Form Soc 2248 - Ihss Complaint Of Suspected Fraud Form Page 6
Download a blank fillable Form Soc 2248 - Ihss Complaint Of Suspected Fraud Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Soc 2248 - Ihss Complaint Of Suspected Fraud Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
No. in household:
Enter the total number of people living in the household
including the recipient.
Authorized no. hours:
Enter the number of hours authorized for purchase.
Date of last Face-to-face (F2F): Enter the date of the last recorded face-to-face
contact the county had with the recipient.
Person who conducted last F2F: Enter the name of the person who conducted the
last face-to-face with the recipient.
Check any of the following applicable boxes:
Severely Impaired:
Check if the recipient meets the Severely Impaired criteria.
Protective Supervision: Check if the recipient is currently authorized Protective
Supervision.
Married:
Check if the recipient is listed as married.
Minor:
Check if the recipient is a minor.
SSN Verified:
Check if Social Security Number was verified.
Program service(s) in question: Enter the services in question based on complaint.
Rank in service(s):
Enter the Functional Index (FI) ranking of the services in
question.
Caseworker contacted for information: Check if the caseworker was contacted for
information.
Name of person completing: Enter the name of the person completing the case file
information.
Enclosures:
Check the applicable boxes for any attached documents.
Pay warrants (copy of front and back): Check if pay warrants are attached to the
complaint form.
Timesheets:
Check if timesheets are attached to the complaint form.
Other (specify):
Check if any other documents are attached. Specify what
documents are attached.
SOC 2248(3/13)
PAGE 6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal