Form Ihss-E 004 - In-Home Supportive Services (Ihss) Program - Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (Apd 006)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
NOTICE OF NON-RECEIPT OF EXEMPTION FROM WORKWEEK LIMITS
PROVIDER AGREEMENT (APD 006)
(ADDRESSEE)
COUNTY OF:
IHSS Office Address:
IHSS Office Telephone:
Notice Date:
Provider Name:
Provider Number:
o: In-Home Supportive Services (IHSS) Provider
As of __________, you were approved for an exemption from workweek limits for
Date
extraordinary circumstances, which authorized you to work up to 360 hours per month
(not to exceed the recipients’ authorized hours).
As a condition of being granted an exemption, you were required to sign the IHSS
Program Exemption from Workweek Limits for Extraordinary Circumstances Approved
Exemption Provider Agreement (APD 006) and return it to the county. The completed
APD 006 would affirm that you understand and agree that you cannot work more than
360 hours per month.
As of the date of this notice, the ____________________ has not received your signed
County IHSS Agency
APD 006. Failure to sign and return the APD 006 will make you ineligible for renewal of
the exemption after the exemption expires on __________.
Date
Without an approved exemption, you are required to comply with the existing workweek
limitations. Therefore, the maximum number of hours you may work in a workweek for
two or more recipients combined is 66 hours. The recipients you work for will need to
hire another IHSS provider(s) to work any remaining authorized IHSS hours.
If you would like to continue to be eligible for the exemption, please complete,
sign, and return the enclosed APD 006 to the IHSS Office Address indicated
above by __________.
Date
If you have any questions about this notice, please contact the IHSS Office at the
telephone number listed above.
IHSS-E 004 (4/17)
PAGE 1 OF 1

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