Form Soc 2269a - In-Home Supportive Services Program Notice To Provider Cancellation Of Alternate Schedule Due To Recurring Event

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO PROVIDER
CANCELLATION OF ALTERNATE SCHEDULE DUE TO RECURRING EVENT
(ADDRESSEE)
County of:
Notice Date:
Provider Name:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Provider
This notice is to inform you that your recipient’s request to adjust his/her maximum
weekly hours for a specified week of each month due to a monthly recurring event has
been cancelled. As of ____________________, you may no longer work additional
CANCELLATION DATE
hours during the specified week of each month.
This means that your recipient’s maximum weekly hours will now be the same for each
week of the month.
If you have any further questions about this notice, you may contact your county IHSS
office at the phone number above.
SOC 2269A (1/16)

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