Form Soc 881 - In-Home Supportive Services Program Notice To Provider Of Inactivity

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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 OF INACTIVITY
(ADDRESSEE)
COUNTY OF:
Notice Date:
Provider Name:
Address of IHSS Office
or Public Authority (PA):
IHSS Office/PA Phone Number:
This notice is to inform you that your status as In-Home Supportive Services (IHSS) provider
has been changed to inactive. Here’s why:
It has been at least one year since you submitted a timesheet for work you performed providing
services for any IHSS recipient(s).
If you have been providing services for an IHSS recipient(s) but you have not been submitting timesheets
regularly, you must let the county know that you are still an active provider. In order to be identified as
an active provider and not continue to receive these notices you must submit your timesheets regularly.
You must complete the bottom section of this notice and return it to the county IHSS office or PA at the
address shown above OR call the county/PA at the phone number shown above. You must return the
notice or call the county/PA within 30 days of the date of this notice.
If you have NOT been providing services for an IHSS recipient but you wish to remain active because
you anticipate being an active provider for an IHSS recipient you must let the county/PA know that you
want to remain in active status. You must complete the bottom section of this notice and return it to the
county IHSS office or PA at the address shown above OR call the county/PA at the phone number shown
above. You must return the notice or call the county/PA within 30 days of the date of this notice.
If you do not return this notice to the county/PA or call the county/PA within 30 days, you will remain in
inactive status. If you decide to become an active IHSS provider in the future, you will have to
re-complete all of the provider enrollment requirements, including submitting fingerprints and
undergoing a criminal background check, before you can receive payment from the IHSS program for
providing services. State law requires that you pay the costs for fingerprinting and the criminal
background check.
If you have questions about the information in this notice, call the telephone number listed above.
REQUEST TO REMAIN IN ACTIVE STATUS
I hereby request to remain an IHSS provider in active status because:
■ ■
I have been an active provider within the past year, but have not submitted timesheets.
I have provided services for the following IHSS recipient(s): _________________________.
■ ■
I anticipate being an active provider for an IHSS recipient.
SIGNATURE:
DATE:
BEFORE RETURNING THIS NOTICE, MAKE A COPY FOR YOUR RECORDS.
SOC 881 (6/12)

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