Form Soc 885 - In-Home Supportive Services (Ihss) Program Notice Of Denial Of Request For In-Home Reassessment Based On State Law Change Page 2
Download a blank fillable Form Soc 885 - In-Home Supportive Services (Ihss) Program Notice Of Denial Of Request For In-Home Reassessment Based On State Law Change 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 885 - In-Home Supportive Services (Ihss) Program Notice Of Denial Of Request For In-Home Reassessment Based On State Law Change 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
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
YOUR HEARING RIGHTS
TO ASK FOR A HEARING:
1. You have the right to ask for a conference with the
county to talk about this action. At the conference, you
•
Fill out this page.
can speak for yourself, or someone else (a lawyer,
•
Make a copy of the front and back of this page for your
relative, friend, or other person) can speak for you. If
records. If you ask, your worker will get you a copy of
you want a conference, contact the county.
this page.
•
Send this page to:
2. Whether or not you ask for a conference, you also have
the right to ask for a hearing if you disagree with any
California Department of Social Services
county action. You have only 90 days to ask for a
State Hearings Division
hearing. The 90 days started the day after the
P.O. Box 944243, Mail Station 8-16-50
county gave or mailed you this notice.
Sacramento, CA 94244-2430
•
Or, call toll free:
1-800-952-5253, or for hearing
3. If you ask for a hearing before an action on your
or
speech
impaired
persons
who
use
TDD,
In-Home Supportive Services (IHSS) takes place, your
1-800-952-8349
services will continue until the hearing. If you make your
request in good faith, you will not have to repay any
REQUEST FOR HEARING
money you receive for services you get pending the
hearing, even if the hearing decision says the county’s
I want a hearing because I disagree with the action of the
action was right.
county regarding my social services. Here’s why:
_______________________________________________
4. You can ask for a hearing in person or in writing. You
_______________________________________________
have to say that you want a hearing and tell the
_______________________________________________
reason(s) you want one.
_______________________________________________
_______________________________________________
5. You can ask for a hearing on your own or you can ask
_______________________________________________
the county for assistance. Either way, you should tell
■ ■
If you need more space, check box and add a page.
your worker as soon as possible.
■ ■
I need the state to provide me with an interpreter at no
6. At a hearing, you can speak for yourself, or someone
cost to me. (A relative or friend cannot interpret for you
at the hearing.)
else (a lawyer, relative, friend, or other person) can
speak for you. You can get free legal help at your local
My language or dialect is: _________________________
legal aid or welfare rights office. For a legal aid referral,
call the toll-free number listed on this page.
PERSON WHOSE SOCIAL SERVICES WERE DENIED, CHANGED OR STOPPED
7. If you do not want to go to the hearing alone, you can
TELEPHONE NUMBER
BIRTH DATE
bring a relative, friend, or other person with you.
STREET ADDRESS
8. You can review the regulations about hearings at your
local IHSS office.
CITY
STATE
ZIP CODE
9. Information Practices: The information you give to ask
SIGNATURE
DATE
for a hearing is required to process your request
according to state law. A case file will be made up for
NAME OF PERSON COMPLETING THIS FORM
TELEPHONE NUMBER
the hearing and you have the right to look at the
information in the file. Any information you give may be
■ ■
I want the person named below to represent me at this
shared with the county or the United States Department
hearing. I give my permission for this person to see my
of Health and Human Services.
records and/or go to the hearing for me. (This person
can be a friend or relative but this person cannot
interpret for you.)
NAME
TELEPHONE NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
Page 2 of ____
NA BACK IHSS (5/09) REQUIRED FORM - NO SUBSTITUTIONS PERMITTED
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Soc 876 - In-home Supportive Services (ihss) Program Notice Of Provisional Approval Health Care Certification Exception Granted
Legal
Form Ihss-e 004 - In-home Supportive Services (ihss) Program - Notice Of Non-receipt Of Exemption From Workweek Limits Provider Agreement (apd 006)
Legal
Form Soc 874 - In-home Supportive Services (ihss) Program Notice To Applicant Of Health Care Certification Requirement
Legal
Form Ihss-e 003 - In-home Supportive Services (ihss) Program - Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances
Legal
Form Ihss-e 002 - In-home Supportive Services (ihss) Program - Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances
Legal
Form Ihss-e 007 - In-home Supportive Services (ihss) Program - Notice To Recipient Of Provider's Expiration Of Exemption From Workweek Limits
Legal
Form Soc 2271a - In-home Supportive Services (ihss) Program Recipient Notice Of Maximum Weekly Hours
Legal
In-home Supportive Services (ihss) Program And Waiver Personal Care Services (wpcs) Program Live-in Self-certification Cancellation Form For Federal And State Tax Wage Exclusion
Legal
Related Categories
Parent category: Legal