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Get and Sign Recipient Designation 2014-2022 Form
Providing authorized services for you.
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You must sign the acknowledgement in PART C of this form.
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Please return this completed and signed form to the county. The county will keep
the original form and give you a copy.
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PART A. RECIPIENT DESIGNATION OF PROVIDER
Recipient’s Name:
County IHSS Case #:
Provider’s Name:
Provider’s Address:
City, State, ZIP Code:
Provider’s Telephone Number:
Provider’s Date of Birth
Provider’s Social Security #*:
Provider’s Gender...
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