County of Sacramento Adding/Deleting Service Provider

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Countywide Services Agency

Department of

Health and Human Services

Senior and Adult Services

Division

Debra J. Morrow

Division Manager

County of Sacramento

Bradley J. Hudson, County Executive

Bruce Wagstaff, Agency Administrator

Ann Edwards, Director

Adding/Deleting Service Provider

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:____________

** I

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

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