Form Na 1250 - Notice Of Action - In-Home Supportive Services (Ihss) Approval
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1STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
NOTICE OF ACTION
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
Notice Date :
APPROVAL
Case Name :
Case Number :
NOTE: This notice relates ONLY to your In-Home Supportive
Social Worker Name :
Social Worker Number :
Services. It does NOT affect your receipt of SSI/SSP, Social
Social Worker Telephone :
Security, or Medi-Cal. KEEP THIS NOTICE WITH YOUR
Social Worker Address :
IMPORTANT PAPERS.
(ADDRESSEE)
Total Hours:Minutes of IHSS you can get each month: _________________.
Based on an assessment done on ____________________, you can get the services shown below for the amount of time shown in the
MMDDYYYY
column "Authorized Amount of Service You Can Get.”
1)
If there is a zero in the "Authorized Amount of Service You Can Get" column or the amount is less than the "Total Amount of Service
Needed" column, the reason is explained on the next page(s).
2)
"Not Needed" means that your social worker found that you do not require assistance with this task. (MPP 30-756.11)
3)
"Pending" means the county is waiting for more information to see if you need that service. See the next page(s) for more information.
TOTAL
ADJUSTMENT
AUTHORIZED
SERVICES
AMOUNT OF
FOR OTHERS
AMOUNT OF
SERVICES
AMOUNT OF
YOU REFUSED
SERVICE
WHO SHARE
SERVICE YOU
SERVICE
OR YOU GET
NEEDED
THE HOME
NEED
YOU CAN GET
FROM
Note:
See the back of the next page for a short
OTHERS
description of each service.
HOURS: MINUTES
(PRORATION)
HOURS: MINUTES
HOURS: MINUTES
DOMESTIC SERVICES (per MONTH):
RELATED SERVICES (per WEEK):
Prepare Meals
Meal Clean-up
Routine Laundry
Shopping for Food
Other Shopping/Errands
NON-MEDICAL PERSONAL SERVICES (per WEEK):
Respiration Assistance (Help with Breathing)
Bowel, Bladder Care
Feeding
Routine Bed Bath
Dressing
Menstrual Care
Ambulation (Help with Walking, including
Getting In/Out of Vehicles)
Transferring (Help Moving In/Out of Bed,
On/Off Seats, etc.)
Bathing, Oral Hygiene, Grooming
Rubbing Skin, Repositioning
Help with Prosthesis (Artificial Limb, Visual/
Hearing Aid) and/or Setting up Medications
ACCOMPANIMENT (per WEEK):
To/From Medical Appointments
To/From Places You Get Services in Place of
IHSS
PROTECTIVE SUPERVISION (per WEEK):
PARAMEDICAL SERVICES (per WEEK):
TOTAL WEEKLY HOURS:MINUTES OF SERVICE YOU CAN GET:
x
4.33
=
MULTIPLY BY 4.33 (average # of weeks per month) TO CONVERT TO MONTHLY HOURS:MINUTES:
SUBTOTAL MONTHLY HOURS:MINUTES OF SERVICE YOU CAN GET:
ADD MONTHLY DOMESTIC HOURS:MINUTES OF SERVICE YOU CAN GET (from above):
TOTAL HOURS:MINUTES OF SERVICE YOU CAN GET PER MONTH:
TIME LIMITED SERVICES (per MONTH):
Heavy Cleaning:
Yard Hazard Abatement
Remove Ice, Snow
Teaching and Demonstration
TOTAL HOURS:MINUTES OF TIME LIMITED SERVICES YOU CAN GET PER MONTH:
Questions?: Please contact your IHSS social worker. See top of page for phone number.
State Hearing: If you think this action is wrong, you can ask for a hearing. The back of this page tells
how.
NA 1250 (11/12) - IHSS APPROVAL
Page 1 of ____
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