In-Home Supportive Services (Ihss) Program. Provider Enrollment Form - California
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT FORM
READ THE INFORMATION BELOW CAREFULLY BEFORE
YOU BEGIN TO COMPLETE THIS FORM
Under state law, if you have been convicted of, or incarcerated following a conviction, for certain
exclusionary crimes within the past 10 years, you are not eligible to be enrolled as a provider or to
receive payment from the IHSS program for providing supportive services except as specified below.
There are two categories of exclusionary crimes.
•
Tier 1 crimes, as set forth in Welfare and Institutions Code (W&IC) section 12305.81,
are:
1. Specified abuse of a child (Penal Code [PC] section 273a[a]*),
2. Abuse of an elder or dependent adult (PC section 368*), and
3. Fraud against a government health care or supportive services program.
•
Tier 2 crimes , as set forth in W&IC section 12305.87, are:
1. A violent or serious felony, as specified in PC section 667.5(c)*, and
PC section 1192.7(c)*,
2. A felony offense for which a person is required to register as a sex offender
pursuant to PC section 290(c)*, and
3. A felony offense for fraud against a public social services program, as defined
in W&IC sections 10980(c)(2)* and (g)(2)*.
A complete listing of Tier 2 crimes is available upon request from the County IHSS Office or
IHSS Public Authority.
*See attached form SOC 426C for the text of these PC and W&IC sections.
- As part of the IHSS provider enrollment process, you must submit fingerprints and undergo a
criminal background check conducted by the California Department of Justice.
- If your responses on this form or the results of the criminal background check show that you have
been convicted of, or incarcerated following a conviction for, either a Tier 1 or Tier 2 crime within
the last 10 years, you will not be eligible to be enrolled as an IHSS provider or to receive payment
from the IHSS program for providing supportive services.
- For Tier 2 crimes, if you have obtained a certificate of rehabilitation or an expungement
(dismissal pursuant to PC section 1203.4), the conviction will not disqualify you from working
as an IHSS provider.
- If your conviction is for a Tier 2 crime, you may qualify for an individual waiver or a general
exception under certain circumstances which are described below.
- There are no waivers or exceptions allowed for Tier 1 crimes.
GO ON TO THE NEXT PAGE
PAGE 1 OF 4
SOC 426 (4/12)
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