Form Ssp 22 - Authorization For Nonmedical Out- Of- Home Care
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1
2STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DATE
AUTHORIZATION FOR NONMEDICAL OUT– OF– HOME CARE
(BOARD AND CARE)
(SSA COMPLETES ALL BUT SECTION 'B')
APPLICANT/RECIPIENT’S NAME
SEX
DATE OF BIRTH
SOCIAL SECURITY NUMBER
M
F
APPLICANT/RECIPIENT’S HOME ADDRESS
RECEIVING IHSS
TELEPHONE NUMBER
REASON FOR CERTIFICATION
AGED
BLIND
CHANGE OF ADDRESS
CHANGE OF
OTHER _____________________
LIVING ARRANGEMENT
DISABLED
TYPE OF DISABILITY
I.
SSA OFFICE REQUEST TO COUNTY WELFARE DEPARTMENT FOR CERTIFICATION
TO
SSA REPRESENTATIVE REQUESTING INFORMATION
NAME
TITLE
TELEPHONE NUMBER
A. SSA OFFICE REQUEST
The above-named person may be entitled to the nonmedical out-of-home care benefit level in the home of a relative or a facility.
(MPP Section 46-140)
FACILITY
NAME OF RELATIVE
RELATIONSHIP
OR
Please certify whether or not this person is receiving nonmedical out-of-home care.
B.
COUNTY WELFARE DEPARTMENT RESPONSE
I certify that the above named
IS NOT receiving nonmedical out-of-home care as authorized under DSS MPP Section 46-140.
IS receiving nonmedical out-of-home care as authorized under DSS MPP Section 46-140 in the arrangement described below.
EFFECTIVE
(See Reverse)
CHECK ONE:
/
/
a. The home of a relative or legally appointed guardian or conservator, or,
________________________
b. A certified family home or foster family home
MONTH
DAY
YEAR
SIGNATURE OF CERTIFYING COUNTY REPRESENTATIVE
TITLE
TELEPHONE
DATE
SIGNATURE OF SUPERVISOR
TITLE
TELEPHONE
DATE
II.
SSA OFFICE VERIFICATION OF LICENSED CARE FACILITIES CASE
A. I have verified that the above-named person lives in a licensed nonmedical out-of-home care facility, license number
/
/
The effective date of the living arrangement is
___________________
MONTH
DAY
YEAR
Current residency was confirmed with _____________________________________________________________________________
NAME
TITLE
B.
Licensure was verified by:
List supplied by State Department of Social Services.
Telephone contact with ____________________________________________________________
Other (specify) ___________________________________________________________________
SIGNATURE OF REPRESENTATIVE
TITLE
OFFICE
DATE
RETURN TO
OFFICE
SSP 22 (6/99)
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