Form Soc 857a - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Acknowledgement Of Receipt Of Invalid Request For Provider Waiver

Download a blank fillable Form Soc 857a - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Acknowledgement Of Receipt Of Invalid Request For Provider Waiver 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 857a - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Acknowledgement Of Receipt Of Invalid Request For Provider Waiver 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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO RECIPIENT OF PROVIDER INELIGIBILITY
ACKNOWLEDGEMENT OF RECEIPT OF INVALID
REQUEST FOR PROVIDER WAIVER
(ADDRESSEE)
COUNTY OF:
Notice Date:
Provider Name:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Recipient
On ______________, you were notified that, based on state law*, _____________________________,
(DATE)
(PROVIDER APPLICANT NAME)
the person you chose to be your IHSS provider, was ineligible because he/she had been convicted of a
disqualifying crime in the last 10 years. The notice explained that if you wanted him/her to be your
provider, even though he/she had been convicted of a disqualifying crime, you could submit a signed
request for a provider waiver to the county/Public Authority (PA)/Non-Profit Consortium (NPC) IHSS
office.
On _____________, the county/PA/NPC IHSS program office received an invalid request
(DATE)
for a provider waiver. The waiver request is invalid because it was signed by _____________________
(PROVIDER APPLICANT NAME)
as your authorized representative. State law* does not allow your authorized representative to sign the
waiver request to be your provider unless he/she is:
•
Your parent, guardian or person having legal custody (if you are a minor), or
•
Your conservator, spouse or registered domestic partner (if you are an adult).
County/PA/NPC records show that _______________________________ is NOT your parent, guardian
(PROVIDER APPLICANT NAME)
or a person having legal custody (if you are a minor), or your conservator, spouse or registered
domestic partner (if you are an adult). If he/she IS your parent, guardian or a person having legal
custody (if you are a minor), or if he/she is your conservator, spouse or registered domestic partner
(if you are an adult), call your IHSS worker at the number shown at the top of this notice.
SOC 857A (4/12)
PAGE 1 OF 2

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Soc 857 - In-home Supportive Services Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver Form Soc 857 - In-home Supportive Services Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver Legal
Form Soc 859a - In-home Supportive Services Program Notice To Recipient Of Provider Ineligibility Tier I Crimes Ineligibility - Subsequent Conviction Form Soc 859a - In-home Supportive Services Program Notice To Recipient Of Provider Ineligibility Tier I Crimes Ineligibility - Subsequent Conviction Legal
Form Soc 2259a - In-home Supportive Services Program Notice To Recipient Of Provider's Fourth Violation (one-year Period Of Ineligibility) For Exceeding Workweek And/or Travel Time Limits Form Soc 2259a - In-home Supportive Services Program Notice To Recipient Of Provider's Fourth Violation (one-year Period Of Ineligibility) For Exceeding Workweek And/or Travel Time Limits Legal
Form Soc 855 - In-home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process Form Soc 855 - In-home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process Legal
Form Soc 2285 - In-home Supportive Services Program Notice To Recipient Upholding Provider's Fourth Violation (one-year Period Of Ineligibility) For Exceeding Workweek And/or Travel Time Limits Form Soc 2285 - In-home Supportive Services Program Notice To Recipient Upholding Provider's Fourth Violation (one-year Period Of Ineligibility) For Exceeding Workweek And/or Travel Time Limits Legal
Form Soc 855a - In-home Supportive Services Program Notice To Recipient Of Provider Ineligibility Tier I Crimes Form Soc 855a - In-home Supportive Services Program Notice To Recipient Of Provider Ineligibility Tier I Crimes Legal
Form Soc 2258a - In-home Supportive Services Program Notice To Recipient Of Provider's Third Violation (90-day Suspension Of Eligibility) For Exceeding Workweek And/or Travel Time Limits Form Soc 2258a - In-home Supportive Services Program Notice To Recipient Of Provider's Third Violation (90-day Suspension Of Eligibility) For Exceeding Workweek And/or Travel Time Limits Legal
Form Soc 2293 - In-home Supportive Services Program Notice To Recipient Of Provider's Failure To Timely Form Soc 2293 - In-home Supportive Services Program Notice To Recipient Of Provider's Failure To Timely Legal
Form Soc 2283 - In-home Supportive Services Program Notice To Recipient Upholding Provider's Third Violation (90-day Suspension Of Eligibility) For Exceeding Workweek And/or Travel Time Limits Form Soc 2283 - In-home Supportive Services Program Notice To Recipient Upholding Provider's Third Violation (90-day Suspension Of Eligibility) For Exceeding Workweek And/or Travel Time Limits Legal
Form Soc 2257a - In-home Supportive Services Program Notice To Recipient Of Provider's First/second Violation For Exceeding Workweek And/or Travel Time Limits Form Soc 2257a - In-home Supportive Services Program Notice To Recipient Of Provider's First/second Violation For Exceeding Workweek And/or Travel Time Limits Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2