Form Na 1253l - Notice Of Action - In-Home Supportive Services (Ihss) Change
ADVERTISEMENT
1
2
3
4
5COUNTY OF
STATE OF CALIFORNIA
NOTICE OF ACTION
HEALTH AND HUMAN
IN-HOME SUPPORTIVE
SERVICES AGENCY
SERVICES (IHSS) CHANGE
CALIFORNIA DEPARTMENT
(ADDRESSEE)
OF SOCIAL SERVICES
NOTE: This notice relates ONLY to your In-Home Supportive
Services. It does NOT affect your receipt of SSI/SSP, Social
Security, or Medi-Cal. KEEP THIS NOTICE WITH YOUR
IMPORTANT PAPERS.
Notice Date:
Case Name:
Case Number:
Social Worker Name:
Social Worker Number:
Social Worker Telephone:
Social Worker Address:
As of __________ the services you can get and/or the amount
of time you can get for services has changed. Here’s why:
Total HRS:MINS of IHSS you can get each month is
now:________. This is a/an increase/decrease of ________.
You will now get the services shown below for the amount of time
shown in the column “Authorized Amount of Service You Can Get.”
That column shows the hours/minutes you got before, the
hours/minutes you will get from now on, and the difference. If you
are getting less time for a service, the reason(s) is shown on the
next page.
NA 1253L (3/15) IHSS CHANGE
Case No.
PAGE 1 of 5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal