STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES …

This document combines all three approval forms and can be word processed and/or printed out and completed by pen. Note: For temporary placements, use the “SOC 815 817-818 Combined for 309(d) or 361.45 Temp Placement.” Date of caregiver’s initial request to be assessed for approval: Primary Care Provider Secondary Care Provider 1. ................
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