Form Soc 2268 - In-Home Supportive Services Program Notice To Recipient Approval For Provider To Work 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 RECIPIENT APPROVAL FOR
PROVIDER TO WORK ALTERNATE SCHEDULE DUE TO RECURRING EVENT
(ADDRESSEE)
County of:
Notice Date:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
This notice is to inform you that your request to adjust your maximum weekly hours for
a specified week of each month due to the monthly recurring event, has been approved.
You may have your provider work the additional hours during the specified week of
each month.
This means that your maximum weekly hours for one week of the month will be different
from the other weeks of the month. Your provider(s) may continue to work this weekly
schedule in all later months as long as you continue to have the need for the adjustment
due to a recurring event. You must notify the county immediately if the situation changes
and you no longer have the need for this adjustment.
Further, if your provider(s) worked these hours, you will need to adjust your work hours
by reducing an amount equal to the exception hours approved, before the end of the
month to make sure your monthly authorized hours are not exceeded. If you do not
adjust your provider’s work hours before the end of the month, your provider(s) will not
be paid for the excess hours by the IHSS program and you will be responsible for the
payment of any service hours worked beyond your authorized monthly hours.
If you have any further questions about this notice, you may contact your county IHSS
office at the phone number above.
SOC 2268 (1/16)

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