Form Soc 855 - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process

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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 INELIGIBILITY
INCOMPLETE PROVIDER PROCESS
(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
The person you have chosen to employ to provide IHSS services to you,
_______________________, is not eligible to receive payment from the IHSS program
for providing services to you or to any other person. Here’s why:
He/she did not complete one or more of the required steps of the provider enrollment
process listed below within 90 days of starting the provider enrollment process.
He/she did not complete, sign and return the IHSS Provider Enrollment Form
(SOC 426) to the county; and/or
He/she did not attend an IHSS Provider Orientation; and/or
He/she did not sign an IHSS Provider Enrollment Agreement (SOC 846);
and/or
He/she did not complete a California Department of Justice criminal
background check.
Because this individual has been deemed ineligible as an IHSS provider, you must
choose a different person to provide services. If you choose to continue receiving
services from this individual, you will be responsible for paying him/her with your own
money for any services provided.
If you need help finding a different provider, call the IHSS Office at the telephone number
listed at the top of this document.
SOC 855 (5/16)

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