In-Home Supportive Services (Ihss) Program. Provider Enrollment Form - California Page 3
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4IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT FORM
INSTRUCTIONS:
•
Use black or blue ink to fill out. Print information clearly.
•
Fill out, sign and return this form in person to the office or location designated by the county. Bring original federal or
state government-issued identification and your original Social Security card when returning this form.
•
Complete all items in PART A, answer the questions in PART B, and read and sign the declaration in PART C.
•
The county will: 1) Review the form to make sure it is complete; 2) Make photocopies of your
identification and Social Security card; and 3) Provide you with a copy of the completed form for your records.
•
You must let the county know if anything you report on this form changes within ten (10) calendar days of the change.
PART A: PROVIDER INFORMATION
3. Gender:
1. Full Name (First Name, Middle Initial, Last Name):
2. Date of Birth:
■ ■
■ ■
If you are under 18 years of age, you must submit a
M
F
.
valid Work Permit with this form
4. Home Address
(Must be physical address, not a Post Office box):
City:
State
ZIP:
:
5. Mailing Address
City:
(if different from home address):
State
ZIP:
:
6. Telephone Number
7. Social Security Number*:
(with Area Code):
b. Expiration Date:
8. a. Driver’s License # or Government Issued ID #:
c. Issuing State:
9. a. Primary Spoken Language:
b. Primary Written Language:
.
NOTES:
*
The collection of the Social Security Number is required pursuant to W&IC 12305.81(a), and the Immigration Reform and Control Act
of 1986, Public Law 99-603 (8 USC 1324a), for the purposes of verifying the individual’s identity and authorization to work in the
United States.
PART B: PROVIDER DISCLOSURE
ANSWER THE FOLLOWING QUESTIONS BY CHECKING THE APPROPRIATE BOX:
1. WITHIN THE PAST 10 YEARS, HAVE YOU BEEN –
■ ■
■ ■
YES
NO
a. Convicted of or incarcerated following a conviction for a Tier 1* crime?.....................................
■ ■
■ ■
YES
NO
b. Convicted of or incarcerated following a conviction for a Tier 2* crime?.....................................
*See Page 1 of this form for a definition of Tier 1 and Tier 2 crimes.
2. IF YOU ANSWERED “YES” TO QUESTION 1.b. ABOVE, have you obtained a certificate of rehabilitation
■ ■
■ ■
YES
NO
or expungement (dismissal pursuant to PC section 1203.4) of the Tier 2 crime? ............................
If YES, you must provide the county with a copy of the certificate of rehabilitation or documentation of the
expungement along with this completed form.
GO ON TO THE NEXT PAGE
PAGE 3 OF 4
SOC 426 (4/12)
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