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You (or your authorized representative) must complete PART A of this form to let the county know who you have chosen to provide your authorized services. If you have multiple providers, you must fill out a separate form for each person who will be providing authorized services for you.
IHSS: In Home Supportive Services (Servicios de apoyo en el hogar): Este programa paga los costos de los servicios de cuidados en el hogar []
An Authorized Representative is responsible for acting on the behalf of the IHSS recipient for purposes of the IHSS program.
This form allows you, as the IHSS applicant/recipient or their legal representative, to choose an Authorized Representative for the IHSS program. An Authorized Representative is responsible for acting on the behalf of the IHSS recipient for purposes of the IHSS program. This form is only for the IHSS program.
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