Form Dhcs 9094 - Request For Suspension Of Medi-Cal Payment Eligibility
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2STATE OF CALIFORNIA – HEALTH & HUMAN SERVICES AGENCY
Department of Health Care Services
REQUEST FOR SUSPENSION OF MEDI-CAL PAYMENT ELIGIBILITY
Of In-Home Supportive Services (IHSS) Medi-Cal Providers
Under Welfare and Institutions Code Sections 14043.6 and 14123
1. Requestor
Job Title
Organization
2. Street Address
City
State
Zip Code
_____________________________________________________________________________________________________________
3. Telephone No.
The agency above hereby requests suspension of the following providers from Medi-Cal:
4. Name
5. Address
6. SSN / TIN
7. Second Identifier
8. S/R
9. Printed Name of Requestor
10. Signature
11. Date
I have reviewed this form and the attached documents, and verified their accuracy. For every provider bearing a mark in
Column 8, I hereby verify that Department of Social Services has formally determined that the provider committed a
crime(s) substantially related to the practice of providing In-Home Supportive Services. (To be completed by DSS Only):
12. Printed Name of DSS Employee
13. Signature
14. Date
DHCS. 9094 (REV. 6/2008)
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