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IHSS SOC 873: California Health Care Certification

California counties need this certification before they can authorize or continue In-Home Supportive Services (IHSS) hours. A licensed health care professional states whether the person cannot perform one or more activities of daily living on their own and whether IHSS services are recommended to prevent out-of-home care. The county IHSS worker weighs it as one factor, alongside other documentation, when deciding eligibility and service hours.

Who completes it

The county fills in Section A and the applicant or recipient signs the release in Section B. A California-licensed health care professional acting within scope, such as a physician, physician assistant, psychologist, occupational or physical therapist, optometrist or public health nurse, completes Sections C and D.

How to fill it in

A. Applicant/Recipient Information (to be completed by the county)

The county enters the applicant or recipient's name, date of birth, address, county of residence and IHSS case number, plus the IHSS worker's name, phone and fax. Check this block before you start: the worker listed here is where the finished form goes, and pages 2 and 3 repeat the name and case number so loose pages can be matched.

B. Authorization to Release Health Care Information (to be completed by the applicant/recipient)

The applicant or recipient, or a legal guardian or conservator, prints their name, signs and dates the release. It authorizes sharing health information about their physical or mental condition with IHSS as it relates to their need for domestic, related and personal care services. If the person signs with an X, a witness signs and dates too.

C. Health Care Information: Questions 1 and 2

Answer Yes or No. Question 1 asks whether the person cannot independently perform one or more activities of daily living, such as eating, bathing, dressing, using the toilet or walking, or instrumental activities such as housekeeping, preparing meals or shopping for food. Question 2 asks whether, in your opinion, one or more IHSS services is recommended to prevent the need for out-of-home care. Page 1 lists those services, from meal preparation and bowel and bladder care to protective supervision and paramedical services.

C. Health Care Information: Questions 3 and 4

Complete these only if both Questions 1 and 2 are Yes. In Question 3, describe the physical or mental condition or functional limitation that has caused or contributed to the person's need for IHSS. Question 4 asks whether the condition or limitation is expected to last at least 12 consecutive months or to result in death within 12 months. If either earlier answer was No, skip both and go on.

C. Health Care Information: Items 5 to 8

These items are not eligibility conditions, but the form asks you to complete them as far as you can. Describe the services you provide to the person (medical treatment, nursing care, discharge planning), how long you have provided them, how often you see the person (monthly, yearly) and the date you last provided services. The IHSS worker uses them to judge how well you know the person's current condition.

D. Licensed Health Care Professional Certification

Print your name, title, address, phone and fax, then sign and date. Enter your professional license number and the licensing authority. By signing, you certify that you are licensed in California and that the information on the form is correct. Return the form to the IHSS worker listed on page 1.

Common mistakes

  • Leaving Question 1 or 2 unanswered; both are a condition of IHSS eligibility, and Questions 3 and 4 become required when both answers are Yes.
  • Stopping after a No answer instead of completing the remaining items and signing the Section D certification, as the form instructs.
  • Omitting the professional license number or licensing authority in Section D, which identifies you as a California-licensed health care professional.
  • Signing with only an out-of-state license; the form defines a licensed health care professional as one licensed by a California regulatory agency.
  • Missing the 45-day due date without the patient first asking the social worker for more time, which can lead to denial or a stop in services.

Submitting and payment

How to submit it
Return the form to the IHSS worker named in Section A, using the fax number or address printed there. The county must have it within 45 days of the request (45 days after a reassessment for current recipients), or the application is denied or services may stop.
Who pays
The SOC 873 and the county notices sent with it list no fee or billing code for completing the certification.

Good to know

  • Questions 1 and 2 are a condition of IHSS eligibility. If either answer is No, skip Questions 3 and 4 but still complete the rest of the form and Section D.
  • Counties may accept alternative documentation, such as hospital discharge papers, if it shows the daily-living limitation, describes the condition causing it, and was signed by a licensed health care professional within the last 60 days.
  • For a patient leaving a hospital or nursing facility, the county may grant provisional IHSS (notice SOC 876) before the certification arrives, but it is still due within the 45-day window.
  • The county sends the blank form with notice SOC 874 to new applicants or SOC 875 to current recipients. CDSS also posts a large-print version, SOC 873L, and a Spanish version.

Get the official form

Download the current version from the source each time; forms change without notice.

In-Home Supportive Services (IHSS) Program Health Care Certification Form

Programa de Servicios de Apoyo en el Hogar (IHSS) Formulario de Certificacion sobre el Cuidado de la Salud

Official pagePDFVersión en español

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can sign the IHSS SOC 873?

Any individual licensed by the appropriate California regulatory agency and acting within the scope of that license. The form lists physicians, physician assistants, regional center clinicians or clinician supervisors, occupational therapists, physical therapists, psychiatrists, psychologists, optometrists, ophthalmologists and public health nurses, and says the list is not exhaustive. Section D asks for the professional license number and licensing authority.

How long does my patient have to return the SOC 873?

The county must receive the completed form or alternative documentation within 45 days of the date the IHSS worker requested it; for current recipients the clock runs from the reassessment. If it cannot be returned in time, the patient should call the social worker before the due date and ask for more time. Without it, the application is denied or services may stop.

Does the SOC 873 decide how many IHSS hours my patient gets?

No. The IHSS worker is responsible for authorizing services and service hours. The certification is one factor in the need for services, and the county considers all relevant documentation, including its own assessment of the person's needs. The worker may contact you for more information or to clarify your answers.

Is the SOC 873 available in Spanish or large print?

Yes. CDSS posts a Spanish version of the Health Care Certification Form and a large-print version, SOC 873L. Other threshold-language translations are on CDSS's translated forms pages. All versions go back to the same county IHSS worker, and the clinician sections ask the same questions as the English form.