Form Soc 857 - In-Home Supportive Services Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver

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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 OF PROVIDER ELIGIBILITY
ACKNOWLEDGEMENT OF RECEIPT OF WAIVER
(ADDRESSEE)
COUNTY OF:
Notice Date:
Applicant Provider Name:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
On ______________, you were informed that, based on Welfare and Institutions Code,
MM/DD/YYYY
Section 12305.87, _________________________ was denied eligibility to work as an
IHSS provider because he/she had been convicted of a felony crime.
On _______________________, the IHSS office received your signed waiver request.
By signing the waiver, you confirmed that you understand that you are employing the
above-named individual to work for you as an IHSS provider with the knowledge of
his/her criminal conviction(s) and that the State of California and the County of
________________ are not liable for the actions of this individual while in your employ
as an IHSS provider.
He/she may begin work as an IHSS provider for you as of the date of this notice. If this
individual has already begun providing IHSS services to you, he/she may be eligible to
receive retroactive payments for any authorized services he/she provided up to 90 days
prior to the date of this notice.
If you move to a different county and wish to retain the above-named individual as your
provider, he/she must go through another criminal background check through the
California Department of Justice to be your provider in that county and you must
complete and submit another IHSS Recipient Request for Provider Waiver (SOC 862)
to that county.
If you have any questions about this notice, call the IHSS office at the telephone number
listed at the top of this document.
SOC 857 (5/16)

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