In-Home Supportive Services (Ihss) Program. Provider Enrollment Form - California Page 2
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4IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT FORM
CONTINUE READING THE INFORMATION BELOW CAREFULLY BEFORE
YOU BEGIN TO COMPLETE THIS FORM
Individual Waiver of an Exclusion for Conviction for a Tier 2 Crime
If you are found ineligible based on a conviction for a Tier 2 exclusionary crime but an IHSS
recipient (or his/her authorized representative) wishes to hire you as his/her provider in spite of
your criminal background, you may obtain a waiver as follows.
•
The IHSS recipient who wishes to hire you (or his/her authorized representative) will be
informed of your conviction and will be directed to keep the information confidential.
•
The recipient who wishes to hire you as his/her provider (or his/her authorized representative)
must submit an IHSS Recipient Request for Provider Waiver (SOC 862) to the County IHSS
Office or IHSS Public Authority.
•
The waiver will allow you to be enrolled to provide services only for the recipient who requested
the waiver.
•
If you, as the provider, are also the recipients’ authorized representative, you are NOT allowed
to sign the waiver on behalf of the recipient to waive crimes for which you have been convicted.
In this case, the waiver must either be signed directly by the recipient or, if that is not possible,
another individual must be declared an authorized representative for purposes of signing this
waiver.
•
For more information about requesting a waiver, the IHSS recipient who wishes to hire you as
his/her provider should contact the County IHSS Office or IHSS Public Authority.
General Exception of an Exclusion for Conviction for a Tier 2 Crime
If you are found ineligible based on a conviction for a Tier 2 exclusionary crime and you want to be
listed on a provider registry or want to provide services for a recipient who has not requested an
individual waiver –
•
You may apply for a general exception of the exclusion by completing the IHSS Applicant
Provider Request for General Exception (SOC 863).
•
You will be required to provide backup documentation, (e.g., employment history, personal
references, etc.), to support your request for a general exception.
•
For more information about requesting a general exception, contact the County IHSS Office or
IHSS Public Authority.
-
Completion of this form satisfies ONE of the IHSS provider enrollment requirements.
-
You must complete ALL of the provider enrollment requirements BEFORE you can be enrolled
as an IHSS provider or get paid from the IHSS program for providing authorized services for an
eligible IHSS recipient.
GO ON TO THE NEXT PAGE
PAGE 2 OF 4
SOC 426 (4/12)
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