Countywide Services Agency
Department of
Health and Human Services
Senior and Adult Services
Division
Debra J. Morrow
Division Manager
Bradley J. Hudson, County Executive
Bruce Wagstaff, Agency Administrator
Ann Edwards, Director
Section 1: RECIPIENT INFORMATION
Recipient’s name: __________________________ Recipient’s Case #: _____________
Section 2: REQUEST TO ADD A SERVICE PROVIDER :
New provider’s name: _____________________________________________________
New Provider’s Social Security #:____________-_____________-__________________
The new provider will start work for me on: (month, day, year) __________________________________
The new provider will work _____________ hours per month for me.
If the provider is working part of a month, list hours worked in that month:____________
F YOU HAVE MORE THAN ONE PROVIDER
LIST EACH PROVIDER AND HOW
MANY HOURS ARE ASSIGNED TO EACH PROVIDER
(Name) ___________________________________ (Hours) ____________________________________
+
(Name) ___________________________________ (Hours) ____________________________________
+
(Name) ___________________________________ (Hours) ____________________________________
=
Total Hours Authorized _____________________
Section 3: REQUEST TO DELETE A SERVICE PROVIDER
Name of provider to be deleted: _____________________________________________
Service Provider Number (last 6 digits of social security #): _______________________
The last day this provider worked for me was (month/day/year): ____________________
How many hours will this provider be claiming for the last month worked: __________
Section 4: RECIPIENT AUTHORIZATION
Recipient’s Signature: __________________________________ Date: ______________
Telephone number: ____________________
SAS 1207 2/28/2012
Sacramento County IHSS
9750 Business Park Drive
Sacramento, CA 95827
(916) 874 9471 Fax: (916) 876-8706