Form Hcs 9184 - Home Care Organization Disassociation Request
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HOME CARE SERVICES BUREAU
HOME CARE ORGANIZATION DISASSOCIATION REQUEST
The Home Care Organization (HCO) Disassociation Request may only be used to request the disassociation of a home
care aide or an employee from your HCO. Please fax this form to (916) 322-6310 or mail to: California Department of
Social Services, Home Care Services Bureau, 744 P Street, MS T8-3-90, Sacramento, CA 95814.
HOME CARE ORGANIZATION INFORMATION
HOME CARE ORGANIZATION NAME
HOME CARE ORGANIZATION NUMBER
REPRESENTATIVE NAME
AREA CODE/TELEPHONE
(
)
PLEASE DISASSOCIATE THE FOLLOWING INDIVIDUALS FROM THE ABOVE HCO:
PERSONNEL/REGISTRATION
DRIVERS LICENSE/
NAME
ID NUMBER (PER ID)
ID NUMBER
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM
ARE CORRECT TO THE BEST OF MY KNOWLEDGE.
HOME CARE ORGANIZATION REPRESENTATIVE SIGNATURE
DATE
HCS 9184 (6/17)
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