PA 1923 - CW Treatment Service Verification Rev 04-08doc - file lacounty-2026

1. Click ‘Get Form’ to open the PA 1923 - CW Treatment Service Verification form in the editor.
2. Begin by completing Section A, PROVIDER CERTIFICATION. Enter the name of the treatment/service provider and certify the services being provided to the participant.
3. In Section B, PARTICIPANT IDENTIFICATION, fill in the participant's name, Social Security number, and DPSS Case number as required.
4. Proceed to Section C for SUBSTANCE ABUSE AND/OR MENTAL HEALTH. Indicate whether services are residential or non-residential and specify the expected duration of treatment.
5. Continue filling out details regarding participation hours in Section C. Ensure to answer questions about eligibility for exemptions accurately.
6. If applicable, complete Section D regarding DOMESTIC VIOLENCE CASE MANAGEMENT AND/OR LEGAL SERVICES by providing necessary details on service hours and waivers.
7. In Section E, list any additional supportive service needs such as childcare or transportation requirements.
8. Finally, ensure that Section G is signed by the participant authorizing verification of their CalWORKs application/case status.

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