Recipient Designation Of Provider Form Page 3
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
2. More than 40 hours for me in a workweek if my maximum weekly hours are
40 hours or less in a workweek.
•
If I do not get an approved exception, my provider will get a violation for working
more than my maximum weekly hours.
•
I can never authorize my provider to work more than my total authorized monthly
service hours. Therefore, when I authorize my provider to work extra hours in one
week, I must have the provider work fewer hours in the other week(s) of the month.
•
If my provider works for another recipient, the maximum number of hours that
he/she may claim in a workweek for all of the time he/she works for his/her recipients
combined is 66 hours. I must make a work schedule for my provider to determine
how many hours he/she will be working for me each week to make sure
he/she does not work more than 66 hours per workweek. I will get a Recipient
Notification of Maximum Weekly Hours (SOC 2271A) which will include information
on my maximum weekly hours so I can use it to make the work schedule for my
provider(s). In order to make the schedule, my provider must tell me how many
hours he/she is available to work for me each workweek. If my provider cannot
work all of my authorized hours, I will need to hire additional provider(s). If I need
help finding and hiring another provider(s), I can call my county IHSS Public
Authority to obtain a provider from the registry or my county IHSS office.
•
The county will send me a notice each time my provider gets a violation. If my
provider gets three violations, he/she will be suspended from providing IHSS for
three months. If he/she gets another violation after being reinstated from the three-
month suspension, he/she will be terminated as a provider for one year.
PART C. RECIPIENT ACKNOWLEDGMENT
I understand and agree to follow all of the requirements listed in this form.
RECIPIENT’S SIGNATURE:
DATE:
PRINTED NAME:
AUTHORIZED REPRESENTATIVE’S SIGNATURE:
DATE:
PRINTED NAME:
FOR COUNTY USE ONLY
WORKER NAME:
DATE:
PAGE 3 OF 3
SOC 426A (1/16)
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