identity?
Sections regarding sexual orientation and gender identity on the SOC 295 form are optional. You can choose not to disclose this information, and it will not affect your eligibility for services. Your privacy is respected, and this information is kept confidential.
How do I know if I am eligible for IHSS?
Eligibility for IHSS is determined based on several factors, including your need for assistance with daily activities and your income level. The completed SOC 295 form will be reviewed by social services staff who will assess your situation to determine eligibility.
What should I do if I have received IHSS before?
If you have received IHSS in the past, you should indicate this on the SOC 295 form. You will need to provide details such as the date and county where you last received services, as well as the total monthly hours you were authorized. This information helps in processing your current application.
Can I get assistance filling out the SOC 295 form?
Yes, assistance is available for completing the SOC 295 form. You can reach out to local social services offices or community organizations that provide support for applicants. They can guide you through the process and ensure that your application is filled out correctly.
What happens after I submit the SOC 295 form?
After submitting the SOC 295 form, it will be reviewed by social services staff. They will verify the information provided and determine your eligibility for IHSS. You will be notified of the decision, and if approved, you will receive further instructions on how to access the services you need.
Filling out the California SOC 295 form can be a straightforward process, but several common mistakes can hinder the application. One frequent error occurs in the Personal Information section. Applicants often forget to include their Social Security Number, which is mandatory. This omission can delay the processing of the application or even result in its rejection. It is essential to double-check that this crucial information is accurately provided.
Another common mistake involves the Sexual Orientation and Gender Identity section. Some applicants may leave this section blank, thinking it is optional and not relevant. While it is true that this information is confidential and does not affect eligibility, failing to complete it can lead to unnecessary follow-up questions. Therefore, it is advisable to fill out this section as completely as possible, even if the answers are “Decline to state.”
In the Veteran Information section, applicants sometimes misidentify their status. It is important to clearly indicate whether you are a veteran or the spouse/child of a veteran. Misunderstanding this distinction can lead to complications in determining eligibility for certain benefits. If unsure, it is wise to consult with someone knowledgeable about veteran benefits before submitting the form.
The SSI/SSP Information section is another area where mistakes frequently occur. Applicants may incorrectly check “No” when they actually receive SSI/SSP benefits. This error can significantly impact the eligibility determination process. Therefore, it is vital to review your benefits status carefully before making a selection in this section.
When providing Household Information, some individuals fail to list all household members or neglect to include their Social Security Numbers. This omission can lead to misunderstandings regarding household composition, which is crucial for eligibility assessments. Ensure that all relevant members are included and that their information is complete to avoid delays.
In the Ethnic and Language Information section, applicants may overlook the requirement to select their ethnic origin and preferred languages. Although social service staff can make determinations if this section is left blank, providing this information can expedite the process and ensure that applicants receive services in their preferred language. Therefore, it is beneficial to take the time to complete this section accurately.
Lastly, in the Communication Accommodations section, applicants sometimes fail to indicate their needs for alternative formats. If you are blind or visually impaired, specifying your preferred format for receiving information is essential. Neglecting to do so can result in difficulties accessing important documents. It is crucial to communicate these needs clearly to ensure proper accommodations are made.
The California SOC 295 form is essential for individuals applying for In-Home Supportive Services (IHSS). Alongside this form, several other documents may be required to complete the application process. Below is a list of related forms and documents that are often used in conjunction with the SOC 295.
These forms and documents support the application process for IHSS and help ensure that applicants receive the services they need. It is important to complete each required form accurately to avoid delays in service delivery.
The California SOC 295 form, used for applying for In-Home Supportive Services (IHSS), shares similarities with several other important documents. Understanding these similarities can help applicants navigate the process more effectively. Here are four documents that bear resemblance to the SOC 295 form:
When filling out the California SOC 295 form, it is important to follow certain guidelines to ensure that your application is processed smoothly. Here are some key dos and don’ts:
Understanding the California SOC 295 form is crucial for applicants seeking In-Home Supportive Services (IHSS). However, several misconceptions can lead to confusion. Here are four common misunderstandings:
This is incorrect. All sections of the SOC 295 form must be completed to process the application. Incomplete forms can delay or deny services.
In fact, providing a Social Security Number is mandatory as per federal law. This information is essential for eligibility determination and coordination with other agencies.
This is a misunderstanding. Responses to these sections are optional and confidential, and they do not impact eligibility for IHSS.
On the contrary, previous IHSS service history is important. Applicants must disclose any past services to provide context for their current needs.
Filling out the California SOC 295 form is a crucial step in applying for In-Home Supportive Services (IHSS). Here are some key takeaways to keep in mind:
Remember to keep a copy of your completed application for your records. This can be helpful for future reference and follow-up.