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Recipient Last Name: First Name: SSN: DOB:
Address: Telephone:
Provider Last Name: First Name: SSN: DOB:
REASON FOR REFERRAL
1. Deceased: Yes No RECIPIENT PROVIDER
2. In Jail: Date RECIPIENT PROVIDER
3. Living out of country: Address Date
With Whom? Telephone RECIPIENT PROVIDER
4. Residing in care facility or hospital: Name/Address
Date(s) of stay Telephone RECIPIENT PROVIDER
5. Need for services is questionable: Have you ever seen the recipient do any of the following:
Cleaning house Preparing food Washing dishes Doing laundry Grocery shopping
Running errands Using restroom Feeding self Dressing self
Walking without assistance Getting in/out of bed by self Bathing self Driving self
Physical activities Physical hobbies Regular community involvement Casinos/Bingo
6. Who lives in the recipient's home?
Name: Age: Relationship
7. Does the recipient work? Yes No
If yes, where: When:
8. Does the recipient have other assets/income? (ie. a second home, lottery winnings, gambling):
Explain
9. Does the recipient drive? Yes No
10. Does the provider have another job? Yes No
If yes, where When
11. Any additional comments or explanation:
Reporting party Telephone
Address E-mail
IHSS Fraud Task Force Sacramento, CA 95812 916.874.3836 ihssfraud@sacda.org