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PA 1923 - CW Treatment Service Verification Rev 04-08doc - file lacounty-2026
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- Click ‘Get Form’ to open the PA 1923 - CW Treatment Service Verification form in the editor.
- Begin by completing Section A, PROVIDER CERTIFICATION. Enter the name of the treatment/service provider and certify the services being provided to the participant.
- In Section B, PARTICIPANT IDENTIFICATION, fill in the participant's name, Social Security number, and DPSS Case number as required.
- 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.
- Continue filling out details regarding participation hours in Section C. Ensure to answer questions about eligibility for exemptions accurately.
- If applicable, complete Section D regarding DOMESTIC VIOLENCE CASE MANAGEMENT AND/OR LEGAL SERVICES by providing necessary details on service hours and waivers.
- In Section E, list any additional supportive service needs such as childcare or transportation requirements.
- Finally, ensure that Section G is signed by the participant authorizing verification of their CalWORKs application/case status.
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