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Get and Sign Recipient Designation 2014-2022 Form

Get and Sign Recipient Designation 2014-2022 Form

Use a Recipient Designation 2014 template to make your document workflow more streamlined.

Providing authorized services for you. • You must sign the acknowledgement in PART C of this form. • Please return this completed and signed form to the county. The county will keep the original form and give you a copy. 1. 2. 3. 4. 5. 6. 7. 8. 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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