STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
RECIPIENT REQUEST FOR ASSIGNMENT OF
AUTHORIZED HOURS TO PROVIDERS
IHSS RECIPIENT CASE NUMBER
RECIPIENT NAME (FIRST MIDDLE
LAST)
PROVIDER NAME (FIRST MIDDLE
LAST)
PROVIDER IDENTIFICATION NUMBER HOURS ASSIGNED PER MONTH
I understand that by completing and submitting this form to the county In-Home Supportive Services (IHSS) program, I am
requesting the IHSS program to assign the indicated number of my authorized hours to the named provider. I further
understand that by making this request, my provider’s timesheets will NOT be processed for more than the hours I have
requested be assigned to him/her on this form. This request will remain in effect until I submit a new request form to the
county IHSS program.
RECIPIENT SIGNATURE
DAT
E
AUTHORIZED REPRESENT
ATIVE
(IF RECIPIENT CANNOT SIGN ON THEIR OWN BEHALF)
RELATIONSHIP TO RECIPIENT
TELEPHONE NUMBER
SIGNATURE OF AUTHORIZED REPRESENTATIVE
DATE
PROVIDER SIGNATURE
DATE
COUNTY USE ONLY
COMMENTS
SOCIAL WORKER NAME
(FIRST MIDDLE LAST)
SOCIAL WORKER IDENTIFICATION NUMBER
SOC 838 (10/12)
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