Form Soc 854 - In-Home Supportive Services Program Notice To Recipient Of Provider Eligibility

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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
(ADDRESSEE)
County of:
Notice Date:
Provider Name:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
As of the date of this notice, __________________________, has been officially enrolled as a provider.
He/she can now begin providing services for you.
If you have any questions, call _______________________________________________________ .
SOC 854 (1/11)

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