Form Soc 870 - In-Home Supportive Services Program Notice To Provider Of Provider Eligibility Acknowledgement Of Receipt Of Waiver

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE TO PROVIDER OF PROVIDER ELIGIBILITY
ACKNOWLEDGEMENT OF RECEIPT OF WAIVER
(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) Provider
On ______________, you were informed that, based on Welfare and Institutions Code,
MM/DD/YYYY
Section 12305.87, you were denied eligibility to work as an IHSS provider because you
have been convicted of a felony crime.
On _______________________, the county/Public Authority/Non-Profit Consortium
IHSS program office received the signed waiver request from ____________________.
You may begin work as an IHSS provider for this recipient as of the date of this notice.
This waiver allows you to work for the above-named recipient only and only in the
county referenced above. If you wish to work for additional recipients, you will need to
obtain a waiver from each of those individuals, or you may request a general exception.
If you have already begun providing IHSS services for this individual, you may be
eligible to receive retroactive payments for any authorized services you provided up
to 90 days prior to the date of this notice.
If the recipient for whom you work moves to a different county or you choose to work
as an IHSS provider for a recipient in a different county, you must go through another
criminal background check through the California Department of Justice to be used in
that county and the recipient for whom you work or will work must complete and submit
another IHSS Recipient Request for Provider Waiver (SOC 862) to that county.
If you have any questions about this notice, call the IHSS office at the telephone number
listed at the top of this document.
SOC 870 (5/16)

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