Form IHSS-E002 "In-home Supportive Services (Ihss) Program Notice to Provider for Discontinuance of Exemption From Workweek Limitations for Extraordinary Circumstances" - California

What Is Form IHSS-E002?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form IHSS-E002 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form IHSS-E002 "In-home Supportive Services (Ihss) Program Notice to Provider for Discontinuance of Exemption From Workweek Limitations for Extraordinary Circumstances" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE TO PROVIDER FOR DISCONTINUANCE OF EXEMPTION FROM
WORKWEEK LIMITATIONS FOR EXTRAORDINARY CIRCUMSTANCES
(ADDRESSEE)
COUNTY OF:
Notice Date:
IHSS Office Address:
IHSS Office Telephone:
Provider Name:
Provider Number:
To: In-Home Supportive Services (IHSS) Provider
As of ________________, you were granted an Exemption from Workweek Limitations
Date of Approval
for Extraordinary Circumstances (Exemption 2) for the IHSS recipients listed below:
Recipient Name: ____________________
Recipient Name: ____________________
Case Number: ______________________
Case Number: ______________________
Recipient Name: ____________________
Recipient Name: ____________________
Case Number: ______________________
Case Number: ______________________
This notice is to inform you that at the end of service month _________________, your
Effective Month and Year
Exemption 2 is being discontinued due to the following:
You are no longer providing services for one or more of the recipients for which
the exemption was granted.
You no longer reside with one or more of the recipients for which the exemption
was granted.
One or more of the recipients for which the exemption was granted has had
a reduction in authorized IHSS hours, which allows you to work within the
workweek limitations.
IHSS-E 002 (1/17)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
NOTICE TO PROVIDER FOR DISCONTINUANCE OF EXEMPTION FROM
WORKWEEK LIMITATIONS FOR EXTRAORDINARY CIRCUMSTANCES
(ADDRESSEE)
COUNTY OF:
Notice Date:
IHSS Office Address:
IHSS Office Telephone:
Provider Name:
Provider Number:
To: In-Home Supportive Services (IHSS) Provider
As of ________________, you were granted an Exemption from Workweek Limitations
Date of Approval
for Extraordinary Circumstances (Exemption 2) for the IHSS recipients listed below:
Recipient Name: ____________________
Recipient Name: ____________________
Case Number: ______________________
Case Number: ______________________
Recipient Name: ____________________
Recipient Name: ____________________
Case Number: ______________________
Case Number: ______________________
This notice is to inform you that at the end of service month _________________, your
Effective Month and Year
Exemption 2 is being discontinued due to the following:
You are no longer providing services for one or more of the recipients for which
the exemption was granted.
You no longer reside with one or more of the recipients for which the exemption
was granted.
One or more of the recipients for which the exemption was granted has had
a reduction in authorized IHSS hours, which allows you to work within the
workweek limitations.
IHSS-E 002 (1/17)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
One or more of the recipients for which the exemption was granted no longer
meets the criteria for an Exemption 2.
The recipient(s) have hired an additional provider(s) and therefore, you are able
to comply with the workweek limitations.
OTHER: _______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
This discontinuance means you will be subject to comply with the existing workweek
limitations. Therefore, the maximum number of hours you may work in a workweek for
two (2) or more recipients combined is 66 hours. Once you work the maximum weekly
hours your IHSS recipients must hire another IHSS provider to work their remaining
authorized IHSS hours.
If you submit timesheets that report working hours that exceed the 66 hour workweek
limitations for pay periods after the effective date of the discontinuance, you will accrue
a violation.
If you have any questions, please contact your recipient’s IHSS County Social Worker
at the IHSS office telephone number above.
IHSS-E 002 (1/17)
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