Form Na 1252 - Notice Of Action - In-Home Supportive Services (Ihss) Denial
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1NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
DENIAL
Notice Date :
Case Name :
Case Number :
Social Worker Name :
NOTE: This notice relates ONLY to your In-Home Supportive
Services. It does NOT affect your receipt of SSI/SSP, Social
Social Worker Number :
Social Worker Telephone :
Security, or Medi-Cal.
KEEP THIS NOTICE WITH YOUR
Social Worker Address :
IMPORTANT PAPERS.
(ADDRESSEE)
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:
Rules: The rules noted above in parentheses apply; you may review the Manual of Policy and Procedures
(MPP) at your local IHSS office.
Questions?: Please contact your IHSS social worker.
State Hearing: If you think this action is wrong, you can ask for a hearing. The back of this page tells how.
NA 1252 (5/09) - IHSS DENIAL
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