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Form Soc 2270a - In-Home Supportive Services Program Notice To Provider Failure To Complete Workweek And Travel Agreement

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

IN-HOME SUPPORTIVE SERVICES PROGRAM

NOTICE TO PROVIDER

FAILURE TO COMPLETE WORKWEEK AND TRAVEL AGREEMENT (SOC 2255)

(ADDRESSEE)

County of:

Notice Date:

Provider Name:

IHSS Office Address:

IHSS Office Telephone Number:

To: In-Home Supportive Services (IHSS) Provider

You have been identified as a provider who works for more than one IHSS program

recipient and has the potential to travel between two or more recipients during a single

work day. Therefore, you must complete or resubmit an IHSS Provider Workweek and

Travel Agreement (SOC 2255) form.

You are receiving this notice for the following reason(s):

The county has not yet received a completed form SOC 2255 from you.

This form must be completed, signed by you and returned to the county

IHSS office listed above in order to verify your workweek and travel information

if applicable.

The form was submitted to the county IHSS office incomplete. All information

contained in the form must be completed for the county to fully evaluate and

verify your workweek and travel information if applicable.

The travel information you provided in Part B. Travel Time indicates that your

total estimated travel time each workweek will exceed seven (7.0) hours.

The maximum amount of time you can spend each workweek traveling

between recipient locations is seven (7.0) hours.

If you only work for a single recipient, it is not necessary for you to complete the form

SOC 2255. Please contact the county IHSS office immediately to inform the office of

this, so that appropriate changes can be made to our records.

If you have any further questions about this notice or need assistance in completing

this form, you may contact your county IHSS office at the phone number above.

SOC 2270A (1/16)

Form Soc 2270a - In-Home Supportive Services Program Notice To Provider Failure To Complete Workweek And Travel Agreement