Form Soc 851 - Notice To Applicant Provider Of Provider Ineligibility - Incomplete Provider Process

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO APPLICANT PROVIDER OF PROVIDER INELIGIBILITY
INCOMPLETE PROVIDER PROCESS
(ADDRESSEE)
COUNTY OF:
Notice Date:
Applicant Provider Name:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Applicant Provider
The county/public authority/non-profit consortium has determined that you are not
eligible to be enrolled as an IHSS provider or to receive payment from the IHSS
program for providing services. You are not eligible because you did not complete one
or more of the required steps of the IHSS provider enrollment process within 90 days
of the start of the enrollment process. You did not complete the step(s) marked below:
You did not complete, sign or return the IHSS Provider Enrollment Form
(SOC 426).
You did not attend an IHSS Provider Orientation session.
You did not sign the IHSS Provider Enrollment Agreement (SOC 846).
You did not submit fingerprints for a California Department of Justice criminal
background check.
If you believe you have completed all of the steps necessary to be eligible as an IHSS
provider or believe you have “good cause” as to why you have not completed all of the
required steps within the 90-day timeframe, you may call the IHSS office at the telephone
number listed at the top of this document to ensure that you receive proper credit for
completing all of the necessary steps or may be given extra time to complete the
enrollment process.
SOC 851 (5/16)

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