Grpg 90-250 Appendix G Form 11-28 Hhsa printable pdf download

Grpg 90-250 Appendix G Form 11-28 Hhsa

90-250 APPENDIX G. FORM 11-28 HHSA

COUNTY OF SAN DIEGO

Notice Date

Case Name

Case Number

Worker Name

Worker Number

Telephone

Worker Hours

Address

All General Relief recipients who are not able to work must provide medical evidence.

Your General Relief case, under the Employable with Limitations, Incapacitated, or Interim Assistance Programs,

may be discontinued unless you provide a new doctor’s statement by ________________.

If you are still not able to work and go to a private provider, you must complete the enclosed medical form(s) and

contact your provider for an appointment to have the form(s) completed. The County will not pay for this

appointment. A CMS provider will not complete it. The completed form(s) must be returned to your by ________.

If you want the County to schedule an appointment for you at no cost to you, you must contact your worker by

__________.

If you are now employable and wish to continue receiving General Relief, contact your worker immediately to set

an appointment to convert your case to the General Relief Employable Program.

If you have any questions, call your worker at the number listed above.

11-28 DSS (4/96) Notice of Required Medical Verification

Grpg 90-250 Appendix G Form 11-28 Hhsa