In-Home Supportive Services (Ihss) Program. Provider Enrollment Form - California Page 4
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4IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT FORM
PROVIDER’S NAME:
PART C: PROVIDER DECLARATION
I UNDERSTAND AND AGREE THAT –
I cannot receive IHSS program funds as payment for authorized services I provide to any eligible
•
recipient of IHSS until I have completed the entire provider enrollment process and I have been officially
enrolled as a provider by the county.
As a part of the provider enrollment process, I must provide fingerprints and undergo a criminal
•
background check. I am responsible for paying the costs of fingerprinting and the background check.
If it is found, either through my responses on this form, the results of the criminal background check, or
•
some other means, that within the past 10 years, I have been convicted of or incarcerated following a
conviction for a Tier 1 exclusionary crime, I will not be eligible to be an IHSS provider, and the recipient
who wished to hire me will be informed that I am ineligible to be a provider because of a disqualifying
criminal conviction which will not be specified.
If it is found, either through my responses on this form, the results of the criminal background check, or
•
some other means, that within the past 10 years, I have been convicted of or incarcerated following a
conviction for a Tier 2 exclusionary crime, and I have not received a certificate of rehabilitation or had the
conviction expunged –
I will not be eligible to be an IHSS provider, unless an IHSS recipient who wishes to hire me to
-
provide his/her services, requests an individual waiver, or I apply for and I am granted a general
exception; and
The IHSS recipient who wishes to hire me as his/her provider will be informed of my conviction
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and the types of crimes for which I was convicted, and he/she will be directed to keep the
information confidential.
IF I AM ENROLLED BY THE COUNTY AS AN IHSS PROVIDER, I UNDERSTAND AND AGREE THAT –
If the person I provide services for receives IHSS through the Medi-Cal program, I will be considered to
•
be a Medi-Cal provider of personal care services. Therefore, I will be required to comply with all
Medi-Cal program rules relating to the provision of services.
Payment for the authorized services I provide to an IHSS recipient will be from federal, state and/or
•
county IHSS funds. Any false statement I provide, including false entries on the timesheet or
withholding of information, may be prosecuted under federal and/or state laws.
I will reimburse the IHSS program for any overpayments paid to me and any overpayment, individually
•
or collectively, may be deducted from a future paycheck for services I provide to any recipient of IHSS.
I will provide all services without discrimination based on race, religion, color, national or ethnic origin,
•
gender, age, sexual orientation, or physical or mental disability.
I declare, UNDER PENALTY OF PERJURY, that all of the information I have provided on this form
is true and correct to the best of my knowledge, and that I agree to all of the statements listed
above.
Signature:_______________________________________________________ Date:____________________________
Printed Name:____________________________________________________
FOR COUNTY USE ONLY
County Representative’s Signature
:____________________________
DATE:_________________
(Optional)
PAGE 4 OF 4
SOC 426 (4/12)
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