STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HOME CARE ORGANIZATION DISASSOCIATION REQUEST
HCS 9184 (6/17)
The Home Care Organization (HCO) Disassociation Request may only be used to request the disassociation of a home
care aide or an employee from your HCO. Please fax this form to (916) 322-6310 or mail to: California Department of
Social Services, Home Care Services Bureau, 744 P Street, MS T8-3-90, Sacramento, CA 95814.
HOME CARE ORGANIZATION INFORMATION
HOME CARE ORGANIZATION NAME HOME CARE ORGANIZATION NUMBER
REPRESENTATIVE NAME AREA CODE/TELEPHONE
( )
PLEASE DISASSOCIATE THE FOLLOWING INDIVIDUALS FROM THE ABOVE HCO:
NAME
PERSONNEL/REGISTRATION
ID NUMBER (PER ID)
DRIVERS LICENSE/
ID NUMBER
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM
ARE CORRECT TO THE BEST OF MY KNOWLEDGE.
HOME CARE ORGANIZATION REPRESENTATIVE SIGNATURE DAT E
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES BUREAU
