Form Soc 849 - Notice Of Incomplete Provider - Enrollment Form

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
COUNTY OF
NOTICE OF INCOMPLETE PROVIDER
ENROLLMENT FORM
(ADDRESSEE)
Notice Date:
Provider Name:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Provider Applicant
The County reviewed the Provider Enrollment Form (SOC 426) you submitted and has found that the
information you provided is incomplete. We are not able to determine if you are eligible to be enrolled
as an IHSS provider because you did not provide all of the necessary information. You must submit all
of the information indicated below within 15 business days of the date of this letter.
Response to Item Number(s) ____________ on the SOC 426
Copy of notice of reinstatement as a provider in the Medicare, Medicaid and/or Medi-Cal
programs
Copy of written confirmation from the licensing authority that your professional privileges have
been restored
Copy of the licensing authority’s decision(s), including terms and conditions, regarding
disciplinary action(s) taken
Other: _______________________________________________________
If you do not provide all of the requested information within 15 business days, you will not be eligible to
be enrolled as an IHSS provider or to receive payment from the IHSS program for providing services.
If you have any questions about this letter, call _________________________________________ .
SOC 849 (10/09)

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