Refer to the back of your Notice of Action for instructions on how to request a State Hearing. Photo: Lea Suzuki, The Chronicle Buy photo Individuals have the right to apply for IHSS services or make an application through another person on their behalf. Download the Registration Form - Dubai Derma, Reg-form DERMA 2013 non promo 2 - Dubai Derma, Conference registration form us$ 270/ aed 1000 - Dubai Derma. You, as the IHSS recipient, must pay the SOC, if any, to the provider monthly. The cookie is used to store the user consent for the cookies in the category "Analytics". If you need assistance completing any of these forms, please contact the IHSS Helpline at (888) 822-9622. This cookie is set by GDPR Cookie Consent plugin. These forms are usually sent my IHSS to recipient/provider they know lives with together like a child/parent. The In-Home Supportive Services (IHSS) program is designed to provide assistance to older adults and individuals with disabilities, who without this care, would be unable to remain safely in their home. When you qualify for IHSS, you can receive help at no or little costwith bathing, dressing, meal preparation and clean up, bowel and bladder care, light housekeeping, laundry, and shopping. Contact Our Registry! If approved, IHSS will tell you the types of services, start date, and the number of IHSS hours per month that have been authorized for you. Disabled children are also potentially eligible for IHSS; Live in your own home. Get the Ihss Reassessment you require. The California Department of Social Services (CDSS) reiterates the In Home Supportive Services (IHSS) requirements for processing applications, completing reassessment, and issuing Quality Improvement Actions Plans. Additionally, if a Provider tests positive for COVID-19 they should not be providing IHSS services for any Recipient as specified by the Dept. The cookie is used to store the user consent for the cookies in the category "Other. IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM PROVIDER ENROLLMENT FORM INSTRUCTIONS: Use black or blue ink to fill out. Your provider may request for an exemption from the vaccine requirement for a qualified medical reason or religious belief. All IHSS recipients will now be assigned "maximum weekly hours." To find your recipients' maximum weekly hours, divide their total monthly authorized hours by four. SOC 295 - Application For In-Home Supportive Services [Espaol] [] [] SOC 295 - Application For In-Home Supportive Services, SOC 295L - Application For In-Home Supportive Services (Large Print), SOC 426A - In-Home Supportive Services Program Designation of Provider, [Espaol] [] [] [] [] [] [Tagalog] [Ting Vit] [], SOC 838 - In-Home Supportive Services Recipient Request for Assignment of Authorized Hours to Provider, SOC 840 - In-Home Supportive Services Program Provider or Recipient Change of Address and/or Telephone, SOC 873 - In-Home Supportive Services Program Health Care Certification Form, SOC 321- Request for Order and Consent Paramedical Services, SOC 825 - Protective Supervision 24-Hours-A-Day Coverage Plan, SOC 839 - In-Home Supportive Services Designation of Authorized Representative, [Espaol][][][][][][Tagalog][Ting Vit], SOC 2256 - In-Home Supportive Services Program Recipient and Provider Workweek Agreement, [Espaol][][][][][][Tagalog][Ting Vit][], SOC 2274 - In-Home Supportive Services Program Accompaniment to Medical Appointment, SOC 2279 - In-Home Supportive Services Program Live-In Family Care Provider Overtime Exemption, SOC 2326 - In-Home Supportive Services Recipients Responsibility to Stop Sexual Harassment in the Workplace, PA 2457 - Civil Rights Information Notice, PUB 13 - Your Rights Under California Welfare Programs, PUB 13 Your Rights Under California Welfare Programs (Large Print). 3. Address: 20101 Hamilton Avenue Suite 250 Torrance, CA 90502, Hours of Operation: Monday - Friday from 8:00 am to 5:00 pm, ___________________________________________________________________________________________________________________________. Demonstrate a need for help with activities of daily living. In an attempt to provide more services to the most vulnerable, the state Health and Human Services Agency created a new office to improve mental health care. You may be asked to perform or describe simple tasks, such as range-of-motion demonstrations. Effective January 17, 2023, the IHSS Hawthorne and Rancho Dominguez Offices have Moved! Fill in the empty fields; engaged parties names, places of residence and numbers etc. NOTE:All other provisions of the September 28, 2021, order are still in effect, including exceptions and exemptions. Sf.ca.us IHSS Applicant Last Name / / Birth date Spouse If in the home First Name Sex M/F MI - /Transgender Y/N Zip N Is Spouse able to do housework Y If no why not Does applicant receive Supplemental Security Income Spouse s Form Popularity ihss application online form. Remember, the SOC is part of provider's salary. If you are unable to print the form yourself, you can contact the IHSS Call Center via phone or email to receive another form: Phone: 530-889-7171 Email: Recipients authorized hours are less than the statutory maximum of 283 hours per month. Masks may be obtained from the, IHSS Helpline (888) 822-9622 or your local IHSS office; or. Recipients can contact Public Authority for assistance in finding another Provider to fill in. Necessary cookies are absolutely essential for the website to function properly. 331 0 obj
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To be eligible for IHSS, you must be one of the following: Years of Age or Older, Legally Blind, or a Disabled Adult or Disabled Child. Complete the SOC 295 Application For IHSS, _________________________________________________________________. View the IHSS Services and Assessment video (English|Espaol|) for more information. The county is required to respond and resolve payment inquiries from recipients and providers. Photo: Associated Press The cookie is used to store the user consent for the cookies in the category "Performance". Be signed and dated by the LHCP within 60 calendar days of submission to the Social Worker. hVRHyu4R2@IP~EI&nid,Cdn}s'lKIZ&NbeJ Recipients can self-register for the TTS by using the 6-digit State Registration Code. Over 550,000 IHSS providers currently serve over 650,000 recipients. SOC 2298 In-Home Supportive Services (IHSS) Program and Waiver Personal Care Personal Services (WPCS) Live-In Self-Certification Form for Federal and State Wage Exclusion W-4 Employees Withholding Allowance Certificate (Federal) DE-4 Employees Withholding Allowance Certificate (State) Do these hours count toward the providers weekly maximum? The types of services which can be authorized through IHSS are housecleaning, meal preparation, laundry, grocery shopping, personal care services (such as bowel and bladder care, bathing, grooming and paramedical services), accompaniment to medical appointments, and protective supervision for the mentally impaired. Currently, no there is not a deadline or end date. IHSS Provider Resources Once you have become an IHSS provider, the following are resources intended to help you as you provide services to your IHSS recipient: IHSS Timesheet Information (EVV) Electronic Visit Verification for Recipients and Providers (ESP) Electronic Services Portal Information Online Direct Deposit Services How to Apply Contact IHSS at (408) 792-1600 or fill out the application and submit using one of the options below. You must apply for Medi-Cal if you are not already receiving. Analytical cookies are used to understand how visitors interact with the website. IHSS Provider Direct Deposit Letter and Form Provider Direct Deposit Outreach Letter 02-16-22 Translations: Spanish (pdf) IHSS Provider Direct Deposit Enrollment/Change/Cancellation Form (SOC 829) (pdf) Paperwork will be mailed to you and must be returned within 60 days of your video or phone assessment. Who is it For: Box 1912. The county will keep the original form and give you a copy. Working more than the maximum weekly limit of 66 hours when he/she works for multiple recipients. Call(415) 557-6200. Care providers may be family members, friends, neighbors or registered providers through the Public Authority. Please review the Recipient Notice and/or the Provider Notice, as well as, the Vaccine Exemption Form below for additional information. Please note Placer County IHSS and Public Authority do not require proof of vaccination or exemption. You must also: 1. Is there a deadline or end date for submitting this claim? IHSS does not provide funding for 24/7 supervision, but it does award a block of hours to cover a portion of this need. To add or change a provider, please call the IHSS Help Line at (888) 822-9622. Continue reporting your hours worked on your timesheet as you always have. Please contact Placer County Payroll at 530-889-7135 or [emailprotected] if you would like to submit a claim. Recipient's Name: 2. You may submit other acceptable forms of alternative documentation, signed by a LHCP, if the SOC 873 is not available. Click on Done following twice-checking all the data. Amendment to the September 28, 2021, Public Health Order, Questions & Answers: Adult Care Facilities and Direct Care Worker Vaccine Requirement, COVID-19 Vaccination Exemption Form- Spanish(Espaol), COVID-19 Vaccination Exemption Form- Armenian(), COVID-19 Vaccination Exemption Form- Chinese(), COVID-19 Vaccination Exemption Form- Cambodian(), COVID-19 Vaccination Exemption Form- Farsi(), COVID-19 Vaccination Exemption Form- Korean(), COVID-19 Vaccination Exemption Form- Russian(), COVID-19 Vaccination Exemption Form- Tagalog(Tagalog), COVID-19 Vaccination Exemption Form- Vietnamese(Ting Vit), Personal Assistance Services Council (PASC), SOC 873 - In-Home Supportive Services Program Health Care Certification Form, Provides services to a family member(s); and, Obtain a weekly COVID-19 test at one of the State testing sites (, Wear a surgical mask or N95 mask, at all times, while providing services in your home. For purposes of monitoring counties compliance with application processing, CDSS will use the protected date of eligibility, and a 90-day timeframe to allow for the 45 days which may be necessary to complete the required Medi-Cal eligibility determination and the Health Care Certification form. In-Home Supportive Services (IHSS) Map/Directions. To qualify as severely impaired, an applicant must need at least 20 total hours per week of services in one or more of the following IHSS areas: non-medical personal services, preparation of meals, meal cleanup (when preparation of meals and feeding are also required), and paramedical services. How Does The IHSS Program Work? Fill in the empty fields; engaged parties names, places of residence and numbers etc. [Ting Vit] SOC 840 - In-Home Supportive Services Program Provider or Recipient Change of Address and/or Telephone Form [] [] [] . Providers who are eligible for the booster dose must comply byMarch 1, 2022. Print information clearly. People at imminent risk of out of home placement can be granted IHSS immediately, and be given 45 days to submit the health care certification, and can have up to 90 days for good cause. Find the right form for you and fill it out: No results. of Public Health until they have been cleared to do so. This health orderdoes not applyto a provider who: If your provider is not related to you and/or does not live with you, theymustget vaccinated. Twice a month, both you and your provider who works for you will receive an "Explanation of IHSS SOC" letter that will tell you how much money to pay the provider. How to obtain PPE (personal protective equipment); COVID sick leave information and forms for providers; medical accompaniment claims for Recipient COVID vaccine appointments. In-Home Supportive Services, also known as IHSS, can help pay for services if youre a low-income elderly, blind or disabled individual, including children, so that you can remain safely in your own home. Contact Us By PhoneToll Free: 877-565-4477Fax: 818-206-8000TTY: 626-737-7512Contact Usinfo@pascla.org, AboutProgramsProviderConsumerCalendarNewsResourcesPolicies and ProceduresComplaint Policy & ProceduresNon-discrimination Policy. the form must be provided and the form must include your signature and the date you signed the form. If the applicant is ineligible for Medi-Cal when they apply, they may be authorized services back to the protected date of eligibility. The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". All recipients for whom the provider works must meet at least one of the following conditions: To apply for an Extraordinary Circumstances exemption, complete the SOC 2305,[Espaol] [] [] and return the form to your assigned IHSS Social Worker. These cookies will be stored in your browser only with your consent. The provider's wages are paid twice per month after the work has been performed. You can fax requested documents to your IHSS District Office using its secure fax: IHSS Office eFax #, Burbank (818)563-9105, Chatsworth (818) 450-0241, El Monte (626) 380-4960, Hawthorne (310) 943-2125, Lancaster (661) 424-7849, Metro IHSS (213) 947-4591, Pomona (909) 752-9402, Rancho Dominguez (310) 943-2125. Visit the IHSS Helpline Community Apply By Mail Complete the SOC 295 Application For IHSS Print and mail to: Box 1677 West Sacramento, CA 95691-6677 What do I do for wages paid before my Self-Certification Form is received? Recipient Forms Recipient Forms Recipient Forms If you need assistance completing any of these forms, please contact the IHSS Helpline at (888) 822-9622. You also have the option to opt-out of these cookies. Plan for this interview to take up to 90 minutes and to show proof of income and resources (bank statements). 517 - 12th Street You may contact PASC at (877) 565-4477 for more information. Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. To learn how to apply for services: Get Services IHSS . Forms; Become a Provider; IHSS Care Providers Support (SIP) IHSS Public Authority; . Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. Once your Medi-Cal is established, expect an IHSS social worker to contact you about scheduling anappointment to assess your ability to perform activities of daily living. We also use third-party cookies that help us analyze and understand how you use this website. Protective supervision is an IHSS service for recipients who require 24/7 supervision to prevent injury to themselves or others due to severely impaired judgment, orientation, and/or memory (their words). How to Submit Forms to IHSS There are three ways that you can submit forms to IHSS: By US Mail: DSS- IHSS PO Box 1912 Fresno, CA 93718-1912 By Fax: (559) 600-5400 (health care certifications, paramedical and protective supervision forms) (559) 600-7762 (change of address, provider terminations) Attending mandatory State training after you start working. Existing Recipients and Providers: Clients: to access your case information, click here. Includes the steps and resources to apply for in-home services, Includes finding, hiring, and managing your IHSS Provider, Also includes hearing requests, and abuse and fraud reporting. You, as an IHSS recipient, may have to pay a certain dollar amount each month toward your medical expenses as part of your SOC. COVID-19 VACCINE BOOSTER DOSE REQUIREMENT. Provider Forms. IHSS office hours To keep you safe during COVID-19, we're here to assist you by email and phone, Monday-Friday, 8:00 a.m. to 5:00 p.m. For IHSS Provider questions Email ihsspaymentunits@sfgov.org . The pay rate in Contra Costa is presently $16.00 per hour. Please review the notices below for IHSS Providers and IHSS Recipients regarding COVID-19 booster requirements. The applicants protected date of eligibility is the date the applicant requests services. In-Home Supportive Services. If the applicant is ineligible for Medi-Cal when they apply, they may be authorized services back to the protected date of eligibility. If you had any loss of IHSS work/income due to COVID-19 between 04/012020 - 09/30/2021 and 01/01/2022 - 09/30/2022 and have not yet received COVID-19 sick leave, you may still be eligible to submit a claim. You may also be asked for a list of your prescribed medications and doctors information. Photo: Lea Suzuki, The Chronicle Image 1 of / 7 Caption Close HSA's new CEO is a woman who grew up without a father 1 / 7 Back to Gallery The IHSS recipient also has the right to choose the licensed health care professional who completes the Paramedical order. window._Taboola = window._Taboola || []; _Taboola.push({mode: 'thumbnails-c', container: 'taboola-interstitial-gallery-thumbnails-7', placement: 'Interstitial Gallery Thumbnails 7', target_type: 'mix'}); _Taboola.push({flush: true}); Complete Health Care Certification Call (415) 557-6200. Provider's Address: City, State, ZIP Code: 5 . It does not store any personal data. Put the day/time and place your electronic signature. 7 Note: the current SOC 321 Form (discussed further below) limits who can authorize paramedical services to a "Physician/Surgeon," "Podiatrist" and "Dentist." IHSS recipients must obtain County approval whenever you need your IHSS provider to work more than his/her maximum weekly hours when the adjustment in the work schedule results in the provider: To request the one-time exception, contact the IHSS Helpline at (888) 822-9622. For help with finding a new care provider during your providers absence, you can contact: Your health care professional may return this form via fax, U.S. Mail or you may return it in-person. The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. Return Completed SOC 2298 Forms to: IHSS - IRS Live-In Self-Certification P.O. P.O. Preparing for Power Outages - Recipient Registration Register for the IHSS Website to: View your timesheet and payment statuses Enter and submit timesheets No longer mail paper timesheets Request additional timesheets Enroll in direct deposit Claim sick leave Registration FAQs (PDF) Recipients of IHSS may hire any person of their choosing to be the in-home care provider. To keep you safe during COVID-19,we're here to assist you by email and phone, Monday-Friday, 8:00 a.m. to 5:00 p.m. Emailihsspaymentunits@sfgov.org. Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. For Recipients: How to obtain a list of providers. The new public heath order issued by the California Department of Public Health requires certain IHSS Providers to be fully vaccinated with the COVID-19 vaccine by November 30, 2021. If the county has the capability, it must also accept applications online and by email. In-Home Supportive Services Referral Form Date Sent Please answer all questions and print clearly Fax to SF HSA Department of Aging and Adult Services Program 415 557-5271 Questions Call 415 355-6700 or email us at ihss ci. Counties must reassess individuals IHSS eligibility every year, and each time a recipient notifies the county of a change in circumstances. Service authorizations are assessed during the needs assessment, which is a comprehensive review of the recipients medical history/diagnosis, medications/purpose, emergency contacts, physicians information, household composition, functional index rankings, mini-mental health assessment, necessary referrals to Adult Protective Services (APS), Child Protective Services (CPS), Fraud, community services, etc., language preferences and whether an interpreter is needed, and a full biopsychosocial assessment. But opting out of some of these cookies may affect your browsing experience. Once completed and signed by the Recipient (or their authorized representative), the Hiring Agreement can be submitted by: Mail to: County of Fresno Department of Social Services. County IHSS Case #: 3. Home and Community Based Alternatives Waiver Agencies (in Los Angeles): Be 65 years old or older, blind, and/or disabled as defined by Social Security Administration (SSA) standards. Provider Phone: 510.577.5694. In addition,you'll be responsible for hiring, supervising, and scheduling your IHSS Providers, and for signing their timesheets. You have the right to interpreter services provided by the County at no cost to you. Live in your own home (your "own home" is any place you choose to live, except a nursing home or other out-of-home care facility, licensed or not). You must live at home or a dwelling of your own choosing (acute care hospital, long-term care facilities, and licensed community care facilities are not considered "own home"). Indicate that the applicant/recipient is unable to independently perform one or more activities of daily living; Describe the applicants/recipients condition or functional limitation that has contributed to the need for assistance; and. Approve Timesheets, Overtime, & Schedules. This cookie is set by GDPR Cookie Consent plugin. Prior to authorization of IHSS services, recipients must submit a Health Care Certification form (SOC 873) completed by a licensed health care professional, except when the recipient is at imminent risk of out of home placement. Need a COVID-19 vaccination? Open it using the online editor and start altering. Be a California resident. Have a complex medical and/or behavioral need that must be met by the provider who lives in the same home as the recipient(s); or, Live in a rural or remote area where available providers are limited; or. (ACIN I-58-21, June 14, 2021. Please return this completed and signed form to the county. Provider's Name: 4. Individuals have the right to apply for IHSS services or make an application through another person on their behalf. If you are approved for IHSS, you must hire someone (your individual provider) to perform the authorized services. If you misplaced your notice of action, contact the IHSS Helpline at (888) 822-9622 and ask for a copy of the notice of action. (MPP 30-767.6) The county also has a grievance procedure it must follow when a grievance or complaint is received about the processing of payment for IHSS services for recipients that get IHSS under the Personal Care Services (PCSP) Program. The California Department of Public Health issued a public health order on September 28, 2021, requiringcertainproviders to be fully vaccinated with the COVID-19 vaccine by November 30, 2021. Mail In-Home Supportive Services PO Box 11018 San Jose, CA 95103-1018 Email SSA_IHSS_ARCCI_Fax@ssa.sccgov.org In Person (, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), COVID-19 CalFresh emergency allotment for July, 2021. %}yB)
_(`[:8%pq~;5 Change the blanks with unique fillable areas. On December 22, 2021, due to the emergence of the Omicron variant, the California Department of Public Health issued anAmendment to the September 28, 2021, Public Health Order. PART A. Includes address updates, tracking your case, and assessments. Change the blanks with exclusive fillable areas. Housing and Urban Development Secretary Julin Castro talks to the media about President Barack Obama's budget for fiscal 2015 at the Treasury Department in Washington, D.C., Wednesday, October 13, 2014. Providers who need to obtain a COVID-19 test may search for a testing site here by entering their address. ), Legal Services of Northern California CFCO provides States with 6% additional federal funding for services and supports. To apply for In-Home Supportive Services, please complete the application (PDF) and first page of the Health Care Certification (PDF).Your Licensed Health Care Professional (LHCP) will need to complete the second page of the Health Care Certification.Fax them to 916-787-8922, ATTN: IHSS Intake and call the Placer County Adult Intake number at 916-787-8860 or toll free at 888-886-5401. Repair services Sitting with you to visit or watch TV Taking you on social outings Applying as a Care Recipient 1. Where can I get another copy of the Medical Accompaniment COVID vaccine claim form? Verification form (Form I-9), which is kept on file by the recipient. Find out how to schedule your vaccination. This cookie is set by GDPR Cookie Consent plugin. Mayor Ed Lee poses for photographers with City Administrator Sabrina Andrew on the steps of City Hall in San Francisco, Calif., on Thursday, January 7, 2015. How many hours can be claimed for these appointments? Phone: (661) 868-1000 Toll Free: (800) 510-2020 . 2. I . If approved, you will be notified of the. Fresno, CA 93718-9889. or by Fax to: (559) 243-7485. For questions regarding a pending Extraordinary Circumstances request, contact the IHSS HelpLine at (888) 822-9622 (Monday through Friday from 8:00 a.m. to 5:00 p.m.). IHSS Public Authority; IHSS Recipient/Consumer Education Videos (provided by CDSS) Transportation Services; Ask a licensed medical professional to verify your need for IHSS by filling out. 1. Those who are not yet eligible for a booster dose must comply within 15 days after the recommended time frame for the booster. Find out about other options for in-home services by visiting: Live at home or in a shelter, but not in a board and care facility, nursing home, or hospital. Cant work more than 66 hours per workweek unless granted an exemption; Can work up to a maximum of 90 hours per workweek, if granted an exemption; and. Counties should prioritize Communities First Choice Options (CFCO) annual reassessments because these recipients are typically most vulnerable. Hospitals, nursing homes, and licensed community care facilities are not considered own home; Participate in a home assessment interview; and, Obtain a health care certification from a licensed health care professional (LHCP) such as a physician, psychiatrist, psychologist, etc., indicating that you are unable to safely perform one or more activities. Please join us! S.F. Not eligible for IHSS? If denied, you will be notified of the reason for the denial. If you do not have your registration code, you can call the TTS help desk at 1-833-342-5388 or you can call your IHSS Social Worker for assistance. In order to be served by the Registry, recipients must already be signed up with the IHSS program.If you are not already signed up with the IHSS program, please call the IHSS intake line at (510) 577-1800 to see if you are eligible and to request an application . Bring original federal or state government-issued identification and your original Social Security card when returning this form. Video instructions and help with filling out and completing ihss application form, Instructions and Help about apply for ihss online form, Narrator In Home Supportive Services is the largest publicly funded non-medical service to help people with disabilities remain inhere homes Applying to the program can be daunting To start the application process contact the IHSS program in your county A representative will gather information about your income disability and what services you may need Elizabeth Worker Some people need a service called Protective Supervision This is an I-H-S-S service for people with cognitive or mental health disabilities in need of 24-hour observation and monitoring to protect them from injuries hazards or accidents Make sure you tell the representative promise that you want protective supervision for your family member if you think they need the service Narrator The county will give you a form called form S-O-C-821 also referred to as assessment of need for protective supervision for in-home supportive services program The doctor will need to fill out this form Explain to the physician that your family member needs constant supervision to keep him or her safe Describe that your family members memory orientation and judgment are impaired and how it affects his or her life It is helpful to provide the doctor with copy of our publication called In-Home Supportive Services Protective Supervision which is available on our website Elizabeth Your family members doctor should check the boxes on the form indicating whether your family member is severely impaired moderately impaired or unimpaired in memory orientation or judgment The doctor should be as detailed as possible and include specific examples Narrator If the doctor runs out of spaceheshe may attach a letter to the form to continue explaining your condition Return the form to your social worker and keep a copy for your own records once it is complete Applying for protective supervision is not guarantee of services If your application is denied request a hearing to appeal the Counties decision or call Disability Rights California for assistance, If you believe that this page should be taken down, please follow our DMCA take down process, This site uses cookies to enhance site navigation and personalize your experience. The provider may be a relative or friend if desired. To be eligible for the Extraordinary Circumstances exemption, the provider must work for two or more IHSS recipients whose circumstances put them at risk of placement in out-of-home care. _fr1K$7HBk|C6w?0&SApG(G[9$a@rRI
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