Form Soc 2251 - To Request Appeal Of Agency Certification Denial

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TO REQUEST APPEAL OF AGENCY CERTIFICATION DENIAL
•
This request for appeal must be received within thirty (30) calendar days of the date of the notice
informing your agency of its denial for certification.
•
Complete and sign the second page of this form.
•
Provide a copy of the denial notification.
•
Make a copy of the front and back page for your records
•
Send this page to:
California Department of Social Services
Claims, Certification and Appeals Bureau
Appeals Unit, MS 9-9-04
Sacramento, CA 94244-2430
•
The California Department of Social Services (CDSS), Appeals Unit (AU), will review the information
contained with the request to make the decision regarding your agency’s certification. Upon
completion of the review of all materials, the AU will make a determination of certification.
•
If you have any questions, call the CDSS AU at 1 (855) 729-2383.
SOC 2251 (1/14) CCI APPEAL FORM
PAGE 1

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