Form Soc 862 - In-Home Supportive Services Program Recipient Request For Provider Waiver

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
RECIPIENT REQUEST FOR PROVIDER WAIVER
(ADDRESSEE)
COUNTY OF:
Notice Date:
Applicant Provider Name:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
I, ___________________________________, am submitting this waiver request to the
________________________________________________ in order to hire the person
COUNTY/PUBLIC AUTHORITY/NON-PROFIT CONSORTIUM
named below to be my In-Home Supportive Services (IHSS) provider. I understand
he/she has been denied eligibility to be paid from the IHSS program, due to a felony
criminal conviction(s). Despite this information, I accept the responsibility for my
decision, and the possible risks involved, in allowing this person to work in my home
as an IHSS provider.
I have chosen to hire ___________________________ to be my IHSS provider and
acknowledge that he/she has been convicted of the following crime(s):
Date of Conviction
Penal Code Section
Felony Conviction Description
1.
2.
3.
4.
5.
PAGE 1 OF 3
SOC 862 (5/16)

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