Form Soc 850 - Notice Of Provider Ineligibility

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
COUNTY OF
NOTICE OF PROVIDER INELIGIBILITY
(ADDRESSEE)
Notice Date:
Provider Name:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Provider Applicant
As of the date of this notice, you are no longer eligible to be an IHSS provider or to receive payment from
the IHSS Program for providing services. Here’s why:
On _______________________, we sent you a notice telling you that the Provider
Enrollment Form (SOC 426) you submitted to the county was incomplete. We asked you to
provide the missing information within 15 business days. You did not submit the requested in-
formation by the date we requested it.
If you have any questions about this letter, call ________________________________________ .
SOC 850 (10/09)

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