Form Na 1250l - Notice Of Action - In-Home Supportive Services (Ihss) Approval
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4COUNTY OF
STATE OF CALIFORNIA
NOTICE OF ACTION
HEALTH AND HUMAN
IN-HOME SUPPORTIVE
SERVICES AGENCY
SERVICES (IHSS) APPROVAL
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:
Total HRS:MINS of IHSS you can get each month: __________.
Based on an assessment done on__________, you can get the
services shown on the next pages for the amount of time shown in
the column "Authorized Amount of Service You Can Get.”
1) If there is a zero in the "Authorized Amount of Service You Can
Get" column or the amount is less than the "Total Amount of
Service Needed" column, the reason is explained on the next
page(s).
2) "Not Needed" means that your social worker found that you do
not require assistance with this task. (MPP 30-756.11)
3) "Pending" means the county is waiting for more information to
see if you need that service. See the next page(s) for more
information.
NA 1250L (3/15) IHSS APPROVAL
Case No.
PAGE 1 of 4
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