Form Soc 828 - Conlan Ii County Verification

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CONLAN II COUNTY VERIFICATION
1. DATE:
2. COUNTY NAME OR COUNTY CODE NUMBER:
3. RECIPIENT’S NAME:
4. CLIENT INDEX NUMBER:
5. STAFF NAME:
6. SIGNATURE:
7. TELEPHONE NUMBER:
INSTRUCTIONS FOR COMPLETING THE CONLAN II COUNTY VERIFICATION
Each county office shall utilize the SOC 828, County Verification Form, in the absence of a NA-690 IHSS Notice of Action
(NOA), to verify the In-Home Supportive Services (IHSS) recipient's medical necessity. The completed original should be
provided to the recipient to be included with their claim package. The county should maintain a copy for their records.
1. Date: Required Field. Enter the date the County Verification is completed.
2. County Name or County Code Number: Required Field. Enter the county name or the county code number of
the county completing the County Verification.
3. Recipient’s Name: Required Field. Enter the name of the IHSS recipient/client.
4. Client Index Number (CIN): Required Field. Enter the CIN number for the IHSS recipient. The CIN is located on
the Recipient Eligibility (REL) Screen in the Case Management, Information and Payrolling System (CMIPS).
5. Staff Name: Required Field. Enter the name of the staff completing the County Verification.
6. Staff Signature: Required Field. Enter the name of the staff signing the County Verification once printed.
7. Telephone Number: Required Field. Enter the telephone number of the staff completing the County Verification.
The county is unable to find the NOA for the above named recipient.
SOC 828 (1/07)

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