Form Temp 2239 - County Ihss Provider Appeals Contact Information
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COUNTY IHSS PROVIDER APPEALS CONTACT INFORMATION
COUNTY:
DATE:
WHICH AGENCY IN YOUR COUNTY IS REVIEWING CRIMINAL HISTORY REPORTS AND
DETERMINING IF A PROVIDER IS INELIGIBLE DUE TO HIS/HER CRIMINAL HISTORY?
■ ■
COUNTY ONLY
■ ■
PUBLIC AUTHORITY (PA)/NON-PROFIT CONSORTIUM (NPC) ONLY
■ ■
BOTH COUNTY AND PA/NPC
[PLEASE PROVIDE TWO CONTACT NAMES]
CONTACT NAME AND TITLE:________________________________________________________
NAME OF AGENCY:________________________________________________________________
ADDRESS:_______________________________________________________________________
CITY, STATE ZIP CODE:____________________________________________________________
TELEPHONE NO.:_________________________________________________________________
FACSCIMILE NO.:__________________________________________________________________
E-MAIL ADDRESS:_________________________________________________________________
CONTACT NAME AND TITLE:________________________________________________________
NAME OF AGENCY:________________________________________________________________
ADDRESS:_______________________________________________________________________
CITY, STATE ZIP CODE:____________________________________________________________
TELEPHONE NO.:_________________________________________________________________
FACSCIMILE NO.:__________________________________________________________________
E-MAIL ADDRESS:_________________________________________________________________
TEMP 2239 (12/09)
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Parent category: Legal