Form Ihss-E 005 - In-Home Supportive Services Program - Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
The recipient(s) is/are not unable to hire a provider who speaks his/her
same language in order to direct his/her own care.
The recipient/authorized representative (AR) you work for have not
explored and exhausted ALL options for finding an additional provider(s)
so that all of their authorized services can be provided within the IHSS
program workweek limits.
OTHER: _______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
To qualify for Exemption 2, the recipient(s)/AR(s) must demonstrate to the county
that all efforts to hire an additional provider have been exhausted. This information
is needed by the county to justify referrals to the California Department of
Social Services.
In the future, if there is a change in your recipients’ circumstances and all of the eligibility
requirements are met, you can work with your recipients’ IHSS Social Worker to
request an Exemption 2.
If you have any questions about the information in this notice, you may call your
recipients’ IHSS Social Worker at the IHSS office telephone number listed above.
IHSS-E 005 (1/17)
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