■
■
■ ■
■ ■ ■
■
■
■
■
■
■
■
■
___________________
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR NONMEDICAL OUT– OF– HOME CARE
(BOARD AND CARE)
(SSA COMPLETES ALL BUT SECTION 'B')
DATE
APPLICANT/RECIPIENT’S NAME
SEX
M
F
DATE OF BIRTH
SOCIAL SECURITY NUMBER
APPLICANT/RECIPIENT’S HOME ADDRESS RECEIVING IHSS
TELEPHONE NUMBER
TYPE OF DISABILITY
AGED
BLIND
DISABLED
REASON FOR CERTIFICATION
CHANGE OF ADDRESS
CHANGE OF
LIVING ARRANGEMENT
OTHER
_____________________
I. SSA OFFICE REQUEST TO COUNTY WELFARE DEPARTMENT FOR CERTIFICATION
ADDRESS FOR
WINDOW ENVELOPE
TO
SSA REPRESENTATIVE REQUESTING INFORMATION
NAME
TITLE
TELEPHONE NUMBER
A. SSA OFFICE REQUEST
The above-named person may be entitled to the nonmedical out-of-home care benefit level in the home of a relative or a facility.
(MPP Section 46-140)
NAME OF RELATIVE RELATIONSHIP
OR
FACILITY
Please certify whether or not this person is receiving nonmedical out-of-home care.
B. COUNTY WELFARE DEPARTMENT RESPONSE
I certify that the above named
■ IS NOT receiving nonmedical out-of-home care as authorized under DSS MPP Section 46-140.
■ IS receiving nonmedical out-of-home care as authorized under DSS MPP Section 46-140 in the arrangement described below.
CHECK ONE:
a. The home of a relative or legally appointed guardian or conservator, or,
b. A certified family home or foster family home
EFFECTIVE
(See Reverse)
MONTH
/
DAY
/
YEAR
SIGNATURE OF CERTIFYING COUNTY REPRESENTATIVE TITLE TELEPHONE DATE
SIGNATURE OF SUPERVISOR TITLE TELEPHONE DATE
II. SSA OFFICE VERIFICATION OF LICENSED CARE FACILITIES CASE
A. I have verified that the above-named person lives in a licensed nonmedical out-of-home care facility, license number
The effective date of the living arrangement is
MONTH
/
DAY
/
YEAR
Current residency was confirmed with
_____________________________________________________________________________
NAME TITLE
B. Licensure was verified by:
List supplied by State Department of Social Services.
Telephone contact with
____________________________________________________________
■
Other (specify)
___________________________________________________________________
SIGNATURE OF REPRESENTATIVE TITLE OFFICE DATE
ADDRESS FOR
WINDOW
ENVELOPE
RETURN TO
OFFICE
SSP 22 (6/99)
