SOC 873 - 10/16 - Health Care Certification Form

Sep 19, 2026

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SOC 873 is a California Department of Social Services In-Home Supportive Services (IHSS) Health Care Certification Form used to support authorization or continuation of IHSS services. It collects applicant and county information, includes an applicant authorization to release health care information, and requires a licensed health care professional to confirm inability to perform daily activities, whether IHSS services are recommended to prevent out-of-home care, and related functional limitations and expected duration.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Applicant/Recipient Information

Authorization to Release Health Care Information

Health Care Information (Licensed Health Care Professional Only)

Daily Living and Instrumental Activities Assessment

IHSS Service Recommendation to Prevent Out-of-Home Care

Functional Limitation Description

Expected Duration (12 Months)

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM HEALTH CARE CERTIFICATION FORM | A. APPLICANT/RECIPIENT INFORMATION (To be completed by the county) | | | --- | --- | | Applicant/Recipient Name: | Date of Birth: | Address: | County of Residence: | IHSS Case \#: | | --- | --- | | IHSS Worker Name: | | | IHSS Worker Phone \#: | IHSS Worker Fax \#: | | B. AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION (To be completed by the applicant/recipient) | | | I, , authorize the release of health care information
(PRINT NAME)
related to my physical and/or mental condition to the In-Home Supportive Services program as it pertains to my need for domestic/related and personal care services.
Signature: Date: / /
(APPLICANT/RECIPIENT OR LEGAL GUARDIAN/CONSERVATOR)
Witness (if the individual signs with an “X”): Date: / / | | | TO: LICENSED HEALTH CARE PROFESSIONAL* –
The above-named individual has applied for or is currently receiving services from the In-Home Supportive Services (IHSS) program. State law requires that in order for IHSS services to be authorized or continued a licensed health care professional must provide a health care certification declaring the individual above is unable to perform some activity of daily living independently and without IHSS the individual would be at risk of placement in out-of-home care. This health care certification form must be completed and returned to the IHSS worker listed above. The IHSS worker will use the information provided to evaluate the individual’s present condition and his/her need for out-of-home care if IHSS services were not provided. The IHSS worker has the responsibility for authorizing services and service hours. The information provided in this form will be considered as one factor of the need for services, and all relevant documentation will be considered in making the IHSS determination.
IHSS is a program intended to enable aged, blind, and disabled individuals who are most at risk of being placed in out-of-home care to remain safely in their own home by providing domestic/related and personal care services. IHSS services include: housekeeping, meal preparation, meal clean-up, routine laundry, shopping for food or other necessities, assistance with respiration, bowel and bladder care, feeding, bed baths, dressing, menstrual care, assistance with ambulation, transfers, bathing and grooming, rubbing skin andrepositioning, care/assistance with prosthesis, accompaniment to medical appointments/alternative resources, yard hazard abatement, heavy cleaning, protective supervision (observing the behavior of a non-self-directing, confused, mentally impaired or mentally ill individual and intervening as appropriate to safeguard recipient against injury, hazard or accident), and paramedical services (activities requiring a judgment based on training given by a licensed health care professional, such as administering medication, puncturing the skin, etc. , which an individual would normally perform for him/herself if he/she did not have functional limitations, and which, due to his/her physical or mental condition, are necessary to maintain his/her health) . The IHSS program provides hands-on and/or verbal assistance (reminding or prompting) for the services listed above. | | | *Licensed Health Care Professional means an individual licensed in California by the appropriate California regulatory agency, acting within the scope of his or her license or certificate as defined in the Business and Professions Code. These include, but are not limited to: physicians, physician assistants, regional center clinicians or clinician supervisors, occupational therapists, physical therapists, psychiatrists, psychologists, optometrists, ophthalmologists and public health nurses. | | SOC 873 (10/16) PAGE 1 OF 2 IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM HEALTH CARE CERTI

FAQs

Who completes the health care information section of the SOC 873 form?

Only a licensed health care professional completes the Health Care Information section.

What does the form require regarding eligibility conditions for IHSS?

Items related to inability to perform daily activities and the recommendation for IHSS services must be completed as conditions of IHSS eligibility.

What duration criterion is used for the individual’s condition or functional limitation?

The licensed professional must indicate whether the condition or limitation is expected to last at least 12 consecutive months or result in death within 12 months.

Sep 19, 2026

Upload by Grenda