STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
RECIPIENT AND PROVIDER
WORKWEEK AGREEMENT
IHSS RECIPIENT CASE NUMBER
RECIPIENT NAME (FIRST, MIDDLE, LAST)
My total authorized hours are ____________.
My total monthly authorized hours will now be divided by 4 to determine my maximum
weekly hours. My maximum weekly hours are __________. Under certain circumstances,
I may be able to adjust my weekly authorized hours which will allow me to give more
hours in one week than I normally give to use, as long as I use less hours in another week.
I understand that this form is a tool to help me schedule hours for my provider(s). This
schedule helps me to ensure that my provider(s) stay(s) within my monthly authorized hours.
INSTRUCTIONS:
1. In Column A below, enter the names of all the providers you wish to receive services
from.
2. In Column B below, enter the provider number of each of your providers. (The
number is located on the timesheet.)
3. In Column C below, enter the total maximum hours assigned per week to each of
your providers.
4. The TOTAL maximum weekly hours for all of your providers (Column C) must add
up to your total weekly maximum service hours.
A B C
PROVIDER NAME
(FIRST, MIDDLE, LAST)
PROVIDER
NUMBER
HOURS
ASSIGNED
PER WEEK
1.
2.
3.
4.
5.
RECIPIENT’S TOTAL MAXIMUM WEEKLY HOURS PER WEEK:
SOC 2256 (11/15)
PAGE 1 OF 3
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)
PAGE 2 OF 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROVIDER ACKNOWLEDGMENT:
I understand that by signing this form I agree to the work schedule and work no
more for the recipient than the hours assigned to me, unless he/she adjusts the
schedule of hours.
I understand that if more than the recipient’s authorized monthly hours are worked,
those services are not considered IHSS and it will not be paid by the IHSS program.
It is the responsibility of my recipient to provide payment for those additional hours.
The IHSS program only pays for IHSS program authorized hours and services.
I understand that I must follow the program requirements that are stated on the
Provider Enrollment Agreement (SOC 846).
1. PROVIDER SIGNATURE
PROVIDER #1 PRINTED NAME AND PROVIDER NUMBER
2. PROVIDER SIGNATURE
PROVIDER #2 PRINTED NAME AND PROVIDER NUMBER
3. PROVIDER SIGNATURE
PROVIDER #3 PRINTED NAME AND PROVIDER NUMBER
4. PROVIDER SIGNATURE
PROVIDER #4 PRINTED NAME AND PROVIDER NUMBER
5. PROVIDER SIGNATURE
PROVIDER #5 PRINTED NAME AND PROVIDER NUMBER
DATE
TELEPHONE NUMBER
DATE
TELEPHONE NUMBER
DATE
TELEPHONE NUMBER
DATE
TELEPHONE NUMBER
DATE
TELEPHONE NUMBER
FOR COUNTY USE ONLY
WORKER NAME (FIRST MIDDLE LAST): WORKER PHONE:
SOC 2256 (11/15)
PAGE 3 OF 3