STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RECIPIENT ACKNOWLEDGMENT:
• I understand that by completing and submitting this form to the county In-Home
Supportive Services (IHSS) program, I am scheduling authorized hours to the
named provider(s).
• I understand that it is my responsibility to make a schedule for each provider so
that the total hours worked by all of my providers do not exceed my maximum
weekly hours or monthly authorized hours.
• I understand that in certain circumstances I can adjust my authorized weekly hours
but that my monthly authorized hours do not change unless I receive a new Notice
of Action with a new authorization by the county.
• I understand that my providers will not be paid by the IHSS program for any excess
hours if the number of hours they provide services for me exceeds my monthly
authorized hours. If my providers work more than my monthly authorized hours or
provide services not authorized by the IHSS program, it is my responsibility to pay
for those additional hours or services.
• I understand that if I want the weekly assigned hours of my provider(s) to stay the
same and the timesheets of my provider(s) to always be processed for the hours I
have assigned to him/her, I will request and complete a Recipient Assignment of
Authorized Hours to Providers (SOC 838) form and submit it to the county.
RECIPIENT SIGNATURE DATE
RECIPIENT NAME (FIRST, MIDDLE, LAST)
AUTHORIZED REPRESENTATIVE (IF RECIPIENT RELATIONSHIP TO RECIPIENT TELEPHONE NUMBER
CANNOT SIGN ON THEIR OWN BEHALF)
SIGNATURE OF AUTHORIZED REPRESENTATIVE DATE
SOC 2256 (11/15)
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