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Form Temp 2262a - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

IN-HOME SUPPORTIVE SERVICES PROGRAM

NOTICE TO RECIPIENT OF PROVIDER INELIGIBILITY

FAILURE TO SUBMIT SOC 846 (REV. 11/15)

(ADDRESSEE)

COUNTY OF:

Notice Date:

Provider Name:

Recipient Name:

Recipient Case Number:

IHSS Office Address:

IHSS Office Telephone Number:

To: In-Home Supportive Services (IHSS) Recipient

In December 2015, your provider _________________________________ received

the Important Information for the In-Home Supportive Services (IHSS) provider mailer

(TEMP 3001) which instructed him/her to return a signed IHSS Program Provider

Enrollment Agreement (SOC 846 [rev. 11/15]) form to the county in order to avoid being

determined ineligible to work and be paid by the IHSS program as an IHSS provider.

Effective July 1, 2017, your provider listed above is no longer eligible to work and be

paid by the IHSS program as an IHSS provider. The reason for this determination of

ineligibility is because he/she has not submitted the signed SOC 846 (rev. 11/15) form

by April 29, 2017.

Because your provider has been determined ineligible as an IHSS provider, you must

choose a different person to be your IHSS provider. Your current provider may not

continue to provide you services under the IHSS program and will not be paid by the

IHSS program for any work you may have him/her perform for you. You will be responsible

for paying this individual for any work you may have him/her perform for you.

If you have any questions about this notice or need help finding a different provider, you

may call your county IHSS office at the telephone number above.

TEMP 2262A (9/16)

Form Temp 2262a - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility