Form Na 1252l - Notice Of Action - In-Home Supportive Services (Ihss) Denial
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1
2COUNTY OF
STATE OF CALIFORNIA
NOTICE OF ACTION
HEALTH AND HUMAN
IN-HOME SUPPORTIVE
SERVICES AGENCY
SERVICES (IHSS) DENIAL
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:
Based on the information you gave the county, and state
regulations, your application for In-Home Supportive Services
(IHSS) has been denied. Here’s Why:
NA 1252L (3/15) IHSS DENIAL
Case No.
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