Alamedasocialservices.org



|Notice Date: |      |

|Case Name: |      |

|Case Number: |      |

|Social Worker Name: |      |

|Social Worker Number: |      |

|Telephone Number: |      |

|Fax Number: |      |

Addressee:

     

     

     

Home Appointment Notice

We have received a request for In-Home Supportive Services stating that you require assistance to remain safely in your home. In order to determine your eligibility for In-Home Supportive Services, a home visit is required in order to assess your needs.

In order to continue to receive In-Home Supportive Services, an annual home visit is required to reassess your needs.

Attached is a Health Care Certification Form which must be completed by your Licensed Health Care Practitioner.

|Your home visit has been scheduled for : |Day:       | |

| |Date:       | |

| |Time:       |AM PM |

Please contact the Social Worker immediately at the phone number listed above if you have a new address or need to reschedule the visit.

Important Notes:

• Please have all of your current medications and the names, addresses, & phone/fax numbers of all the doctors you have seen in the past 12 months available.

• If you do not speak English and you do not have anybody to assist you with translation, please contact the Social Worker immediately to arrange for an interpreter.

• If you have pets, please put them in another room during this visit.

• If you have locked gates or screen doors, please unlock them so the Social Worker can knock at your door upon arrival.

• If you fail to complete the home visit, your In-Home Supportive Services application may be denied or if you are currently receiving In-Home Supportive Services, your case may be discontinued.

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