Form Ihss-E 002 - In-Home Supportive Services (Ihss) Program - Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE TO PROVIDER FOR DISCONTINUANCE OF EXEMPTION FROM
WORKWEEK LIMITATIONS FOR EXTRAORDINARY CIRCUMSTANCES
(ADDRESSEE)
COUNTY OF:
Notice Date:
IHSS Office Address:
IHSS Office Telephone:
Provider Name:
Provider Number:
To: In-Home Supportive Services (IHSS) Provider
As of ________________, you were granted an Exemption from Workweek Limitations
Date of Approval
for Extraordinary Circumstances (Exemption 2) for the IHSS recipients listed below:
Recipient Name: ____________________
Recipient Name: ____________________
Case Number: ______________________
Case Number: ______________________
Recipient Name: ____________________
Recipient Name: ____________________
Case Number: ______________________
Case Number: ______________________
This notice is to inform you that at the end of service month _________________, your
Effective Month and Year
Exemption 2 is being discontinued due to the following:
You are no longer providing services for one or more of the recipients for which
the exemption was granted.
You no longer reside with one or more of the recipients for which the exemption
was granted.
One or more of the recipients for which the exemption was granted has had
a reduction in authorized IHSS hours, which allows you to work within the
workweek limitations.
IHSS-E 002 (1/17)
PAGE 1 OF 2

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