Form Soc 312 - In-Home Supportive Services - Special Pre-Authorized Transactions

Download a blank fillable Form Soc 312 - In-Home Supportive Services - Special Pre-Authorized Transactions in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Soc 312 - In-Home Supportive Services - Special Pre-Authorized Transactions with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN–HOME SUPPORTIVE SERVICES
SPECIAL PRE-AUTHORIZED
TRANSACTIONS
1.
NUMBER
2.
NUMBER
RECIPIENT
PROVIDER
COUNTY
CASE NUMBER
CHECK
DIGIT
SUPPLEMENT/
3.
TYPE
4.
REASON
5.
NOA
REASON
CODES
1 -
EMERGENCY
M
C
N
6.
FROM DATE
7.
TO DATE
8.
GROSS
9.
HOURS
10. RATE
11. SHARE/COST
M
M
D
D
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
12. TYPE
13. REASON
2 -
REPLACEMENT
14. WARRANT#
15. WARRANT DATE
16. NET AMOUNT
M
M
D
D
Y
Y
Y
Y
17. TYPE
18. REASON
3 -
VOID WARRANT
19. WARRANT#
20. WARRANT DATE
21. NET AMOUNT
M
M
D
D
Y
Y
Y
Y
22. TYPE
23. REASON
24. FROM DATE
25. TO DATE
M
M
D
D
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
4 -
ADJUSTMENT
26. WARRANT#
27. PAY PERIOD
28. GROSS AMOUNT
29. F.I.C.A.
30. MED
M
M
D
D
Y
Y
Y
Y
31. SDI
32. FED
33. STATE
34. EIC
35. SOC
36. NET
37. HOURS
38. NUMBER
40. NAME
39.
AUTHORIZED
FORCE
PAYEE
BY
ACCEPT?
COUNTY VALIDATION
41. AUTHORIZATION
42. DATE
43. REMARKS
44. VALIDATION
45. DATE
46. REMARKS
SOC 312 (5/00)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Soc 449 - In-home Supportive Services Program - Public Authority/non-profit Consortium Rate Form Soc 449 - In-home Supportive Services Program - Public Authority/non-profit Consortium Rate Legal
Form Soc 330 - In-home Supportive Services - Overpayment Collection Transaction Form Soc 330 - In-home Supportive Services - Overpayment Collection Transaction Legal
Form Soc 2271 - In-home Supportive Services (ihss) Program Provider Notification Of Recipient Authorized Hours And Services And Maximum Weekly Hours Form Soc 2271 - In-home Supportive Services (ihss) Program Provider Notification Of Recipient Authorized Hours And Services And Maximum Weekly Hours Legal
Form Soc 2301 - In-home Supportive Services (ihss) Or Waiver Personal Care Services (wpcs) Recipient Confirmation Of Enrollment In Electronic Timesheet Service Or Telephone Timesheet System Form Soc 2301 - In-home Supportive Services (ihss) Or Waiver Personal Care Services (wpcs) Recipient Confirmation Of Enrollment In Electronic Timesheet Service Or Telephone Timesheet System Legal
Form Soc 885 - In-home Supportive Services (ihss) Program Notice Of Denial Of Request For In-home Reassessment Based On State Law Change Form Soc 885 - In-home Supportive Services (ihss) Program Notice Of Denial Of Request For In-home Reassessment Based On State Law Change Legal
Form Soc 2320 - In-home Supportive Services (ihss) And Waiver Personal Care Services (wpcs) Cdss Violation Removal Request Form Soc 2320 - In-home Supportive Services (ihss) And Waiver Personal Care Services (wpcs) Cdss Violation Removal Request Legal
Form Soc 811 - In-home Supportive Services (ihss) - Sponsor To Alien Deeming Worksheet Form Soc 811 - In-home Supportive Services (ihss) - Sponsor To Alien Deeming Worksheet Legal
Form Soc 426 - In-home Supportive Services (ihss) Program - Provider Enrollment Form Form Soc 426 - In-home Supportive Services (ihss) Program - Provider Enrollment Form Legal
Form Soc 317 - In-home Supportive Services - Batch Cover Sheet Form Soc 317 - In-home Supportive Services - Batch Cover Sheet Legal
Form Soc 2289 - In-home Supportive Services Program State Administrative Review Request Response Letter To Recipient Rescinding Provider's Third Or Fourth Violation For Exceeding Workweek And/or Travel Time Limits Form Soc 2289 - In-home Supportive Services Program State Administrative Review Request Response Letter To Recipient Rescinding Provider's Third Or Fourth Violation For Exceeding Workweek And/or Travel Time Limits Legal

Related Categories

Parent category: Legal
Download
Go