Form Soc 2277 - Service Report
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SERVICE REPORT
Agency: ________________________________________ County: ___________________________ Month: ___________________________ Year: __________
DPSS (County) Authorized Hours
Total Served
Total Unserved
Case Number
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Number of Referrals for Contract Mode Received in the Month from the County,
Care Coordination Team, or Managed Care Plan (MCHP)
Name of MCHP
Total from Each MCHP
Total Referrals for the Month:
From: _______________ County:
Care Coordination Team:
MCHP:
Total # of Recipients who Received Services During the Month:
SOC 2277 (2/15)
PAGE 1 OF 2
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