Form Na 1250l - Notice Of Action - In-Home Supportive Services (Ihss) Approval Page 4
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4NOTICE OF ACTION IN-HOME SUPPORTIVE SERVICES COUNTY OF
TIME LIMITED SERVICES (per MONTH)
TOTAL
SERVICES
ADJUSTMENTS
AMOUNT
AUTHORIZED
SERVICES
AMOUNT OF
YOU
FOR OTHERS
OF THE
AMOUNT OF
Note: See the “Description of
THE
REFUSED
WHO SHARE
SERVICE
SERVICE YOU
SERVICE
OR GET
Services” insert for a short
THE HOME
YOU NEED
CAN GET
NEEDED
FROM
description of each service.
OTHERS
HRS:MINS
(PRORATION)
HRS:MINS
HRS:MINS
Heavy Cleaning
Yard Hazard Abatement
Remove Ice, Snow
Teaching and Demonstration
TOTAL HRS:MINS OF TIME LIMITED SERVICES YOU CAN GET PER MONTH:
Questions? Please contact your IHSS social worker. See top of page 1 for phone number.
State Hearing: If you think this action is wrong, you can ask for a hearing. The State Hearing Rights included in this
notice tells how.
NA 1250L (3/15) IHSS APPROVAL
Case No.
Page 3 of 4
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