STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SERVICE REPORT
Agency: ________________________________________ County: ___________________________ Month: ___________________________ Year: __________
Case Number
DPSS (County) Authorized Hours
Total Served
Total Unserved
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Number of Referrals for Contract Mode Received in the Month from the County,
Care Coordination Team, or Managed Care Plan (MCHP)
Total Referrals for the Month:
From: _______________ County:
Care Coordination Team:
MCHP:
Total # of Recipients who Received Services During the Month:
Name of MCHP
Total from Each MCHP
SOC 2277 (2/15)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Instructions for the Contract Mode Service Report
The attached Form SOC 2277 is a hard copy version of the Contract Mode Service Report. An electronic version of the report will be sent to Qualified Agencies to
use for monthly completion and submittal. To request the electronic version please contact the Contract Mode and Certification Unit at 916-651-5332.
1. Enter the name of the Qualified Agency completing the report in cell F1.
2. Enter the name of the County in which the Agency is providing service(s) in cell C2.
3. Enter the year in which the Agency provided the service(s) in cell E2.
4. Enter the month in which the Agency provided the service(s) in cell G2.
5. Enter the Consumer Name, Case Number, Zip Code, DPSS Authorized Hours, Total Hours Served, and Total Hours Unserved in cells B4, C4, D4, E4, F4,
and G4. Complete this information for all consumers served by the Agency in the reporting month.
6. Enter the total number of referrals for Contract Mode received for the reporting month in cell K4.
7. Enter the total number of referrals received from the County in cell K7, the Care Coordination Team in cell K8, and the MCHP in cell K9.
8. Enter the name(s) of the MCHP in cells I12, I13, I14, I15, and I16 (as needed). Enter the total number of referrals from each MCHP in cells N12, N13,
N14, N15, and N16 (as needed).
9. Enter the total number of recipients who received services from the Agency during the reporting month in cell I22.
10. The Agency shall submit completed Service Report to the applicable county, MCHP, and CDSS by the 5th day of each month, however no later than the
10th day of each month. The Service Report shall be submitted to CDSS electronically to rolonda.moen@dss.ca.gov.
SOC 2277 (1/15)
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