Form Soc 853 - In-Home Supportive Services Program Notice Of Provider Ineligibility

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
COUNTY OF
NOTICE OF PROVIDER INELIGIBILITY
(ADDRESSEE)
Notice Date:
Provider Name:
IHSS Office Address:
IHSS Office Telephone Number:
To: In-Home Supportive Services (IHSS) Provider Applicant
Based on the information you provided on the Provider Enrollment Form (SOC 426), you are not
eligible to be enrolled as an IHSS provider or to receive payment from the IHSS program for providing
services. Here’s why:
■ ■
You were suspended as a provider from the Medicare, Medicaid or Medi-Cal programs, and
you were not reinstated. Any provider who has been suspended from the Medicare, Medicaid
or Medi-Cal program and who has not been reinstated is ineligible to be enrolled as a provider
or to receive payment for providing supportive services.
■ ■
A licensing authority took disciplinary action against your professional license, certificate or
other authorization to provide health care. We reviewed the terms and conditions of the
licensing authority’s decision(s) and found that the terms and conditions prohibit you from
providing supportive services.
Because you are not eligible to be an IHSS provider, we will forward this information to the California
Department of Health Care Services (CDHCS) and ask that your name be placed on the Medi-Cal
Suspended and Ineligible Providers list. You will get a letter from CDHCS when your name is added to
the list.
If you disagree with this decision, the back of this page explains how you can request an appeal. You
must submit your appeal request within 60 calendar days from the date of this letter.
If you have any questions about this letter, call _________________________________________ .
SOC 853 (10/09)

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Form Soc 2292 - In-home Supportive Services Program Notice To Provider Of Failure To Timely Form Soc 2292 - In-home Supportive Services Program Notice To Provider Of Failure To Timely Legal
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Related Categories

Parent category: Legal
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